The experiences and perceptions of people with chronic and rare diseases during political-economic sanctions in Iran: a qualitative study.

BACKGROUND: Economic sanctions aim to exert pressure on political and economic foundations. Hypothesizing that sanctions might affect various aspects of population health, this study, as a component of a broader investigation to ascertain the trend effects of sanctions on selected health outcomes in Iran, seeks to explore the experiences of Iranian citizens associated with the imposed sanctions. METHODS: This is a qualitative study. We conducted 31 semi-structured interviews with randomly selected patients diagnosed with at least one chronic and rare disease from diverse backgrounds across four provinces in Iran. We analyzed data using an inductive content analysis approach, facilitated by the MAXQDA10 software. RESULTS: We identified three primary themes: direct effects, side effects, and coping strategies. The immediate effects were perceived to be manifested through the restriction of healthcare service availability and affordability for citizens. The side effects included the economic hardships experienced in individuals' lives and the perceived devastation caused by these difficulties. Some coping mechanisms adopted by patients or their families/relatives included prioritizing comorbidities, prioritizing health needs within families with multiple ill members, and readjusting health/illness requirements in light of daily living needs. CONCLUSION: In addition to the inherent burden of their illness, patients faced substantial healthcare costs as a result of sanctions, restricted access to medications, and availability of low-quality medications. We advocate considering these challenges within the healthcare system resilience framework as a crucial first step for policymakers, aiming to determine actionable measures and mitigate the adverse effects of sanctions on citizens, particularly the most vulnerable groups.

Coronary artery disease incidence, risk factors, awareness, and medication utilization in a 10-year cohort study.

BACKGROUND: There is a substantial disparity in coronary artery disease (CAD) burden between Iran and other nations that place a strong emphasis on the assessment of CAD risk factors and individuals' awareness and ability to control them. METHODS: Two thousand participants of a community-based Iranian population aged 20-74 years were investigated with a mean follow-up of 9.9 years (range: 7.6 to 12.2). An analysis of Cox regression was conducted to determine the association between CAD development and classic risk factors such as age, sex, smoking, physical activity, education, obesity, dyslipidemia, hypertension, and diabetes mellitus. Furthermore, we computed the population attributable fraction for these risk factors. RESULTS: After a follow-up period of nearly 10 years, 225 CAD events were reported, constituting 14.5% of the overall incidence. Nighty three percent of participants had more than one risk factor. Age was the most predictive risk factor, with a hazard ratio (HR) and confidence interval (CI) of 5.56 (3.87-7.97, p < 0.001) in men older than 45 and females older than 55 compared to lower ages. In comparison to females, males had an HR of 1.45 (CI: 1.11-1.90, p value = 0.006) for developing CAD. Nearly 80% of the patients had dyslipidemia, with a hazard ratio of 2.19 (CI: 1.40-3.44, p = 0.01). Among the participants, 28.9% had hypertension, and 52% had prehypertension, which had HRs of 4.1 (2.4-7.2, p < 0.001) and 2.4 (1.4-4.2, p < 0.001), respectively. Diabetes, with a prevalence of 17%, had an HR of 2.63 (CI: 2 -3.47, p < 0.001), but prediabetes was not significantly associated with CAD. Awareness of diabetes, dyslipidemia, and hypertension was 81%, 27.9%, and 48.1%, respectively. Regarding medication usage, the corresponding percentages were 51% for diabetes, 13.2% for dyslipidemia, and 41% for hypertension. CONCLUSIONS: Compared to previous studies in Iran and neighboring countries, the current study found a higher incidence of CAD, more prevalent risk factors, and a lower awareness and ability to control these risk factors. Thus, an effective preventive strategy is needed to reduce the CAD burden in Iran.

An innovative model for predicting coronary heart disease using triglyceride-glucose index: a machine learning-based cohort study.

