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Background Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications. Methods The Canadian Community Health Survey (CCHS) (2003–2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history. Results A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a ‘healthy profile’ was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada. Conclusion Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development.

Objectives: To develop a Critical Appraisal tool for non-computational-specialist public health professionals to assess the quality and relevance of modelling studies about Test and Trace (and Protect – TTP) programmes’ impact on COVID-19 transmission.Study Design: Decision-making tool developmentMethods: Using Tugwell et al.’s Health Care Effectiveness equation as a conceptual framework, combined with a purposive search of the relevant early modeling literature, we developed six critical appraisal questions for the rapid assessment of modeling studies related to the evaluation of TTP programmes’ effectiveness.Results: By applying the Critical Appraisal tool to selected recent COVID-19 modeling studies we demonstrate how models can be evaluated using the six questions to evaluate internal and external validity, and relevance.Conclusions: These six critical appraisal questions are able to discriminate between modeling studies of higher and lower quality and relevance to evaluating TTP programmes’ impact. However, these questions require independent validation in a larger and systematic sample of relevant modeling studies which have appeared in later stages of the pandemic.

We assess the extent and quality of High-Income Countries’ (HIC) practices in monitoring Socioeconomic Inequalities in Health (SIH) through routine data collection/collation and analysis systems. Official websites of government authorities of eligible countries were examined for any reports containing data on SIH, which were assessed for quality from an epidemiological perspective, using published guidelines for monitoring of socioeconomic inequalities in health status.Despite the global commitment to Sustainable Development Goal 10, and recommendations of the WHO 2008 Commission of Social Determinants of Health, most of the thirty-six HIC whose websites were searched appear not to be routinely monitoring SIHs. Only seven HIC websites were found to have SIH monitoring reports that were readily discoverable on their official websites. Only two countries (England and Scotland) have been publishing such trends in detail for more than a half-decade. Although an SIH monitoring system is not itself a sufficient condition for reducing SIH, it is likely a necessary one. For countries that are planning to establish a system, lessons from others who have established such systems include the value of routinely and automatically post-coding of major health outcomes, with robust assignment of average socio-economic status to each local area.

Twelve years have now passed since the influential WHO Report on the Social Determinants of Health (SDoH) in 2008. A group of senior international public health scholars and decision-makers met in Italy in mid-2019 to review the legacy of the SDoH conceptual framework and its adequacy for the many challenges facing our field as we enter the 2020s. Four major categories of challenges were identified: emerging “exogenous” challenges to global health equity, challenges related to weak policy and practice implementation, more fundamental challenges related to SDoH theory and research, and broader issues around modern research in general. Each of these categories is discussed, and potential solutions offered. We conclude that although the SDoH framework is still a worthy core platform for public health research, policy, and practice, the time is ripe for significant evolution.

Background Governments and health policymakers are now looking for strategies to lift the COVID-19 lockdown, while reducing risk to the public. Methods We propose the population attributable risk (PAR) as an established epidemiological tool that could support decision-making through quickly estimating the main benefits and costs of various exit strategies. Results We demonstrate the feasibility of use of PAR using pandemic data, that were publicly available in mid-May 2020 from Scotland and the US, to estimate the proportion of COVID-19 hospital admissions which might be avoided, and the proportion of adverse labour market effects – for various scenarios – based on maintaining the lockdown for those of certain ages with and without comorbidities. Conclusion These calculations could be refined and applied in different countries to inform important COVID-19 policy decisions, using routinely collected data., Highlights • Many countries have tried to exit COVID-19 lockdown. Typically, trade-offs are required. • A simple epidemiological tool -- population attributable risk -- can help quantify these trade-offs. • This paper quantifies the proportion of COVID-19 hospitalisations averted, versus the proporition of the labour force locked down, for various combinations of age- and comorbidity-related lockdown exit strategies. • We show that both continuing lockdown for all persons over 65, and those with comorbidities over 50, have similar effects on hospitalisations. • Other considerations, such as equity and acceptability of these policy options, are therefore critical in these final policy decisions.

New 5G (fifth generation) telecommunications systems, now being rolled out globally, have become the subject of a fierce controversy. Some health protection agencies and their scientific advisory committees have concluded that there is no conclusive scientific evidence of harm. Several recent reviews by independent scientists, however, suggest that there is significant uncertainty on this question, with rapidly emerging evidence of potentially harmful biological effects from radio-frequency electromagnetic field (RF-EMF) exposures, at the levels 5G rollout will entail. This essay identifies four relevant sources of scientific uncertainty and concern: 1) lack of clarity about precisely what technology is included in 5G; 2) a rapidly accumulating body of laboratory studies documenting disruptive vitro and in vivo effects of RF-EMFs -- but one with many gaps in it; 3) an almost total lack (as yet) of high-quality epidemiological studies of adverse human health effects from 5G EMF exposure specifically, but rapidly emerging epidemiological evidence of such effects from past generations of RF-EMF exposure; 4) persistent allegations that some national telecommunications regulatory authorities do not base their RF-EMF safety policies on the latest science, related to unmanaged conflicts of interest. The author, an experienced epidemiologist, concludes that one cannot dismiss the growing health concerns about RF-EMFs, especially in an era when higher population-levels of exposure are occurring widely, due to the spatially dense transmitters which 5G systems require. Based on the Precautionary Principle, the author echoes the calls of others for a moratorium on the further rollout of 5G systems globally, pending more conclusive research on their safety. BACKGROUND5G (fifth generation) technology is being widely promoted by politicians, government officials, and private sector interests [1-3]. They contend that its advent will bring clear economic and lifestyle benefits, through massive increases in wireless and mobile connectivity at home, work, school and in the community. Examples of these 5G benefits include driverless vehicles, and “The Internet of Things” – automated and continuous communication between the machines in our daily lives [4,5]. On the other hand, the public health response to this wave of communications innovation has become a sense of deep concern, related to widespread scientific uncertainties, as well as a lack of use of existing evidence, in the current international safety guidelines for 5G and related radio-frequency electromagnetic field (RF-EMF) exposures [5-8]. This commentary sets out the reasons for such concern.

