BMJ public health最新文献

Background: Little is known about the protective effects of social support and mental well-being for late-life cognition among different immigrant generations.

Methods: Kaiser Healthy Aging and Diverse Life Experiences participants were categorised as 1st-generation arriving age <18 years (n=73), first-generation arriving ≥18 years (n=282), 2nd-generation (n=279) or ≥3rd-generation (n=174). Social support (emotional, instrumental), loneliness and depressive symptoms were assessed at baseline. Verbal episodic memory (VEM) and executive function (EF) were assessed up to four times (max. years=6.6). Linear mixed-effects models examined associations of social support, loneliness and depression with EF and VEM, adjusting for covariates overall and in race/ethnic-stratified models. Interactions by immigrant generation were tested.

Results: First-generation immigrants arriving <18 years old had the lowest instrumental support (mean (SD)=-0.18 (1.0)) and the highest loneliness (mean (SD)=0.25 (0.93)) and depressive symptom (mean (SD)=-0.04 (0.80)) scores. Instrumental (β=0.05 (95% CI 0.003 to 0.10)) support and emotional support (β=0.06 (95% CI 0.01 to 0.11)) were positively associated with baseline EF. Loneliness (β=-0.08 (95% CI -0.13 to -0.03)) and depressive symptoms (β=-0.09 (95% CI -0.15 to -0.04)) were negatively associated with baseline EF. For associations with VEM, instrumental support (β=0.02 (95% CI -0.04 to 0.07)) and emotional support (β=0.03 (95% CI -0.03 to 0.09)) were not significantly associated. Loneliness (β=-0.07 (95% CI -0.13 to -0.02)) was negatively associated and depression (β=-0.04 (95% CI -0.11 to 0.03)) trended negatively with VEM. All associations with cognitive change were null. In race/ethnic stratified models, associations were more pronounced for Latino participants, whereas associations for Asian participants were generally weaker and non-significant.

Conclusions: Social support and mental well-being may be most pertinent for late-life EF among older Latinos, as associations were generally stronger among Latino adults and closer to null among Asian adults. These findings reiterate the importance of considering both immigrant generation and race/ethnicity in evaluations of late-life cognition risk and resilience factors.

Introduction: The social determinants of health play a significant role in posing numerous health challenges for individuals and causing health disparities at the societal level. This study aims to outline evidence-based interventions that are practical and easy to use for frontline healthcare workers as part of routine practice. These interventions were derived from the Community Links Evidence to Action Research (CLEAR) toolkit and adapted to the sociocultural context of Khyber Pakhtunkhwa (KPK), Pakistan.

Methods: This facility-based interventional exploratory qualitative study was conducted at Mardan Medical Complex, KPK, Pakistan, between January 2021 and November 2022. Using a three-phase design (pre-intervention, intervention and post-intervention), purposive sampling was used to recruit 16 healthcare workers (nine doctors and seven nurses) for in-depth semi-structured interviews conducted before and after the intervention. During the intervention phase, 115 healthcare workers received structured CLEAR toolkit training delivered through small-group, interactive sessions. Interview data were analysed using thematic analysis following Consolidated Criteria for Reporting Qualitative Research guidelines.

Results: In the pre-intervention phase, healthcare workers identified three major barriers faced when addressing patients' social needs: distrust in sharing social life issues, cultural barriers in symptom communication and fear of privacy breaches. In the post-intervention phase, six major themes emerged: (1) Breaking Barriers, Building Bridges: Addressing Sociocultural Barriers in Patient Care; (2) Patient Counselling Sessions as Catalysts for Personal Growth; (3) Community Awareness Campaigns by Healthcare Workers; (4) Strategies to Address Financial Issues of Patients; (5) Healthcare Workers as Pillars of Organisational Support; and (6) Challenges in Addressing Social Determinants.

Conclusion: The application of the CLEAR toolkit training in healthcare settings enables healthcare workers to better identify and address the social problems underlying poor health outcomes, particularly in developing countries such as Pakistan. Incorporating such training fosters a holistic and patient-centred approach to healthcare delivery.

Introduction: The association between lead exposure and aggressive behaviour has been documented internationally. However, evidence among adolescents in low- and middle-income countries-particularly using non-blood-based exposure screening tools-remains limited.