BACKGROUND: Various predictive models have been developed for predicting the incidence of coronary heart disease (CHD), but none of them has had optimal predictive value. Although these models consider diabetes as an important CHD risk factor, they do not consider insulin resistance or triglyceride (TG). The unsatisfactory performance of these prediction models may be attributed to the ignoring of these factors despite their proven effects on CHD. We decided to modify standard CHD predictive models through machine learning to determine whether the triglyceride-glucose index (TyG-index, a logarithmized combination of fasting blood sugar (FBS) and TG that demonstrates insulin resistance) functions better than diabetes as a CHD predictor. METHODS: Two-thousand participants of a community-based Iranian population, aged 20-74 years, were investigated with a mean follow-up of 9.9 years (range: 7.6-12.2). The association between the TyG-index and CHD was investigated using multivariate Cox proportional hazard models. By selecting common components of previously validated CHD risk scores, we developed machine learning models for predicting CHD. The TyG-index was substituted for diabetes in CHD prediction models. All components of machine learning models were explained in terms of how they affect CHD prediction. CHD-predicting TyG-index cut-off points were calculated. RESULTS: The incidence of CHD was 14.5%. Compared to the lowest quartile of the TyG-index, the fourth quartile had a fully adjusted hazard ratio of 2.32 (confidence interval [CI] 1.16-4.68, p-trend 0.04). A TyG-index > 8.42 had the highest negative predictive value for CHD. The TyG-index-based support vector machine (SVM) performed significantly better than diabetes-based SVM for predicting CHD. The TyG-index was not only more important than diabetes in predicting CHD; it was the most important factor after age in machine learning models. CONCLUSION: We recommend using the TyG-index in clinical practice and predictive models to identify individuals at risk of developing CHD and to aid in its prevention.

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies.

BACKGROUND: The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees. OBJECTIVES: To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations. METHODS: Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services. RESULTS: Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general. CONCLUSIONS: Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Predictive Utility of Composite Child Feeding Indices (CCFIs) for Child Nutritional Status: Comparative Analyses for the Most Suitable Formula for Constructing an Optimum CCFI.

Composite child feeding indices (CCFIs) developed from various relevant measures of dietary intake by infants and young children have several potential applications in nutritional epidemiological studies for the development and deployment of precise public health nutrition interventions against child undernutrition. The predictive utility of some CCFIs (computed from varying formulation components) for child nutritional status (stunting, wasting, and underweight) were compared. The purpose of the study was to identify the most suitable among them for possible standardization, validation, and adoption by nutritional health researchers. Using cluster sampling, data from 581 mother-child pairs were collected. Multivariable regression analyses were applied to the data obtained through a community-based analytical cross-sectional survey design. Three of the CCFIs were found to be significantly associated with only wasting (WHZ) from the linear regression models after adjusting for potential confounders and/or correlates. None of the CCFIs (whether in the continuous nor categorical form) was consistently predictive of all three measures of child nutritional status, after controlling for potential confounders and/or correlates, irrespective of the choice of regression method. CCFI 5 was constructed using a dimension reduction technique-namely principal component analysis (PCA)-as the most optimal summary index in terms of predictiveness for child wasting status, validity, and reliability (Cronbach's α = 0.80) that captured relevant dimensions of optimal child food intake. The dimension reduction approach that was used in constructing CCFI 5 is recommended for standardization, validation, and possible adoption for wider applicability across heterogeneous population settings as an optimum CCFI usable for nutritional epidemiological studies among children under five years.

Loneliness as a mediator of social relationships and health-related quality of life among refugees living in North Rhine-Westphalia, Germany.

BACKGROUND: Since 2015, more than one million people fled to Germany - mainly from war-affected countries. Nevertheless, little is known about social determinants in refugees located in Germany. This study aims to test the mediation effect of loneliness between social relationships, comprising social integration and social support, and health-related quality of life among refugees living in North Rhine-Westphalia, Germany. METHODS: The investigation utilizes data from the FlueGe Health Study (N=326), a cross-sectional study conducted by Bielefeld University. The data was collected between February and November 2018 and included interviews and examinations. Participants were recruited from shared and private accommodation in several cities in North Rhine-Westphalia, Germany. We first analyzed correlations between social integration, social support, loneliness, and physical and mental component of health-related quality of life. We then conducted mediation analyses using structural equation modeling. RESULTS: The majority of respondents were socially isolated, perceiving a moderate degree of loneliness and social support. In addition, the physical and mental components of health-related quality of life indicate that participants predominantly experienced mental rather than physical impairments. Results from mediation analyses showed indirect effects of loneliness on the association between social integration and mental health (ß = 0.495, 95% bias-corrected and accelerated confidence interval (BCa CI) = [0.018, 0.972]), and between social support and both physical (ß = 0.022, 95% BCa CI = [0.004, 0.040]) and mental health (ß = 0.067, 95% BCa CI = [0.037, 0.097]). CONCLUSIONS: Loneliness played a mediating role in the association between social relationships and health-related quality of life among refugees living in North Rhine-Westphalia, Germany. The results provide implications for both, health policy and the host society.