Men who have sex with men (MSM) continue to be the largest risk group for HIV infections in the U.S., where crystal methamphetamine abuse heightens risk for HIV infection through greater engagement in condomless anal sex (CAS). One potential contributor to the intractability of existing crystal methamphetamine treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. The hypothesis was that, for MSM abusing crystal methamphetamine, re-learning how to engage in non-drug-using aspects of life would facilitate their ability to benefit from sexual risk reduction (SRR) counseling. Project IMPACT was a pilot randomized controlled trial. Forty-six MSM at sexual risk of acquiring HIV who met DSM-IV criteria for crystal methamphetamine dependence were enrolled. Of those MSM, 41 were randomized: 21 were assigned to the intervention, consisting of two sessions of SRR, ten sessions of BA with SRR, and one session of relapse prevention (13 sessions total); 20 participants were assigned to a control condition (two sessions of SRR). At the acute post-intervention visit, intervention participants reported an average of 3.2 CAS acts with men who were HIV-infected or whose status they did not know, compared to 4.5 among control participants (β=−0.36;95%CI:−0.69,−0.02;p=0.035). At the 6-month post-intervention visit, intervention participants reported 1.1 CAS acts with men who were HIV-infected or whose status they did not know compared to 2.8 among control participants (β=−0.95;95%CI:−1.44,−0.46;p

The study was funded by the UK National Institute for Health Research (NIHR, PHR 10/3000/07). Objectives. Point of sale (POS) displays are one of the most important forms of tobacco marketing still permitted in many countries. Reliable methods for measuring exposure to such displays are needed in order to assess their potential impact, particularly on smoking attitudes and uptake among young people. In this study we use a novel method for evaluating POS exposure based on young people's use of retail outlets and recall of tobacco displays and observational data on the characteristics of displays. Study design. Observational audit of retail outlets (n = 96) and school-based pupil survey (n = 1482) in four Scottish communities reflecting different levels of social deprivation and urbanisation, conducted in 2013 before legislation to remove POS displays was implemented in supermarkets. Methods. Measures were taken of: visibility and placement of tobacco displays; internal and external advertising; display unit size, branding and design; visibility of pack warnings; proximity of tobacco products to products of potential interest to children and young people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco displays. Variation in POS exposure across social and demographic groups was assessed. Results. Displays were highly visible within outlets and, in over half the stores, from the public footway outside. Tobacco products were displayed in close proximity to products of interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled seeing tobacco displays, with those from deprived areas more likely to recall displays in small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/convenience stores (two of the outlet types most often visited by young people) were examined separately, average tobacco display unit sizes were significantly larger in those outlets in more deprived areas. Conclusions. POS displays remain a key vector in most countries for advertising tobacco products, and it is important to develop robust measures of exposure. The data reported in this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting such displays. Publisher PDF

Introduction: As further restrictions have been placed on tobacco advertising and promotions, point-of-sale (PoS) displays of cigarettes in shops have become an increasingly important source of young people’s exposure to tobacco products. This study explored the relationship between PoS displays of cigarettes and brand awareness among secondary school students in Scotland. Methods: Cross-sectional school surveys (n = 1406) and focus groups (n = 86) were conducted with S2 (13–14 years) and S4 (15–16 years) students in four schools of differing socioeconomic status in 2013, prior to the PoS display ban in large shops. Adjusted negative binomial regression analysis examined associations between brand awareness and exposure variables (visiting tobacco retailers, noticing displays of tobacco products). Results: Students visiting small shops more frequently (relative rate ratio [RRR] 1.19, 95% confidence interval [CI] 1.01–1.41) and those who noticed cigarette displays in small shops (RRR 1.24, 95% CI 1.03–1.51) and large supermarkets (RRR 1.15, 95% CI 1.01–1.30) had higher brand awareness. The focus groups supported these findings. Participants described PoS tobacco displays as being eye-catching, colorful and potentially attractive to young people. Conclusions: This mixed-methods study showed that higher cigarette brand awareness was significantly associated with regularly visiting small shops and noticing PoS displays in small and large shops, even when students’ smoking status, smoking in their social networks, leisure activities, and demographics were included as confounding variables. This highlights the importance of PoS displays of tobacco products in increasing brand awareness, which is known to increase youth smoking susceptibility, and thus the importance of implementing PoS display bans in all shops. Implications: As increasing restrictions have been placed on tobacco promotion in many countries, PoS displays of cigarettes in shops have become an important source of young people’s exposure to tobacco products and marketing. This mixed-methods study showed that prior to the PoS display ban in Scotland, and controlling for other factors, 13- and 15-year olds who regularly visited small shops and those who noticed PoS displays in small and large shops, had a higher awareness of cigarette brands. This highlights the importance of PoS displays in increasing youth brand awareness, which increases smoking susceptibility, and thus the need for comprehensive bans on PoS displays which cover all shops.

Objectives To assess what proportion of the association between household low income and incidence of adverse childhood experiences (ACE) would be eliminated if all households had access to housing, transportation and childcare services, breastfeeding counselling, and parks. Methods Using Growing Up in Scotland birth cohort data (N = 2816), an inverse probability-weighted regression-based mediation technique was applied to assess associations between low-income status (

ObjectiveTo examine changes in minimum wage associated with changes in women’s weight status.DesignLongitudinal study of legislated minimum wage levels (per month, purchasing power parity-adjusted, 2011 constant US dollar values) linked to anthropometric and sociodemographic data from multiple Demographic and Health Surveys (2000–2014). Separate multilevel models estimated associations of a $10 increase in monthly minimum wage with the rate of change in underweight and obesity, conditioning on individual and country confounders. Post-estimation analysis computed predicted mean probabilities of being underweight or obese associated with higher levels of minimum wage at study start and end.SettingTwenty-four low-income countries.SubjectsAdult non-pregnant women (n150 796).ResultsHigher minimum wages were associated (OR; 95 % CI) with reduced underweight in women (0·986; 0·977, 0·995); a decrease that accelerated over time (P-interaction=0·025). Increasing minimum wage was associated with higher obesity (1·019; 1·008, 1·030), but did not alter the rate of increase in obesity prevalence (P-interaction=0·8). A $10 rise in monthly minimum wage was associated (prevalence difference; 95 % CI) with an average decrease of about 0·14 percentage points (−0·14; −0·23, −0·05) for underweight and an increase of about 0·1 percentage points (0·12; 0·04, 0·20) for obesity.ConclusionsThe present longitudinal multi-country study showed that a $10 rise in monthly minimum wage significantly accelerated the decline in women’s underweight prevalence, but had no association with the pace of growth in obesity prevalence. Thus, modest rises in minimum wage may be beneficial for addressing the protracted underweight problem in poor countries, especially South Asia and parts of Africa.