Methods: This cross-sectional study investigates the relationship between potential lead exposure and aggressive behaviour in adolescents. The study subjects were middle and high school students aged 13-18 years residing in Jakarta. Data on the potential lead exposure were obtained using a lead exposure risk questionnaire from the Ministry of Health of the Republic of Indonesia, while data on aggressive behaviour were collected using the Buss Perry Aggression Questionnaire Scale. The likelihood of aggressive behaviour was analysed using logistic regression.

Results: The study, conducted between June and October 2024, involved 488 high school students from five municipalities in Jakarta. 76 students (15.6%) exhibited aggressive behaviour. It did not differ significantly by sex (p=0.817), parental education (p=0.916) or socioeconomic status (p=0.162). Potential lead exposure was significantly associated with aggressive behaviour (p=0.001), with a higher prevalence observed among participants reporting multiple exposure sources (p<0.001). Subjects with a potential lead exposure had a significantly higher likelihood of exhibiting aggressive behaviour (adjusted OR=10.0; 95% CI 1.32 to 77.3) compared with those not exposed. Residing in older buildings with deteriorating wall paint or furniture emerged as the sole significant source of potential lead exposure associated with elevated aggressive behaviour (adjusted OR=2.98; 95% CI 1.66 to 5.38). Additional risk factors included prior traumatic experiences, inadequate parental attention and frequent exposure to violent media.

Conclusions: This study demonstrates a significant relationship between the potential lead exposure and aggressive behaviour. Improved policies for preventing lead exposure are necessary to protect the health of adolescents in Jakarta and the community from the long-term impacts of lead exposure.

Introduction: It is unclear whether tax waivers are a useful public health intervention for lowering food prices and improving nutrition, or whether fiscal gains go largely to importers, wholesalers and retailers. Tonga reduced and removed 10% to 20% import tariffs and consumption taxes on a selection of healthy foods in 2013, 2015 and 2016. This study investigates the impact of these changes on retail prices and import volumes of targeted foods.

Methods: Interrupted time series analysis was used to quantify the percentage changes in retail prices and import volumes in the first year after each tax waiver compared with a counterfactual based on pre-existing trends. A segmented linear regression model was run with adjustment for autocorrelation and the effects of gross domestic product, international visitors, month, exchange rate and international oil prices. Meta-analysis technique was used to summarise findings across foods.

Results: On average, there was a suggestion of a small decline in retail price of tax waivered foods (-4%, CI -10% to 2%) with an average pass-through to a reduced price for consumers of 51%. Two of nine relevant foods had statistically significant evidence of price declines: frozen vegetables (-20%, CI -25% to -14%) and cooking oil (-3%, CI -5% to 0%). Overall, import volumes of tax waivered foods did not increase, and instead, there was suggestive decline (-20%, CI -45% to 15%). No import changes were statistically significant.

Conclusion: While there was no evidence of increased food supply for tax waivered foods, significant price declines were observed for frozen vegetables and tinned mackerel. There was evidence of moderate pass-through of tax waivers to lower retail prices. Interpretability was limited by variability in estimates and a shift from imported to locally sourced foods. Further evaluation of tax waiver effects is needed.

Objective: There is a paucity of information regarding the mortality profile in community-dwelling elderly as well as the associated risk factors for mortality. The primary objective was to report the 6-year mortality profile in free-living elderly population aged 65 years and above from Ernakulam, Kerala, India via longitudinal follow-up.

Methods: The study was a prospective cohort with stratified random cluster sampling. We collected baseline information via house visits using a predefined questionnaire. The subjects were followed up after recruitment for a median of 60 months by phone calls at regular intervals. Calls not answered were followed up by house visits by research personnel. All deaths were verified by reviewing medical records available at subjects' homes.

Results: We recruited a total of 1000 participants from 40 individual predesignated clusters (cluster size=25). The median follow-up was 71.8 (70.5-72.8) months and the cumulative follow-up was 5352.16 person years. A total of 262 (26.2%) subjects died during the follow-up period. The mortality rate for the overall cohort was 48.95 per 1000 person years. The corresponding figures for elderly men and women were 54.25 and 45.07 per 1000 person years, respectively. The mortality rate for elderly subjects residing in rural and urban areas was 57.59 and 45.33 per 1000 person years, respectively. Independent predictors of mortality in the study population identified by Cox regression-based analysis were age, sex, orthostatic hypotension, dependence in instrumental activities of daily living and adiposity.