Impact of Family Separation on Subjective Time Pressure and Mental Health in Refugees from the Middle East and Africa Resettled in North Rhine-Westphalia, Germany: A Cross-Sectional Study.

Little is known about social determinants among refugees resettled in Germany. This study aims to examine the impact of family separation on refugees' subjective time pressure and mental health. Data come from the FlueGe Health Study (n = 208), a cross-sectional study administered by Bielefeld University. We used logistic regression analysis to investigate the effect of family separation on (i) being time-stressed and (ii) having a high risk for adverse mental health, considering sociodemographic and postmigration factors. As a result, more than 30% of participants with a spouse or partner and about 18% with a child or children reported separation. Multiple logistic regression showed that family separation was not associated with being time-stressed, but separation from at least one child was associated with adverse mental health (OR = 3.53, 95% CI = [1.23, 10.11]). In conclusion, family separation primarily contributes to adverse mental health among refugees from the Middle East and Africa resettled in North Rhine-Westphalia, Germany. Therefore, policies and practices that facilitate family reunification can contribute significantly to the promotion of refugees' mental health and well-being.

Body mass index and associated factors among refugees living in North Rhine-Westphalia, Germany: a cross-sectional study.

BACKGROUND: This study aims to determine: (i) information on overweight and obesity, represented by body mass index using measured anthropometric data, among refugees living in North Rhine-Westphalia, Germany, (ii) how body mass index changed throughout the migratory journey to Germany, and (iii) factors influencing body mass index. METHODS: The study utilizes data from the FlueGe health study, a cross-sectional study conducted by Bielefeld University. The data was collected between February and November 2018 in which participants were recruited in several cities in North Rhine-Westphalia (N = 326). We analyzed differences in body mass index before the escape, upon arrival, and since arrival as well as correlations between body mass index since arrival and explanatory variables using linear regression models. RESULTS: The overall prevalence of overweight and obesity before the escape (t0), upon arrival (t1) and since arrival (t2) were 55.2% (150/272), 45.6% (133/292) and 54.8% (171/312), respectively, with 16.2% (44/272), 12.0% (35/292) and 16.0% (50/312) being obese. There was a significant change between t0 and t1 (p < 0.001), and between t1 and t2 (p < 0.001), but no change over time (between t0 and t2, p = 0.713). Results from multivariate linear regression showed that high education, male sex, higher body mass index before the escape, Iranian or Iraqi nationality, and sobriety were the significant factors for body mass index since arrival. However, when focusing on those who have reported weight gain only, higher body mass index before the escape, male sex, and Iraqi nationality were the significant factors. CONCLUSIONS: Overweight and obesity were common among refugees after settlement in Germany. In particular, sociodemographic factors were associated with a higher body mass index since arrival. Thus, it is important to develop and apply nutrition-related intervention programs for adult refugees that are culturally appropriate and tailored to education level and sex.

Association between Infant and Young Child Feeding (IYCF) Indicators and the Nutritional Status of Children (6-23 Months) in Northern Ghana.

Although recommended infant and young child feeding (IYCF) practices have been found to be protective against undernutrition in some settings, there is no finality yet due to inconsistencies in the literature. A cross-sectional survey of 581 mother-child pairs was conducted in northern Ghana in June 2018. The association between IYCF indicators and child undernutrition (stunting and wasting) were assessed. The descriptive analysis showed that 66.4% of the children (6-23 months) were introduced to complementary feeding in a timely manner, 69.4% met the minimum meal frequency, and 38.9% met the minimum acceptable diet daily. The prevalence of stunting, wasting, underweight and overweight was 33.2%, 14.1%, 27% and 2.6%, respectively. From the multivariable binary logistic regression, child gender, child age group and source of power for lighting the household were significantly associated with wasting. Intake of iron-rich foods, child age group, and maternal height were significantly associated with stunting after adjusting for confounders. The prevalence of the compliance with IYCF indicators was relatively high. None of the individual IYCF indicators showed significant association with undernutrition, except intake of iron-rich foods for stunting. Nutrition-specific interventions targeted at improving IYCF practices, dietary diversification and intake of nutrient-rich meals, should be adopted and scaled up to address undernutrition in northern Ghana.