BackgroundThis study examines whether young never smokers in Scotland, UK, who have tried an e-cigarette are more likely than those who have not, to try a cigarette during the following year.MethodsProspective cohort survey conducted in four high schools in Scotland, UK during February/March 2015 (n=3807) with follow-up 1 year later. All pupils (age 11–18) were surveyed. Response rates were high in both years (87% in 2015) and 2680/3807 (70.4%) of the original cohort completed the follow-up survey. Analysis was restricted to baseline ‘never smokers’ (n=3001/3807), 2125 of whom were available to follow-up (70.8%).ResultsAt baseline, 183 of 2125 (8.6%) never smokers had tried an e-cigarette and 1942 had not. Of the young people who had not tried an e-cigarette at baseline, 249 (12.8%) went on to try smoking a cigarette by follow-up. This compares with 74 (40.4%) of those who had tried an e-cigarette at baseline. This effect remained significant in a logistic regression model adjusted for smoking susceptibility, having friends who smoke, family members’ smoking status, age, sex, family affluence score, ethnic group and school (adjusted OR 2.42 (95% CI 1.63 to 3.60)). There was a significant interaction between e-cigarette use and smoking susceptibility and between e-cigarette use and smoking within the friendship group.ConclusionsYoung never smokers are more likely to experiment with cigarettes if they have tried an e-cigarette. Causality cannot be inferred, but continued close monitoring of e-cigarette use in young people is warranted.

Several countries have increased their legal minimum age for work in line with international conventions on child labor. We evaluated the effect of increasing the legal minimum age for work on school attendance in 3 low- and middle-income countries using difference-in-differences analyses. Increasing the legal minimum age for work increased school attendance by 3.0 (0.2, 5.8) percentage-points in Malawi, and 2.0 (0.2, 3.6) percentage-points in Colombia. In Malawi, we found a greater policy effect among girls compared to boys. In Colombia, the poorest tercile experienced the greatest improvement in educational outcomes. We found no evidence of an impact of increasing the legal minimum age for work on school attendance in Burkina Faso. Our findings suggest that increasing the legal minimum age for work has had a positive effect on educational outcomes in some low and middle income countries., Highlights • Many countries increased legal minimum age for work (LMAW) in line with ILO conventions on child labor. • Increasing LMAW increased school attendance by 3.0 percentage-points in Malawi, and 2.0 percentage-points in Colombia. • In Malawi, we found a greater policy effect among girls compared to boys. • In Colombia, the poorest tercile experienced the greatest improvement in educational outcomes. • We found no evidence for a policy effect in Burkina Faso.

To examine the socioeconomic gradients in birth outcomes among singleton infants in Argentina, 2003–2007. We analyzed data of 3,230,031 singleton infants born in 2003–2007, obtained from vital statistics. Associations between birth outcomes [small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB)] and socioeconomic indicators (maternal education and area-based material deprivation quintiles) were assessed with logistic regression. The risk of SGA increased with higher socioeconomic disadvantage, but that of PTB decreased. Compared to mothers who attained a tertiary or university degree, mothers who did not complete primary school were more likely to have a SGA infant [adjusted OR (95 % CI): 1.65 (1.62, 1.68)], but less likely to deliver preterm [0.92 (0.90, 0.94)]. As a result of the conflicting trends in SGA and PTB, LBW exhibited inconsistent socioeconomic gradients. The excess risk of adverse birth outcomes associated with socioeconomic disadvantage was consistently reflected by SGA, but not by LBW and PTB. These findings challenge the usefulness of LBW as an indicator population health. Further research is needed to explain the reverse socioeconomic gradients in PTB.

The observed clustering, and shared underlying determinants, of risk behaviours in young people has led to the proposition that interventions should take a broader approach to risk behaviour prevention. In this review we synthesized the evidence on ‘what works' to prevent multiple risk behaviour (focusing on tobacco, alcohol and illicit drug use and sexual risk behaviour) for policy-makers, practitioners and academics. We aimed to identify promising intervention programmes and to give a narrative overview of the wider influences on risk behaviour, in order to help inform future intervention strategies and policies. The most promising programme approaches for reducing multiple risk behaviour simultaneously address multiple domains of risk and protective factors predictive of risk behaviour. These programmes seek to increase resilience and promote positive parental/family influences and/or healthy school environments supportive of positive social and emotional development. However, wider influences on risk behaviour, such as culture, media and social climate also need to be addressed through broader social policy change. Furthermore, the importance of positive experiences during transition periods of the child-youth-adult phase of the life course should be appropriately addressed within intervention programmes and broader policy change, to reduce marginalization, social exclusion and the vulnerability of young people during transition periods.