Conclusions: Approximately a quarter of community-dwelling elderly individuals died within the next 6 years. Future interventions targeting a reduction in mortality among the elderly need to focus on modifiable risk factors like orthostatic hypotension, adiposity and dependence in instrumental activities of daily living.

Introduction: Hepatitis C virus (HCV) affects 50 million people globally, with Pakistan contributing 17.8% of the burden. Despite elimination efforts, national estimates overlook high-risk underserved populations, necessitating region-specific data. This study evaluates HCV seroprevalence and viraemic burden in rural and periurban Sindh, Pakistan, highlighting the urgency for targeted interventions.

Methods: A cross-sectional survey (May-July 2023) was conducted in Mirpurkhas, Tando Allahyar, and Sukkur districts using two-stage PPS sampling at public and public-private sector health facilities. Individuals (≥10 years) were screened for anti-HCV antibodies using rapid diagnostic tests and confirmed for viraemia via PCR. Sociodemographic and risk factor data were collected through structured questionnaires. Survey-adjusted seroprevalence and viraemic prevalence were estimated, with multivariable logistic regression identifying risk factors. Prevalence estimates were extrapolated to the entire Sindh population aged ≥10 years to estimate the absolute number of exposed and infected individuals.

Results: Among 3380 participants, the weighted prevalence of anti-HCV positivity was 17.1% (95% CI 11.9 to 24.1). Of those who screened anti-HCV positive, 44.8% (95% CI 39.4 to 50.3) were viraemic, corresponding to a weighted viraemic prevalence of 7.7% (95% CI 5.5 to 10.6). Extrapolated estimates suggest 4.5-10.4 million Sindh residents may have been exposed to HCV. Women aged ≥30 years, individuals with limited education and rural residents were disproportionately affected, with healthcare access disparities posing service barriers.

Conclusion: Rural and periurban Sindh faces a significant HCV burden due to healthcare access limitations, low health literacy, stigma and socioeconomic constraints. Targeted, community-based care models are essential. The Prime Minister's Hepatitis Elimination Program (2024-2030) offers an opportunity for expanded screening and treatment, but success requires improving healthcare access, workforce capacity, surveillance and public awareness to prevent infections and promote safer health practices.

Introduction: Domestic workers (DWs) worldwide face precarious and informal working conditions, including unstable employment, extended hours and insufficient labour protections, impacting their health. This study examines the health and healthcare access of women DWs in Peru, focusing on differences related to formal and informal employment.

Methods: This participatory action research surveyed women DWs in Lima, La Libertad and Piura, Peru, from September 2023 to March 2024 using respondent-driven sampling (RDS). We gathered sociodemographic, healthcare access and health status data and reported counts and percentages with RDS-II estimators (95% CI). We compared health status and healthcare access by formal and informal employment using bootstrap RDS methods.

Results: The study analysed data from 456 DWs. Most were between 19 and 45 years old (60.0%, 95% CI 50.1% to 70.0%), resided in Lima (69.8%, 95% CI 57.5% to 82.0%) and self-identified as Mestizo (54.8%, 95% CI 45.0% to 64.7%). Most respondents were precariously employed as informal DWs (90.5%, 95% CI 87.5% to 93.6%). A higher percentage of informal workers reported difficulty obtaining workplace permission for healthcare visits (32.2%, 95% CI 21.3% to 43.1% vs 21.2%, 95% CI 4.3% to 28.2%; p=0.187) and spent over 100 PEN (US$28) out of pocket on medical visits in the past year (21.2%, 95% CI 14.1% to 28.4% versus 10.5%, 95% CI 0.0% to 32.5%; p=0.249). Despite access to public health insurance, a higher percentage of informal workers visited private healthcare facilities (14.4%, 95% CI 8.3% to 20.5%) than formal workers (4.7%, 95% CI 1.5% to 7.8%) (p=0.084). A higher percentage of informal workers reported a diagnosis of depression (9.7%, 95% CI 5.1% to 14.4% vs 1.6%, 95% CI 0.0% to 4.4%; p=0.052) and anxiety (12.3%, 95% CI 6.1% to 18.5% vs 3.5%, 95% CI 0.0% to 9.1%; p=0.322). Obesity (43.0%) and depressive symptoms (41.4%) were prevalent across the DW population, regardless of employment status.