Dietary habits and the 10-year risk of overweight and obesity in urban adult population: A cohort study predicated on Yazd Healthy Heart Project.

BACKGROUND AND OBJECTIVE: Overweight and obesity are thought to be associated with increased risk of chronic disease in the Middle East. The present study aimed to determine the association between dietary habits and the incidence of overweight and obesity in urban adult population in the central part of Iran after a 10-year follow-up. METHODS: This cohort study was initiated with 2000 participation aged 20-74 years from Yazd city in Iran based on Yazd Healthy Heart Project (YHHP). The participants without overweight and obesity at the baseline of the study were followed up to 10 years. Demographic data, anthropometric measurements, behavioral and metabolic risk factors of cardiovascular diseases and dietary habits were assessed at baseline and phase II. RESULTS: After a 10-year follow up, 516 non-overweight and 1068 non-obese participants were included for the final analysis. Once adjustments were made for all potential confounders including age, sex, smoking, economic status, physical activity and education, it was identified that lack of weight control increased the risk of obesity (hazard ratio; 95% CI) in total population (1.9; 1.06, 3.4), as well as the risk of overweight (2.39; 1.07, 5.27) and obesity (2.65; 1.13, 6.25) in men. Moreover, consumption of mayonnaise increased the 10-year risk of overweight in women (6.09; 1.2, 30.99). CONCLUSIONS: As revealed by the present study, unhealthy dietary habits can increase the incidence of overweight and obesity in central part of Iran. Therefore, changing the lifestyle appears to be urgent in reducing the risk of overweight and obesity.

The Prevalence of Violent Behavior among Lebanese University Students: Association with Behavioral and Mental Health Factors.

OBJECTIVES: We estimated the prevalence of 2 key violent behaviors (weapons carrying and physical fighting), determined the health risk correlates of violent behavior, such as current tobacco smoking, alcohol binge drinking, and having multiple sexual partners, and investigated the potential mental health factors related to violent behavior among Lebanese university students. METHODS: Using a cross-sectional design, data were collected from 450 Lebanese university students based on proportionate cluster sampling. Various health and behavioral risk factors were considered for the analyses. RESULTS: The overall prevalence of weapon carrying and physical fighting was reported at 12.7% and 19.1%, respectively. Males reported more violent behavior than females; weapon carrying (20.7% vs 5.2%, p < .001), and physical fighting (31.8% vs 7.3%, p < .001). Students who engaged in violent behaviors were more likely to have risky health behaviors than those who were not involved in violent behaviors. Religiosity had a significant protective effect against engaging in physical fighting after adjusting for socio-demographic factors. CONCLUSIONS: This study bridges the gap in the literature about violent behavior among emerging adults in Lebanon. There is a need to monitor weapon carrying by university students especially in a volatile setting like Lebanon.

Heterogeneity in coverage for measles and varicella vaccination in toddlers - analysis of factors influencing parental acceptance.

BACKGROUND: In 2004, routine varicella vaccination was introduced in Germany for children aged 11-14 months. Routine measles vaccination had already been introduced in 1973 for the same age group, but coverage is still too low (<95%) in some areas to eliminate measles. The present study assessed varicella and measles vaccination coverage and determinants of parental acceptance in two study regions, situated in Northern and Southern Bavaria (Germany). METHODS: From 2009 to 2011, annual cross-sectional parent surveys were performed on random samples of 600 children aged 18-36 months in the Bavarian regions of both Munich and Würzburg. Logistic regression models were used to identify factors associated with varicella and measles vaccination. RESULTS: In 2009, 2010 and 2011, vaccination coverage was lower in Munich than in Würzburg, for both varicella (Munich 53%, 67%, 69% vs. Würzburg 72%, 81%, 83%) and for measles (Munich 88%, 89%, 91% vs. Würzburg 92%, 93%, 95%). Recommendation by the physician was the main independent factor associated with varicella vaccination in both regions (adjusted odd ratios (OR) with 95% confidence interval (CI): Munich OR 19.7, CI 13.6-28.6; Würzburg OR 34.7, CI 22.6-53.2). Attendance at a childcare unit was positively associated with a higher acceptance of varicella vaccination in Munich (OR 1.5, CI 1.1-2.2). Regarding measles vaccination, attendance at a childcare unit was positively associated in both regions (Munich OR 2.0; CI 1.3-3.0; Würzburg OR 1.8; CI 1.1-3.1), and a higher level of parental school education was negatively associated in Würzburg (OR 0.5, CI 0.3-0.9). CONCLUSIONS: Vaccination rates differed between regions, with rates constantly higher in Würzburg. Within each region, vaccination rates were lower for varicella than for measles. Measles vaccination status was mainly dependent upon socio-demographic factors (attendance at a childcare unit, parental school education), whereas for the more recently introduced varicella vaccination recommendation by the physician had the strongest impact. Hence, different strategies are needed to further improve vaccination rates for both diseases.