Context: In this article we present “best practice” guidelines for monitoring socioeconomic inequalities in health status in the general population, using routinely collected data. Methods: First, we constructed a set of critical appraisal criteria to assess the utility of routinely collected outcomes for monitoring socioeconomic inequalities in population health status, using epidemiological principles to measure health status and quantify health inequalities. We then selected as case studies three recent “cutting-edge” reports on health inequalities from the Scottish government and assessed the extent to which each of the following outcomes met our critical appraisal criteria: natality (low birth weight rate, LBW), adult mortality (all-cause, coronary heart disease [CHD], alcohol-related, cancer, and healthy life expectancy at birth), cancer incidence, and mental health and well-being. Findings: The critical appraisal criteria we derived were “completeness and accuracy of reporting”; “reversibility and sensitivity to intervention”; “avoidance of reverse causation”; and “statistical appropriateness.” Of these, the most commonlyunmetcriterionacrosstheroutinelycollectedoutcomeswas“reversibility and sensitivity to intervention.” The reasons were that most mortality events occur in later life and that the LBW rate has now become obsolete as a sole indicator of perinatal health. Other outcomes were also judged to fail other criteria, notably alcohol-related mortality after midlife (“avoidance of reverse causation”); all cancer sites’ incidence and mortality (statistical appropriateness due largely to heterogeneity of SEP gradients across different cancer sites, as

Objectives We previously assessed inter-rater reliability of expert raters using six scales to estimate the intensity of literature-based mechanical exposures. The objectives of this study were to estimate the impact on the inter-rater reliability of using non-expert (NE) raters and to assess the validity of our scales. Methods We used 7-point scales to represent three dimensions of mechanical exposures at work: 1) trunk posture, 2) weight lifted or force exerted and 3) spinal loading. We estimated both peak and cumulative loads and called this an “interpretive translation” of exposure. A second method, “algorithmic translation”, used the original units in which the exposure data was collected. These data were used to assess the inter-rater reliability and validity of the NE interpretive translation of exposure. Results The NE inter-rater reliability for the scales ranged from 0.24 to 0.46. The correlation between the means of the NE and expert ratings were >0.7. Although there was a strong relationship between the NE interpretive and the algorithmic translation, there was some evidence that the interpretive translation plateaus at higher level of exposure. Conclusions This study supports using NE raters to estimate the intensity of literature-based mechanical exposure metrics using a common set of scales which can be applied across epidemiologic studies. We would need to average the ratings of at least five NE raters to have an acceptable level of reliability (>0.7). These metrics may be useful to quantify the relationship between workplace mechanical exposure and low back pain in a systematic review and meta-analysis.

Thomas McKeown was right in his primary claim that changing environments, rather than improved medical care, were responsible for much of the long wave of historical mortality decline in the UK since 1700. He was, however, apparently unaware that the beginning of the decline in infant and early-childhood mortality lagged behind that for adults by a few decades, and therefore that its causes might have been fundamentally different. In fact, current evidence indicates that his suggestion, that ‘improved nutrition’ was the underlying factor in the overall decline, now appears to have been essentially correct for the much earlier decline in adult mortality, especially due to tuberculosis. However, the current consensus is that changing reproductive patterns, occasioned by a changing socio-cultural and perhaps legal environment, related to child labor laws, lay behind the much later and very rapid decline in early-life mortality. One must therefore give McKeown great credit for his grasp of both the importance...

The sexual and reproductive health needs of young people perinatally infected with HIV in Uganda remain largely unaddressed by existing HIV/AIDS programs mostly because, such programs encourage young HIV-positive clients to refrain from or postpone sexual activity. This study examines the sexual expressions and experiences as well as the preventive practices of 732 adolescent boys and girls aged 15-19 years who were born with HIV with a view to identifying the preventive service needs of these young people and the implications of these needs for HIV/AIDS programs. The data come from a project on the sexuality of young people perinatally infected with HIV conducted in 2007 in four districts of Uganda, that is, Kampala, Wakiso, Masaka, and Jinja. The analysis involves both quantitative and qualitative approaches: the quantitative approach entails cross-tabulations with chi-square tests as well as significance tests of proportions while the qualitative approach involves an analysis of individual case stories, in-depth probes and focus group discussions for content. The findings show disconnect between: (1) the information the service providers give to the young people and their actual needs and desires; (2) the fears of the adolescents and their actual preventive practices; and (3) the high level of reported condom use and the frequency of use. Programs will therefore need to recognize that young people perinatally infected with HIV are sexually active or anticipate being so in future. Thus, both sexually active and non-sexually active young people require information and services on prevention of unwanted pregnancies as well as avoiding infecting their sexual partners with HIV and re-infecting themselves. Programs will need to devise ways of responding to these needs which should include emphasizing the disclosure of HIV status to the partner as well as the need to accompany such disclosure with consistent condom use.

Counseling programs for adolescents living with human immunodeficiency virus (HIV) encourage abstinence from sex and relationships. This Uganda study, however, found that many of these adolescents are sexually active or desire to be in relationships but engage in poor preventive practices. Programs for HIV and acquired immunodeficiency syndrome (AIDS) programs therefore need to strengthen preventive services to this group.

Ce document dresse l’historique et la justification du programme des Centres nationaux de collaboration en santé publique, établi par l’Agence de santé publique du Canada en 2004. Les centres ne sont pas axés sur la recherche primaire, mais plutôt sur la synthèse des preuves scientifiques mondiales qui sont pertinentes pour les politiques, les programmes et les pratiques de santé publique–et leur conversion en « produits du savoir » pour les professionnels de la santé publique, les responsables des politiques et les groupes communautaires afin de guider la prise de décision en santé publique. Les grands principes de la synthèse et de l’application/échange des connaissances (SAEC) aux fins de la santé publique sont passés en revue, de même que de récents sites Web et publications décrivant des projets internationaux dans ce domaine en plein essor. Enfin, certaines pratiques exemplaires pour la SAEC en santé publique provenant d’expériences au Canada et ailleurs dans le monde sont décrites.

