BMJ public health最新文献

Introduction: We compared the incidence density (ID) and hazards of ischaemic heart disease (IHD), heart failure (HF), stroke, composite cardiovascular disease (CVD), all-cause (ACM) and cardiovascular mortality (CVM) in a nationwide cohort of patients with youth-onset type 1 (T1D) and type 2 diabetes (T2D) with age of diabetes onset <40 years.

Methods: A total of 6059 patients with T1D (T1D_<25) and 120 704 patients with T2D (T2D_<25) with an age of diabetes onset <25 years and 1691 patients with T1D (T1D_25-39) and 378 070 patients with T2D (T2D_25-39) with an age of diabetes onset ≥25-39 years were linked to Taiwan's National Health Insurance databases and Death Registry to identify IHD, HF, stroke, composite CVD, ACM and CVM. The person‒year approach and Cox proportional hazard regression model were used to determine the ID and hazards of cardiovascular-related study endpoints, with adjustments for age, sex, geographic area, medications and duration of diabetes.

Results: Patients with T1D_<25 had the lowest ID, whereas those with T2D_25-39 had the greatest rates of cardiovascular outcomes. Compared with patients with T1D_<25, patients with T2D_<25 had greater risks of IHD, HF, stroke and composite CVD (adjusted HRs (aHRs): 1.47, 1.86, 1.81 and 1.54, respectively). The aHRs of cardiovascular endpoints in patients with T2D_<25 were greater than those in patients with T1D_25-39 but comparable to those in patients with T2D_25-39. Patients with T2D_<25, T1D_25-39 and T2D_25-39 all had increased risks of ACM, but only patients with T2D_25-39 had elevated hazards of CVM compared with those of patients with T1D_<25.

Conclusions: Our findings highlight substantial heterogeneity in cardiovascular risk within youth-onset diabetes, particularly among patients with early-onset T2D_<25. Hazards of cardiovascular outcomes in patients with T2D_<25 were greater than those in patients with T1D at any age of diabetes onset, and they were as high as those in patients with T2D_25-39.

Background: Frequent users (FUs) of emergency departments (EDs) attend repeatedly, placing a disproportionate burden on healthcare systems. Although known to be heterogeneous, there is limited international evidence characterising FU subpopulations or examining how healthcare costs and outcomes differ across groups. Advancing this understanding is important for developing tailored interventions to meet diverse care needs.

Methods: FUs were defined as individuals with ≥5 ED attendances/year. We used two large UK datasets: Hospital Episode Statistics (HES, 2016-2019) and the Centre for Urgent and Emergency Care database (CUREd, 2017-2020). Together, these included over 148 000 FUs from 5 million ED users. Latent class analysis (LCA) was used to identify FU subgroups based on attendance patterns, healthcare use and diagnostic characteristics.

Results: We identified three consistent subgroups (HES and CUREd): (1) low-severity FUs (n=23 034, 43.2%; n=7081, 32.7%); (2) high-intensity FUs with mental health and neurological needs (n=6288, 11.8%; n=3456, 15.9%); (3) older FUs with chronic illness and high inpatient use (n=24 028, 45.0%; n=11 139, 51.4%). Subgroups differed substantially in healthcare utilisation, costs and mortality. A fourth class varied across datasets: in HES, it showed moderate morbidity and complex needs; in CUREd, high morbidity and high-intensity ED use.

Discussion: This is the first FU study to apply LCA across large-scale, multiyear ED datasets, identifying a potentially universal subgroup structure. Current services focus on a narrow subset of high-intensity users. Additional tailored strategies are needed to address the full spectrum of FU needs.

Introduction: Breast cancer is a global health issue, contributing to a significant number of cancer-related deaths among women. Early detection through breast cancer screening is essential for reducing mortality and morbidity rates. We aimed to assess the individual and community-level factors associated with breast cancer screening among women of reproductive age in Tanzania.