Chemical characterization and sources of personal exposure to fine particulate matter (PM2.5) in the megacity of Guangzhou, China.

Concurrent ambient and personal measurements of fine particulate matter (PM2.5) were conducted in eight districts of Guangzhou during the winter of 2011. Personal-to-ambient (P-C) relationships of PM2.5 chemical components were determined and sources of personal PM2.5 exposures were evaluated using principal component analysis and a mixed-effects model. Water-soluble inorganic ions (e.g., SO42-, NO3-, NH4+, C2O42-) and anhydrosugars (e.g., levoglucosan, mannosan) exhibited median personal-to-ambient (P/C) ratios < 1 accompanied by strong P-C correlations, indicating that these constituents in personal PM2.5 were significantly affected by ambient sources. Conversely, elemental carbon (EC) and calcium (Ca2+) showed median P/C ratios greater than unity, illustrating significant impact of local traffic, indoor sources, and/or personal activities on individual's exposure. SO42- displayed very low coefficient of divergence (COD) values coupled with strong P-C correlations, implying a uniform distribution of SO42- in the urban area of Guangzhou. EC, Ca2+, and levoglucosan were otherwise heterogeneously distributed across individuals in different districts. Regional air pollution (50.4 ± 0.9%), traffic-related particles (8.6 ± 0.7%), dust-related particles (5.8 ± 0.7%), and biomass burning emissions (2.0 ± 0.2%) were moderate to high positive sources of personal PM2.5 exposure in Guangzhou. The observed positive and significant contribution of Ca2+ to personal PM2.5 exposure, highlighting indoor sources and/or personal activities, were driving factors determining personal exposure to dust-related particles. Considerable discrepancies (COD values ranging from 0.42 to 0.50) were shown between ambient concentrations and personal exposures, indicating caution should be taken when using ambient concentrations as proxies for personal exposures in epidemiological studies.

Secondhand smoke exposure at home among middle and high school students in the United States - does the type of tobacco product matter?

BACKGROUND: A decline in the prevalence of secondhand smoke (SHS) exposure has been observed in the United States of America (USA) during the past few decades. Nevertheless, nearly half of non-smoking students are still exposed to SHS. This paper aims to describe the factors associated with SHS exposure stratified by type of exposure (overall, cigarettes and electronic cigarettes). METHODS: The analysis is based on secondary data taken from the National Youth Tobacco Survey 2014. Overall, 22,007 middle and high school students from the USA are included in the sample. Descriptive and bivariate statistics as well as binary logistic regression models were performed. RESULTS: Overall, 44.5% (n=9,798) of the study participants declared themselves to be exposed to SHS, 29.1% (n=6,394) declared to be exposed to SHS caused by cigarette smoke and 9.4% (n=2,067) claimed that a person who lives with them uses electronic cigarettes. There is a considerable overlap between the two types of SHS exposure, because 74.9% (n=1,548) of students declaring that a person within their household uses electronic cigarettes also declare a person in the household smoking cigarettes. The strengths of association between independent variables and SHS exposure differs by type of exposure and also by smoking status of respondents. CONCLUSIONS: Although only small differences are obvious in the factors associated with SHS exposure stratified by the type of tobacco product, there are still some variations which should be considered in policy making to allow for a targeted approach in prevention campaigns or legislation.

Suicidal ideation and planning among Palestinian middle school students living in Gaza Strip, West Bank, and United Nations Relief and Works Agency (UNRWA) camps.