Background The combined effect of socioeconomic, organizational, psychosocial, and physical factors on work-related musculoskeletal disorders (WRMSDs) were studied in a heterogeneous, socioeconomically diverse sample (cases and their matched referents) of hospital workers. Methods Cases were defined by a new acute or cumulative work-related musculoskeletal injury; referents were matched by job group, shift length, or at random. Information was obtained through telephone interviews and on-site ergonomics observation. Questionnaire items included sociodemographic variables, lost work time, work effectiveness, health status, pain/disability, and psychosocial working conditions using Effort Reward Imbalance (ERI) and Demand-Control (DC) models. Two multivariate models were tested: Model 1 included occupation as a predictor; Model 2 included education–income as a predictor. Results Cases reported greater pain, disability, lost time, and decreased work effectiveness than the referents. Model 1 was statistically significant for neck/upper extremity injury (Chi-square = 19.3, P = 0.01), back/lower extremity injury (Chi-square = 14.0, P = 0.05), and all injuries combined (Chi-square = 25.4, P = 0.001). “Other Clinical” occupations (34% mental health workers) had the highest risk of injury (OR 4.5: 95%CI, 1.7–12.1) for all injuries. The ERI ratio was a significant predictor for neck and upper extremity (OR 1.5: 95%CI, 1.1–1.9) and all injuries (OR 1.3; 95%CI, 1.04–1.5), per SD change in score. Conclusions In this study, the risk of WRMSDs was more strongly influenced by specific psychosocial and physical job-related exposures than by broad socioeconomic factors such as education and income. Am. J. Ind. Med. 2007. © 2007 Wiley-Liss, Inc.

Objectives: In May 2008, the National Health Service (NHS) Lanarkshire (NHSL) implemented a unique telephone-based sickness absence management service entitled “EASY” (Early Access to Support for You). The EASY service supplements existing absence policies and enables telephone communication between the absentee, their line manager, and the EASY service from the first day of absence and referral to occupational health services at day ten. The aim of this study was to determine if the EASY service was effective between May 2008 and May 2012 in reducing sickness absence in NHSL compared to normal occupational healthcare in NHS Scotland and is, as such, a cost-saving intervention.\ud Methods: This study included time-series analysis of health board sickness absence data and analyses of the EASY service database (survival analyses and Cox’s proportional hazards model).\ud Results: The EASY service was effective in reducing sickness absence by 21% in NHSL, whereas the nonspecific tightening of the sickness absence policies across the rest of Scottish NHS health boards reduced sickness absence by approximately 9%. The richness of the EASY database gave detailed information on absentees by cause, duration, job family, and reporting compliance. The mean duration of musculoskeletal absences was significantly shorter in years 2, 3, and 4 compared to year 1. Those absentees contacted by phone on the first day of absence were more likely to return to work than those contacted on subsequent days. The EASY service improves economic efficiency; the value of the hours saved from the reduced sickness absence exceeds the cost of operating the service.\ud Conclusion: The study highlights the importance of an early telephone-based intervention for sickness absence management.

▪ Abstract This article reviews the historical development of population health indicators. We have long known that environmental, socioeconomic, early life conditions, individual actions, and medical care all interact to affect health. Present quantitative reporting on the impact of these factors on population health grew out of Bills of Mortality published in the 1500s. Since then, regular censuses, civil registration of vital statistics, and international classification systems have improved data quality and comparability. Regular national health interview surveys and application of administrative data contributed information on morbidity, health services use, and some social determinants of health. More recently, traditional health databases and datasets on “nonhealth” sector determinants have been linked. Statistical methods for map-making, risk adjustment, multilevel analysis, calculating population-attributable risks, and summary measures of population health have further helped to integrate information. Reports on the health of populations remain largely confined to focused areas. This paper suggests a conceptual framework for using indicators to report on all the domains of population health. Future ethical development of indicators will incorporate principles of justice, transparency, and effectiveness.

Objective: We sought to better use qualitative approaches in occupational health research and integrate them with quantitative methods. Methods: We systematically reviewed, selected, and adapted qualitative research methods as part of a multisite study of the predictors and outcomes of work-related musculoskeletal disorders among hospital workers in two large urban tertiary hospitals. Results: The methods selected included participant observation; informal, open-ended, and semistmctured interviews with individuals or small groups; and archival study. The nature of the work and social life of the hospitals and the foci of the study all favored using more participant observation methods in the case study than initially anticipated. Conclusions: Exploiting the full methodological spectrum of qualitative methods in occupational health is increasingly relevant. Although labor-intensive, these approaches may increase the yield of established quantitative approaches otherwise used in isolation.

Motor vehicles emit particulate matter < 2.5 microm in diameter (PM(2.5)), and as a result, PM(2.5) concentrations tend to be elevated near busy streets. Studies of the relationship between motor vehicle emissions and respiratory health are generally limited by difficulties in exposure assessment. We developed a refined exposure model and implemented it using a geographic information system to estimate the average daily census enumeration area (EA) exposure to PM(2.5). Southeast Toronto, the study area, includes 334 EAs and covers 16 km(2) of urban area. We used hospital admission diagnostic codes from 1990 to 1992 to measure respiratory and genitourinary conditions. We assessed the effect of EA exposure on hospital admissions using a Poisson mixed-effects model and examined the spatial distributions of variables. Exposure to PM(2.5) has a significant effect on admission rates for a subset of respiratory diagnoses (asthma, bronchitis, chronic obstructive pulmonary disease, pneumonia, upper respiratory tract infection), with a relative risk of 1.24 (95% confidence interval, 1.05-1.45) for a log(10) increase in exposure. We noted a weaker effect of exposure on hospitalization for all respiratory conditions, and no effect on hospitalization for nonrespiratory conditions.

It has been recently reported that both dynamic movement characteristics, as well as the duration of postures adopted during work, are important in the development of low back pain (LBP). This paper presents a video-based posture assessment method capable of measuring trunk angles and angular velocities in industrial workplaces. The interobserver reliability, system accuracy, and the relationship of the measured exposures to the reporting of low back pain are reported. The video analysis workstation consisted of a desktop computer equipped with digital video capture and playback technology, a VCR, and a computer game type joystick. The operator could then use a joystick to track trunk flexion and lateral bending during computer-controlled video playback. The joystick buttons were used for binary input of twisting. The inter-observer reliability for peak flexion and percentage of time spent in posture category variables were excellent (ICC>0.8). Lower reliability levels were observed for peak and average velocity and movement related variables. The video analysis system time series data showed very high correlation to the criterion optoelectronic imaging system (r ¼ 0:92). Root mean square errors averaged 5.81 for the amplitude probability distribution function data. Trunk flexion variables including peak level, peak velocity, average velocity indicators, and percent time in flexion category indicators all showed significant differences between cases and controls in the epidemiological study. A model consisting of the measures peak trunk flexion, percent time in lateral bend and average lateral bending velocity emerged after multivariable analysis for relationship to low back pain. Relevance to industry Risk of injury for the low back is multifactorial. The trunk position and movement velocity are emerging as important parameters. This analysis confirms the importance of these factors and demonstrates the utility of a videobased method to measure them in industrial settings. r 2001 Elsevier Science B.V. All rights reserved.