Methods: An analytical cross-sectional survey was conducted using secondary data from the 2022 Tanzania demographic and health survey. Considering the complex survey design, a multilevel mixed-effects binary logistic regression was used to determine the individual and community-level factors associated with breast cancer screening. Adjusted OR with corresponding 95% CIs was used to estimate the strength of the association. Statistical significance was set at a p<0.05.

Results: The prevalence of breast cancer screening among women of reproductive age in Tanzania was 5.2% (95% CI 4.7 to 5.7). At the individual level, being aged ≥25 years, educated, working, living in wealthier households, using contraceptives, having media exposure, healthcare insurance coverage and visiting health facilities in the last 12 months were associated with higher odds of breast cancer screening. At the community level, being from communities with a high level of poverty and residing in rural settings was associated with lower odds of breast cancer screening. While residing in northern, southern and lake zones was associated with higher odds of breast cancer screening.

Conclusions: The study highlights a critical need for enhanced efforts in breast cancer screening among women of reproductive age in Tanzania, where current participation rates remain disconcertingly low. The multifactorial nature of screening behaviours, influenced by age, education, employment status and socioeconomic conditions, underscores the complexity of addressing this public health challenge. Implementing targeted educational programmes, improving healthcare access and leveraging community resources can increase awareness and utilisation of screening services.

Introduction: In Sub-Saharan Africa, validated measures of men's gender equality attitudes remain limited amid slow progress in gender equality and sexual and reproductive health outcomes. This study aimed to develop and examine the socio-demographic correlates of a Men's Gender Egalitarian Attitudes Scale (MGEAS) in Nigeria.

Methods: The study drew on data from the 2018 Nigeria Demographic and Health Survey, restricted to 8057 men aged 20-59 years who were married or cohabiting with a female partner. The MGEAS was developed using psychometric analyses of 12 items related to men's gender attitudes in the men's dataset. Principal component analysis, parallel analysis and factor analysis were used to identify scale dimensions and retain items. Scale reliability was assessed using Cronbach's alpha, and confirmatory factor analysis evaluated dimensionality and internal validity. Scores for each retained dimension and for the overall scale were generated using an unweighted method. External validity and socio-demographic correlates were assessed using differentiation by known groups and multivariable regression analyses.

Results: Psychometric analyses supported the retention of 10 items structured into three dimensions: Opposition to violence, Upholding equal decision-making power and Affirmation of women's contraception autonomy. The overall scale demonstrated good internal consistency (Cronbach's alpha=0.77), and confirmatory factor analysis indicated satisfactory construct validity. Scores for all dimensions and the overall scale were right-skewed, with a median overall score of 4.25 out of 5. Higher scores across all dimensions were independently associated with schooling level and region of residence.

Conclusions: The proposed MGEAS proved to be valid and multidimensional. The scale provides a novel framework to measure men's gender egalitarian attitudes, which covers dimensions that are not necessarily covered by existing measures of gender equality and can be used for further analysis of reproductive preferences, behaviours and related reproductive health outcomes.

Introduction: Using green space improves health and well-being. However, there are many barriers to green space use, including poor health. Evidence is lacking on how health-related barriers to green space differ by chronic health condition. This study investigates health-related barriers to green space use, chronic health conditions and sociodemographic characteristics.

Methods: We assessed health-related barriers to green space use using Natural England's People and Nature Survey. Data from 5 months of the nationally representative survey of English adults (aged 16+) were used (n=10 415), collected during November 2020-March 2021. To assess relationships between reporting of health-related barriers to using green space, an individual's chronic health conditions and sociodemographic characteristics, structural equation modelling was used (n=201).