The goal of this study was to identify the prevalence and correlates of suicidal thinking among Palestinian middle school students by using complex samples analysis to explore data about suicidal ideation and suicidal planning in the past year from 14,303 students in grades 7, 8, and 9 (roughly ages 13-15 years) who participated in the Global School-based Student Health Survey (GSHS) in 2010 in the Occupied Palestinian Territory (OPT) and United Nations Relief and Works Agency (UNRWA) refugee camps. We also analyzed data from the seven other GSHS-participating countries from the Eastern Mediterranean region: Iraq, Jordan, Kuwait, Lebanon, Morocco, Tunisia, and the United Arab Emirates. The overall prevalence of suicidal ideation and/or planning was 25.6%. Males were more likely than females to report suicidal thinking. The health behaviors and exposures most strongly associated with suicidal thinking were marijuana use, having no close friends, tobacco use, loneliness, worry-induced insomnia, food insecurity, and being the victim of a bully. Being involved in physical fights and attacks, skipping school, and perceptions of limited parental support were also associated with suicidal thinking. The prevalence of suicidal thinking among Palestinian adolescents was higher than the rates in the other GSHS-participating countries, pointing toward a need for improved access to adolescent mental health services.

Characterization of ambient-generated exposure to fine particles using sulfate as a tracer in the Chinese megacity of Guangzhou.

Total personal exposures can differ from the concentrations measured at stationary ambient monitoring sites. To provide further insight into factors affecting exposure to particles, chemical tracers were used to separate total personal exposure into its ambient and non-ambient components. Simultaneous measurements of ambient and personal exposure to fine particles (PM2.5) were conducted in eight districts of Guangzhou, a megacity in South China, during the winter of 2011. Considerable significant correlations (Spearman's Rho, rs) between personal exposures and ambient concentrations of sulfate (SO42-; rs>0.68) were found in contrast to elemental carbon (EC; rs>0.37). The average fraction of personal SO42- to ambient SO42- resulting in an adjusted ambient exposure factor of α=0.72 and a slope of 0.73 was determined from linear regression analysis when there were minimal indoor sources of SO42-. From all data pooled across the districts, the estimated average ambient-generated and non-ambient-generated exposure to PM2.5 were 55.3µg/m3 (SD=23.4µg/m3) and 18.1µg/m3 (SD=29.1µg/m3), respectively. A significant association was found between ambient-generated exposure and ambient PM2.5 concentrations (Pearson's r=0.51, p<0.001). As expected, the non-ambient generated exposure was not related to the ambient concentrations. This study highlights the importance of both ambient and non-ambient components of total personal exposure in the megacity of Guangzhou. Our results support the use of SO42- as a tracer of personal exposure to PM2.5 of ambient origin in environmental and epidemiological studies.

Alcohol consumption among university students: a Sino-German comparison demonstrates a much lower consumption of alcohol in Chinese students.

BACKGROUND: Alcohol use is reported in university students with discrepancy between countries. The study objectives were to assess prevalence and associated factors of alcohol consumption among university students in Germany and China. METHODS: Data used were from 1853 Chinese and 3306 German university students. Alcohol consumption frequency was measured by a question "How often did you drink alcohol in the last three months?" with six possible responses, which were later collapsed into three categories of "At least once a week", "Less than once a week" and "Never". Problem drinking was measured by the CAGE test and defined as a CAGE score of two or more (four as the maximum). Simple and multivariable logistic regressions were used for association analyses. RESULTS: German students reported more often "At least once a week" drinking (59.8 vs. 9.0 %). Among Germans, women drank less often "At least once a week" (OR = 0.40, 0.30-0.53). Among Chinese, a higher BMI was associated with drinking "At least once a week" (OR = 1.09, 1.02-1.18). Age revealed a positive association with "At least once a week" drinking in Chinese (1.33, 1.21-1.46) but a negative association in Germans (OR = 0.97, 0.94-0.99). Having a father with high educational level was positively related to "At least once a week" drinking in both countries (OR = 4.25, 2.67-6.78 for Chinese; OR = 1.32, 1.01-1.72 for Germans). Doing less than once a week physical exercise was negatively associated with "At least once a week" drinking in Chinese and German students (OR = 0.27, 0.15-0.48 for Chinese; OR = 0.69, 0.49-0.96 for Germans). Among the German students, 20.3 % reported problem drinking. Being a female (OR = 0.32, 0.26-0.40) and performing less than once a week physical activity (OR = 0.73, 0.56-0.95) were negatively associated with problem drinking, while having a father with high educational level (OR = 1.32, 1.09-1.60) and experiencing higher level of perceived stress (OR = 1.08, 1.04-1.13) were positively related to problem drinking. CONCLUSIONS: Country-specific strategies for reducing alcohol consumption, e.g. educational awareness programmes of alcohol use on Chinese campuses and alcohol prevention schemes among German youth before entering university, are sensible.