Modified-work programs are designed to facilitate the return to work for employees with a work-related injury. Although extensive published literature exists that describes and evaluates "ideal" programs, to date there is a paucity of data describing practice. To address this pertinent issue, we administered a survey to a large sample of 1833 workers with soft-tissue injuries in Ontario, Canada, and asked them detailed questions about modified work and employer contact. Our results reveal that most workers (66%) were contacted by someone from their workplace to check on how they were doing. However, only a minority (36%) were offered arrangements by their employer to help them return to work after developing a work-related soft-tissue injury. Most arrangements that were offered to injured workers consisted of such temporary modifications as reduced hours (24%), flexible work hours (25%), or a lighter job (57%) rather than more permanent changes to the way that work is conducted, such as changes to the work layout or equipment (8%). Merely being contacted by the workplace to check on how the worker was doing was not associated with reduced compensation benefit duration. Workplace offers of arrangements to help the worker return to work were associated with reduced compensation benefit duration but were not statistically associated with workers' pain grade. Language: en

A posture and load sampling approach to measure physical exposures was implemented within a case-control study of low-back pain reporting. The purpose of this paper was to determine how well this method was able to identify known low-back pain risk factors. Subjects, including both cyclic production and non-cyclic support workers, were studied while working in an automotive assembly facility. The study included 104 (with 20 proxies) cases, workers who reported low-back pain at work, and 129 randomly selected controls. Results indicate significant associations between low-back pain reporting and peak spinal loads (OR=2.0 for compression), shift-average spinal loading (OR=1.7 for compression), percent of time with loads in the hand (OR=1.5), maximum flexion angle (OR=2.2), and percent of time spent forward flexed beyond 458(OR=1.3). Posture and hand load variables, considered to be intermediate exposure variables, were handled separately in multivariable regression analyses from variables of peak and average spine force which directly estimate tissue loading. The work and posture sampling approach is particularly useful for heterogeneous work situations where traditional task analysis is diAcult and can provide information on work and tissue load parameters which have been directly associated with risk of reporting low-back pain. Relevance to industry

Roots of the epidemic of alcohol-related problems among many Native North Americans are sought in cultural responses to European arrival, the role of alcohol in frontier society, and colonial and postcolonial policies. Evidence from the historical record is considered within the framework of current social science. Initially, Native American's responses to alcohol were heavily influenced by the example of White frontiersmen, who drank immoderately and engaged in otherwise unacceptable behavior while drunk. Whites also deliberately pressed alcohol upon the natives because it was an immensely profitable trade good; in addition, alcohol was used as a tool of "diplomacy" in official dealings between authorities and natives. The authors argue that further research into the origins of modern indigenous people's problems with alcohol would benefit from an interdisciplinary "determinants of health" approach in which biological influences on alcohol problems are investigated in the context of the cultural, social, and economic forces that have shaped individual and group drinking patterns.

The Global Health Research Initiative (GHRI) involving the Canadian International Development Agency, the Canadian Institutes of Health Research, Health Canada and the International Development Research Centre seeks to coordinate Canada's research response to global health challenges. In light of numerous calls to action both nationally and internationally, an orientation to applied health policy and systems research, and to public health research and its application is required to redress global inequalities in wealth and health and to tackle well-documented constraints to achieving the United Nations Millennium Development Goals. Over the last four years, the GHRI has funded close to 70 research program development and pilot projects. However, longer-term investment is needed. The proposed dollars 100 million Teasdale-Corti Global Health Research Partnership Program is such a response, and is intended to support teams of researchers and research users to develop, test and implement innovative approaches to strengthening institutional capacity, especially in low- and middle-income countries; to generating knowledge and its effective application to improve the health of populations, especially those most vulnerable; and to strengthen health systems in those countries. While Canada stands poised to act, concerted leadership and resources are still required to support "research that matters" for health and development in low- and middle-income countries.

We would like to thank Maes and colleagues for their timely and comprehensive summary of European-based studies on the effectiveness of workplace-based interventions to promote healthy eating.1 Their broad inclusion in particular, of a wide range of study designs and efforts to grade both study reporting and intervention quality are to be commended. However, they may be doing their own efforts a disservice, in that their discussion and conclusions seem overly cautious and conservative. For example, the results cited include: Given the widely acknowledged difficulties around implementing sustainable dietary behaviour change, we feel that the review as presented should be considered as encouragement for further workplace-based interventions, aimed at improving dietary quality. Another recent review not restricted to European-only studies also found that worksite health promotion programmes …

Background The global and within-country epidemiology of cervical cancer exemplifies health inequity. Public health programs may reduce absolute risk but increase inequity; inequity may be further compounded by screening programs. In this context, we aimed to explore what the impact of human papillomavirus (HPV) vaccine might have on health equity allowing for uncertainty surrounding the long-term effect of HPV vaccination programs. Methods A simple static multi-way sensitivity analysis was carried out to compare the relative risk, comparing after to before implementation of a vaccination program, of infections which would cause invasive cervical cancer if neither prevented nor detected, using plausible ranges of vaccine effectiveness, vaccination coverage, screening sensitivity, screening uptake and changes in uptake. Results We considered a total number of 3,793,902 scenarios. In 63.9% of scenarios considered, vaccination would lead to a better outcome for a population or subgroup with that combination of parameters. Regardless of vaccine effectiveness and coverage, most simulations led to lower rates of disease. Conclusions If vaccination coverage and screening uptake are high, then communities are always better off with a vaccination program. The findings highlight the importance of achieving and maintaining high immunization coverage and screening uptake in high risk groups in the interest of health equity.