Results: Respondents with progressive illnesses or physical disabilities had a higher likelihood of reporting multiple (four) health-related barriers as important compared with respondents with arthritis or diabetes (both had no barriers that they were more likely to report). For example, respondents with physical disabilities (32%) and progressive illnesses (31%) had an increased likelihood of reporting lack of disabled facilities as an important barrier to using green space compared with those with other conditions. Those with progressive illnesses (34%) had a particularly higher likelihood of reporting having no one to go with/help as an important barrier to using green space (p=0.001). Both physical health-related (eg, fatigue) and place-based (eg, poorly maintained sites) factors are barriers to green space use for individuals reporting a chronic condition.

Conclusions: The results suggest that those with physical disabilities and progressive illnesses would benefit most from reducing place-based and support barriers, such as a lack of disabled facilities and no one to go with/help. By improving the suitability of green spaces using this evidence, barriers to green space would be reduced for all users, which may improve the quality of the space.

Introduction: Asthma represents a significant global public health concern, especially in children, due to its high prevalence and burden on the healthcare system. Early-life exposures, particularly to antibiotics and bronchiolitis, have been independently linked to an increased risk of wheezing and subsequent asthma. Despite extensive research on these risk factors, their interplay and combined impact throughout early childhood remains unclear. This study aims to clarify these relationships by investigating the mediating role of recurrent wheezing in the inception of childhood asthma.

Methods: A retrospective birth-cohort study was conducted using data from the Italian Pedianet database, including children followed for at least 5 years. Exposure to antibiotics and bronchiolitis during the first year, episodes of wheezing between ages 1-4, and asthma diagnoses from age 5 onward were identified in outpatient records. Mediation analysis assessed the association between early-life exposures and asthma risk, with recurrent wheezing considered a potential mediator.

Results: Among 121 255 children, 2.33% developed asthma after age 5. Our results support the hypothesis that early-life bronchiolitis and antibiotic use increase asthma risk through an indirect pathway mediated by recurrent wheezing, which accounts for the majority of the effect (up to 74%), and a direct pathway, independent of wheezing, which may reflect mechanisms such as immune dysregulation, airway remodelling or microbiome alterations. The strong mediated component underscores recurrent wheezing as a clinically relevant marker and key target for preventive strategies. Nonetheless, the presence of a residual direct effect suggests that interventions focusing exclusively on wheezing may not entirely eliminate asthma risk (up to 70%), even though they could substantially reduce it.

Conclusions: Our findings highlight the importance of preventing bronchiolitis and wheezing to reduce asthma incidence, supporting antibiotic stewardship and respiratory syncytial virus immunisation as public health interventions.

Objectives: This scoping review explores the health of international students (IS) in Canada by focusing on publicly funded healthcare eligibility, health outcomes and healthcare services, and the social and structural determinants of health (SSDOH).

Design: We registered a protocol and followed scoping review guidance. A search strategy was developed by a librarian, and Google Advanced Search was used for grey literature. Two reviewers screened peer-reviewed studies and one reviewer screened grey literature.

Data sources: Government websites were searched to understand healthcare eligibility. Six databases were searched for peer-reviewed studies. Grey literature sources included news media and websites of educational institutions and non-profits.

Eligibility criteria: We included peer-reviewed and grey literature on IS published between 2013 and 2024. We excluded non-English language studies, protocols and abstracts.

Data extraction and synthesis: Two reviewers extracted data for peer-reviewed studies, produced descriptive statistics and narrative summaries. One reviewer conducted these for grey literature sources.

Results: Most IS in Canada are ineligible for publicly funded healthcare. Among 282 peer-reviewed studies, 26 met our inclusion criteria. Mental health (MH) was the most frequently mentioned, while grey literature also emphasised violence and mortality. Studies focusing on MH generally found better outcomes among IS compared with domestic students. Qualitative studies reported on the SSDOH more than quantitative studies, highlighting that the social environment contributed to MH challenges.

Conclusions: Public healthcare eligibility for all IS may improve access. Differing cultural understandings of MH may have influenced how IS reported experiences. Culturally safe MH supports and large representative studies are needed.

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.