Barriers and Strategies in Guideline Implementation-A Scoping Review.

Research indicates that clinical guidelines are often not applied. The success of their implementation depends on the consideration of a variety of barriers and the use of adequate strategies to overcome them. Therefore, this scoping review aims to describe and categorize the most important barriers to guideline implementation. Furthermore, it provides an overview of different kinds of suitable strategies that are tailored to overcome these barriers. The search algorithm led to the identification of 1659 articles in PubMed. Overall, 69 articles were included in the data synthesis. The content of these articles was analysed by using a qualitative synthesis approach, to extract the most important information on barriers and strategies. The barriers to guideline implementation can be differentiated into personal factors, guideline-related factors, and external factors. The scoping review revealed the following aspects as central elements of successful strategies for guideline implementation: dissemination, education and training, social interaction, decision support systems and standing orders. Available evidence indicates that a structured implementation can improve adherence to guidelines. Therefore, the barriers to guideline implementation and adherence need to be analysed in advance so that strategies that are tailored to the specific setting and target groups can be developed.

Sense of coherence and associated factors among university students in China: cross-sectional evidence.

BACKGROUND: Sense of Coherence (SOC) is considered as a health-promoting resource; it is mainly developed before the age of 30. The multiple demands university students face, such as study-related stress and financial difficulty, could challenge their SOC development. This study aimed to: 1) investigate the association between SOC, socio-demographic and lifestyle-related characteristics; 2) assess the effect of perceived stress on SOC controlling for other variables among the Chinese university students. Analyses were done to derive a better view on possible strategies to strengthen students' SOC and with that to promote their health. METHODS: The data used were from a Chinese university student health survey (N = 1,853). Logistic regression analyses were used to explore the effects of varied socio-demographic, lifestyle-related variables on students' level of SOC, as well as the association between perceived stress and SOC controlling for other variables in the analysis. RESULTS: Both social support (OR = 2.56 [1.87-3.50]) and better performance compared with peers (OR = 1.64 [1.15-2.34]) were associated with a stronger SOC. Not feeling isolated at university (OR = 1.60 [1.04-2.47]) and satisfaction with the political situation (OR = 2.05 [1.57-2.67]) were also associated with a stronger SOC. This counts also for high health awareness (OR = 1.40 [1.05-1.87]) and nutrition importance (OR = 1.67 [1.04-2.69]). Perceived stress (OR = 0.81 [0.79-0.83]) was negatively associated with a strong SOC when controlling for socio-demographic and lifestyle-related variables. CONCLUSION: We suggest integrating stress coping, emotion management training programmes as well as measures promoting social integration for students and teachers at campus, promoting healthy behaviours, and creating a supportive learning environment as strategies for enhancing the SOC level of university students in China.

Factors associated with secondhand smoke exposure in different settings: Results from the German Health Update (GEDA) 2012.

BACKGROUND: The ubiquity of secondhand smoke (SHS) exposure at home or in private establishments, workplaces and public areas poses several challenges for the reduction of SHS exposure. This study aimed to describe the prevalence of SHS exposure in Germany and key factors associated with exposure. Results were also differentiated by place of exposure. METHODS: A secondary data analysis based on the public use file of the German Health Update 2012 was conducted (n = 13,933). Only non-smokers were included in the analysis. In a multivariable logistic regression model the factors associated with SHS exposure were calculated. In addition, a further set of multivariable logistic regressions were calculated for factors associated with the place of SHS exposure (workplace, at home, bars/discotheques, restaurants, at the house of a friend). RESULTS: More than a quarter of non-smoking study participants were exposed to SHS. The main area of exposure was the workplace (40.9 %). The multivariable logistic regression indicated young age as the most important factor associated with SHS exposure. The odds for SHS exposure was higher in men than in women. The likelihood of SHS exposure decreased with higher education. SHS exposure and the associated factors varied between different places of exposure. CONCLUSIONS: Despite several actions to protect non-smokers which were implemented in Germany during the past years, SHS exposure still remains a relevant risk factor at a population level. According to the results of this study, particularly the workplace and other public places such as bars and discotheques have to be taken into account for the development of strategies to reduce SHS exposure.