Objectives. We used individual participant data from multiple studies to conduct a comprehensive meta-analysis of mechanical exposures in the workplace and low back pain. Methods. We conducted a systematic literature search and contacted an author of each study to request their individual participant data. Because outcome definitions and exposure measures were not uniform across studies, we conducted 2 substudies: (1) to identify sets of outcome definitions that could be combined in a meta-analysis and (2) to develop methods to translate mechanical exposure onto a common metric. We used generalized estimating equation regression to analyze the data. Results. The odds ratios (ORs) for posture exposures ranged from 1.1 to 2.0. Force exposure ORs ranged from 1.4 to 2.1. The magnitudes of the ORs differed according to the definition of low back pain, and heterogeneity was associated with both study-level and individual-level characteristics. Conclusions. We found small to moderate ORs for the association of mechanical exposures and low back pain, although the relationships were complex. The presence of individual-level OR modifiers in such an area can be best understood by conducting a meta-analysis of individual participant data.

The UK Medical Research Council (MRC) Population Health Sciences Research Network is a network of MRC research units and centres that aims to bring together and add value to existing MRC investment in public health, health services and epidemiological research. This symposium held in August 2011 at the World Congress of Epidemiology, Edinburgh, discussed a range of topics including methodology and analytical issues based on a number of examples of cohort studies within the context of lifecourse epidemiology. © 2012 The Royal Society for Public Health.

Preplacement screening is put forth by some as an effective method for preventing low back disability at the workplace. Although there are still large gaps in knowledge regarding the natural history of and risk factors for back disability, it is clear that the majority of costs are derived from the small proportion of those that will suffer with back symptoms for 6 months or more. Thus, if preplacement screening is to have an impact on health care spending and compensation costs, the screening test will have to be predictive not so much of all back injuries, but rather of work absenteeism and especially chronic disability. This paper presents some criteria for evaluating a screening program and explores the effect of choosing different outcomes for evaluation. The literature on the effectiveness of a number of preplacement screening techniques is examined. Current legislation related to preplacement screening is also described. The natural history, etiologic factors, and prognostic markers for back injuries need to be elucidated further before effective screening strategies can be developed to reduce the incidence of back injuries and back disability in the population.

Background Hospital workers are at high risk of work-related musculoskeletal disorders (WRMSDs), but outcomes following such injuries have not been well studied longitudinally. Aims To ascertain functional recovery in hospital workers following incident WRMSDs and identify predictors of functional status. Methods Cases (incident WRMSD) and matched referents from two hospitals were studied at baseline and at 2 year follow-up for health status [SF-12 physical component summary (PCS)], lost workdays, self-rated work effectiveness and work status change (job change or work cessation). Predictors included WRMSD and baseline demographics, socio-economic status (SES), job-related strain and effort–reward imbalance. Logistic regression analysis tested longitudinal predictors of adverse functional status. Results The WRMSD-associated risk of poor (lowest quartile) PCS was attenuated from a baseline odds ratio (OR) of 5.2 [95% confidence interval (CI) 3.5–7.5] to a follow-up OR of 1.5 (95% CI 1.0–2.3) and was reduced further in multivariate modelling (OR = 1.4; 95% CI 0.9–2.2). At follow-up, WRMSD status did not predict significantly increased likelihood of lost workdays, decreased effectiveness or work status change. In multivariate modelling, lowest quintile SES predicted poor PCS (OR = 2.0; 95% CI 1.0–4.0) and work status change (OR = 2.5; 95% CI 1.1–5.8). High combined baseline job strain/effort–reward imbalance predicted poor PCS (OR = 1.7; 95% CI 1.1–2.7) and reduced work effectiveness (OR = 2.6; 95% CI 1.6–4.2) at follow-up. Conclusions Baseline functional deficits associated with incident WRMSDs were largely resolved by 2 year follow-up. Nonetheless, lower SES and higher combined job strain/effort–reward imbalance predicted adverse outcomes, controlling for WRMSDs.

The psychosocial working environment is an important determinant of health status and health inequalities in Canada. Particular dimensions of the psychosocial work environment such as low job control, job strain and imbalances between perceived efforts and rewards have been related to cardiovascular disease (the leading cause of mortality in Canada) and poorer mental health status. Despite its importance to the health of Canadians and health inequalities in Canada, the national surveillance of the psychosocial work environment is decreasing. Currently, the surveillance of the psychosocial work environment in Statistic Canada’s population health surveys is limited to convenience-based samples within particular health regions. Not including important dimensions of the health, such as the psychosocial work environment, in our population-based surveys limits the ability of these surveys to help us better understand the challenges and opportunities to reducing health inequalities in Canada. Key words: Psychological factors; surveillance; public health; Canada Resume L’environnement psychosocial de travail est un important determinant de l’etat de sante et des inegalites en sante au Canada. Certains aspects, comme le manque de liberte de decision, le stress au travail et les desequilibres entre les efforts et les recompenses percus, ont ete lies aux maladies cardiovasculaires (lesquelles sont la principale cause de mortalite au Canada) et a la degradation de l’etat de sante mentale. Malgre son importance pour la sante des Canadiens et le redressement des inegalites en sante au Canada, la surveillance nationale de l’environnement psychosocial de travail diminue. Aujourd’hui, ce type de surveillance dans les enquetes sur la sante de la population de Statistique Canada se limite a des echantillons de commodite preleves dans certaines regions sanitaires. L’absence d’aspects de la sante aussi importants que l’environnement psychosocial de travail dans les enquetes representatives canadiennes reduit l’utilite de ces enquetes lorsqu’il s’agit de comprendre les difficultes et les possibilites de reduire les inegalites en sante au Canada. Mots cles : facteurs psychologiques; surveillance; sante publique; Canada

Objectives. We compared the influence of the residential environment and maternal country of origin on birthweight and low birthweight of infants born to recent immigrants to urban Ontario. Methods. We linked delivery records (1993–2000) to an immigration database (1993–1995) and small-area census data (1996). The data were analyzed with cross-classified random-effects models and standard multilevel methods. Higher-level predictors included 4 independent measures of neighborhood context constructed by factor analysis and maternal world regions of origin. Results. Births (N = 22 189) were distributed across 1396 census tracts and 155 countries of origin. The associations between neighborhood indices and birthweight disappeared after we controlled for the maternal country of origin in a cross-classified multilevel model. Significant associations between world regions and birthweight and low birthweight persisted after we controlled for neighborhood context and individual characteristics. Conclusions. The residential environment has little, if any, influence on birthweight among recent immigrants to Ontario. Country of origin appears to be a much more important factor in low birthweight among children of recent immigrants than current neighborhood. Findings of neighborhood influences among recent immigrants should be interpreted with caution.