Conclusions: Informal employment among women DWs in Peru may be linked to greater health challenges and barriers to care, despite public health insurance coverage. Addressing these inequities requires stronger labour protections.

Background: Gallstone disease (GSD) is a prevalent gastrointestinal condition with known associations to gallbladder cancer (GBC). India exhibits heterogeneity in GSD burden across different geographic regions. However, limited data are available from high and low-risk regions.

Methods: A community-based cross-sectional study was conducted across high-risk (Kamprup (Guwahati), Silchar, Mullanpur, Varanasi) and low-risk (Barshi) GBC regions using structured interviews. Self-reported history of gallstones was collected through interviewing participants from two sources, the Gallstone Survey (GS) and the 0.5 Million Indian Women Screening study. Per cent prevalence was estimated for GSD and stratified analysis based on sex, age and region was conducted. We estimated the population attributable fraction (PAF) for GSD in high and low risk GBC regions.

Results: A total of 28 395 participants (9158 males, 19 237 females) aged 30-65 years were enrolled. Gallstone prevalence was highest in Mullanpur (10.8%, 95% CI 8.4% to 13.5%) and Kamprup (Guwahati) (10.7%, 95% CI (7.7% to 14.4%) and lowest in Barshi (0.3%, 95% CI 0.3% to 0.4%). Age and gender stratified analysis showed increasing gallstone prevalence with age among females in high-risk GBC regions, and no age-linked trends in GSD prevalence were observed in low-risk regions for both genders. The estimated overall PAF for high risk GBC regions was 2.7%, whereas in the low-risk region of Barshi the overall PAF was 0.2%.

Conclusion: Significant regional and sex-based variation in GSD prevalence across India aligns with high-risk zones for GBC, underscoring the need for targeted surveillance and aetiologic research.

Introduction: In China, the increase in high-risk pregnancies along with rising maternal age and complications has underscored the need for the development of maternal and newborn risk management programmes. The Chinese National Maternal and Newborn Safety Action Plan (CNMNSAP) was initiated in 2017. Given that neonatal mortality is a key indicator of healthcare quality, we evaluate the real-world effects of CNMNSAP against neonatal mortality among pregnant women with high-risk conditions.

Methods: In this retrospective, matched, population-based cohort study, we collected information on all pregnant women with clinically diagnosed conditions from electronic medical records in Chengdu, China, between July 2014 and December 2019. Individual-level data, covering all healthcare services and testing records in public hospitals, were obtained and categorised into two groups based on the timing of CNMNSAP implementation (pre-CNMNSAP vs post-CNMNSAP). After 1:1 propensity score matching, we calculated the annual percentage change (APC) of neonatal mortality within 7 days post-delivery and compared outcomes between two groups of pregnant women with conditions. We then employed multivariate log-binomial regression models to examine the association between the CNMNSAP implementation and temporal changes in neonatal mortality.

Results: During the 5-year study period, a total of 241 343 women with high-risk conditions delivered prior to CNMNSAP and 163 367 after its implementation. After 1:1 propensity score matching, 299 190 mothers were included for analysis. We estimated that the APC changed from 10.0% (95% CI -0.4% to 21.5%) prior to the maternal risk management programme to -28.5% (95% CI -44.2% to -8.4%) after its implementation, with an attributed risk reduction of 1.29 neonatal deaths per 1000 deliveries annually. In subgroup analysis, we found a significant reduction in neonatal mortality after policy implementation among mothers aged 18-34 years, those with a normal body mass index and those having a history of abortion.

Conclusions: The CNMNSAP was found to be associated with a significant annual reduction in early neonatal mortality risk among pregnant women with high-risk conditions in Chengdu, China. The maternal risk management programme effectively improved outcomes for high-risk pregnancies, highlighting the importance of maternal risk classification and management throughout pregnancy.