The “hardening hypothesis” suggests that as smoking prevalence decreases, lighter smokers will quit first, leaving more “hardcore” smokers in the population. At a population level, however, the weight of evidence suggests that no hardening is occurring. By understanding the lessons from Geoffrey Rose's model of population-level risk factor change, we argue that the hardening of the smoking population is not inevitable. The Rose model predicts that the effect of policy interventions, and changes in social norms, can shift the population-level risk distribution for continuing to be a smoker, making it more likely that all smokers will quit. This analysis also suggests that further reductions in smoking prevalence will not come without further changes in the underlying – and largely cultural – root causes of smoking in a population.

Objective: To examine the pathways through which job control affects health status; to examine if the effects of job control on health status are attenuated by including other measures associated with lower socioeconomic status, and to examine if the relationship between job control and health status is consistent across socioeconomic status groups. Design: A prospective observational cohort study over eight years (1994–2002). Participants: 4886 Respondents aged 25–60 years, who were non-self-employed labour force participants, working more than 20 hours per week, without physical or mental limitations restricting the type or amount of work they could do at baseline. After longitudinal attrition, the remaining study sample was 3411 (87% of the original study sample who did not die or become pregnant during the survey period). Main results: Low job control in 1994 was associated with worse than expected self-rated health in 2002, both directly and indirectly via a lower physical activity level in 1996. Adjustment for other factors associated with low socioeconomic status did not attenuate these relationships to a large extent. No differences were found in the effects of job control on physical activity or health status between socioeconomic groups (high and low education and high and low household income). Conclusions: The inclusion of other factors associated with lower socioeconomic status did not attenuate the direct and indirect effects of job control on health status. The finding that low job control is associated with lower physical activity levels deserves further investigation, given the increasing concern about rising levels of obesity in the developed world.

In public health, the generation, management, and transfer of knowledge all need major improvement. Problems in generating knowledge include an imbalance in research funding, publication bias, unnecessary studies, adherence to fashion, and undue interest in novel and immediate issues. Impaired generation of knowledge, combined with a dated and inadequate process for managing knowledge and an inefficient system for transferring knowledge, mean a distorted body of evidence available for decisionmaking in public health. This article hopes to stimulate discussion by proposing a Global Registry of Anticipated Public Health Studies. This prospective, comprehensive system for tracking research in public health could help enhance collaboration and improve efficiency. Practical problems must be discussed before such a vision can be further developed.

This discussion paper is intended to start a dialogue about prevention among those who are interested in making workplaces safer and healthier. The following four key themes are presented to build a framework for further discussion and activity: theme 1 -- with multiple causes for workplace injury, illness, and disability, preventing these problems requires multiple solutions, operating in synergy; theme 2 -- efforts to reduce workplace injury, illness, and disability must build on both primary and secondary prevention approaches, merging these to create a more effective strategy; theme 3 -- before which strategies work and which do not can be agreed upon, a shared understanding is needed of how the effectiveness of occupational health interventions should be evaluated; and theme 4 -- building relationships between those who do research and those who use research knowledge is important if relevant research is to be produced that is readily taken up and applied to improve occupational health and safety.

As a social epidemiologist, and former GP in clinical settings with major psychiatric caseloads, I confess that I tend to avoid scholarly books about mental health. My bias is that mental health professionals are typically unenlightened healthcare providers, on the subject of the social determinants of health. This cynical view arises from nearly 40 years as a physician, watching modern psychiatry bend itself out of shape at least a few times. Psychiatry first embraced and then largely rejected psychoanalysis, with its relative inattention to social position as an important contributor to lifelong health and function—only to then fall head over heels in love with modern neurobiology and pharmacotherapy, again with little emphasis on the social roots of much mental (and physical) illness. However, at last here is an enlightening book that even the most psychiatrically critical health practitioners and researchers can read with pleasure. For it brings to the front and centre the enormous and convincing (but largely ignored) global literature on the social origins of the most common mental health problems, especially the ‘neuroses’. As well, the book expertly traces the profound influence of social and economic factors on the natural history of very severe mental illnesses (such as bipolar disorder and schizophrenia) which science now believes …

Background Psychosocial working conditions are likely to contribute to work-related musculoskeletal disorders (WRMSDs), but a lack of standardized measurement tools reflects both the theoretical and methodological limitations of current research. Methods An interdisciplinary team including biomedical, behavioral, and social science researchers used an iterative process to adapt existing instruments for an interviewer-administered questionnaire assessing psychosocial workplace exposure related to musculoskeletal disorders. Results The resulting questionnaire included measures of psychosocial workplace factors based on two theoretical models (the demand-control-support and the effort-reward imbalance models), supplemented by the additional constructs of “emotional demands,” and “experiences of discrimination.” Other psychosocial and physical measures selected for questionnaire inclusion address physical workload, sociodemographic and anthropometric characteristics, social relations and life events, health behaviors, and physical and psychological health. Conclusion Using an interdisciplinary approach facilitated the development of a comprehensive questionnaire inclusive of key measures of psychosocial factors that may play a role in the complex mechanisms leading to WRMSDs. Am. J. Ind. Med. 45:428–439, 2004. © 2004 Wiley-Liss, Inc.