RESUMEN
BACKGROUND: Population-level factors within and beyond the scope of the World Health Organization's (WHO) MPOWER policy package have significant impacts on smoking rates. However, no synthesis of the existing evidence exists. This systematic review identifies population-level factors that influence cigarette smoking rates in European countries. METHODS: We searched the ProQuest database collection for original, peer-reviewed quantitative evaluations that investigated the effects of population-level exposures on smoking rates in European countries. Of the 3122 studies screened, 62 were ultimately included in the review. A standardized data extraction form was used to identify key characteristics of each study including publication year, years evaluated, countries studied, population characteristics, study design, data sources, analytic methods, exposure studied, relevant covariates and effects on tobacco smoking outcomes. RESULTS: One hundred and fifty-five population-level exposures were extracted from the 62 studies included in the review, 99 of which were related to WHO MPOWER measures. An additional 56 exposures fell into eight policy realms: economic crises, education policy, macro-economic factors, non-MPOWER tobacco regulations, population welfare, public policy, sales to minors and unemployment rates. About one-half of the MPOWER exposures affected smoking rates (55/99) and did so in an overwhelmingly positive way (55/55). Over three-quarters of the non-MPOWER exposures were associated with statistically significant changes in smoking outcomes (43/56), with about two-thirds of these exposures leading to a decrease in smoking (29/43). CONCLUSIONS: Population-level factors that fall outside of the WHO's MPOWER measures are an understudied research area. The impacts of these factors on tobacco control should be considered by policymakers.
RESUMEN
Although the theory and methods of legal epidemiology-the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury in a population-have been well developed in the context of domestic law, the challenges posed by shifting the frame of analysis to the global legal space have not yet been fully explored. While legal epidemiology rests on the foundational principles that law acts as an intervention, that law can be an object of scientific study and that law has impacts that should be evaluated, its application to the global level requires the recognition that international laws, policies and norms can cause effects independently from their legal implementation within countries. The global legal space blurs distinctions between 'hard' and 'soft' law, often operating through pathways of global agenda setting, legal language, political pressures, social mobilisation and trade pressures to have direct impacts on people, places and products. Despite these complexities, international law has been overwhelmingly studied as operating solely through national policy change, with only one global quasi-experimental evaluation of an international law's impact on health published to date. To promote greater adoption of global legal epidemiology, we expand on an existing typology of public health law studies with examples of policymaking, mapping, implementation, intervention and mechanism studies. Global legal epidemiology holds great promise as a way to produce rigorous and impactful research on the international laws, policies and norms that shape our collective health, equity and well-being.
RESUMEN
BACKGROUND: A high burden of HIV in many sub-Saharan African countries has triggered renewed interest in volunteer-based community health programmes as a way to support treatment roll-out and to deliver services to children orphaned due to HIV. This study was undertaken as an evaluation of a USAID project implemented by a consortium of 7 NGOs operating in 52 Zambian districts. We aimed to examine motivations for becoming volunteer caregivers, experiences in service and commitment to continue volunteering in the future. METHODS: A mixed-method survey approach was adopted incorporating close- and open-ended questions. District selection (3 of 52) was purposive, based on representation of urban, peri-urban and rural volunteers from a mix of the consortium's NGO affiliates. Individual volunteer recruitment was achieved via group information sessions and opportunistic sampling was used to reach a quota (~300) per study district. All participants provided written informed consent. RESULTS: A total of 758 eligible caregivers were surveyed. Through parallel analyses of different data types and cross-over mixed analyses, we found shifting patterns in motivations across question type, question topic and question timing. In relation to motivations for entering service, responses to both open- and close-ended questions highlighted the importance of value-oriented functions and higher order social aspirations such as "helping society" or "humanity". However, 70% of participants also agreed to at least one close-ended economic motivation statement and nearly a quarter (23%) agreed to all four. Illustrating economic need, as well as economic motivation, over half (53%) the study respondents agreed that they had become a volunteer because they needed help from the project. Volunteers with lower and mid-level standard-of-living scores were significantly more likely to agree with economic motivation statements. CONCLUSIONS: Reliance by national and international health programmes on volunteer workforces is rooted in the assumption that volunteers are less costly and thus more sustainable than maintaining a professional cadre of community health workers. Understanding individuals' motivations for entering and remaining in volunteer service is therefore critical for programme planners and policy makers. This study demonstrated that volunteers had complex motivations for entering and continuing service, including "helping" and other pro-social values, but also manifest expectations of and need for material support. These findings contribute to evidence in support of various reforms needed to strengthen the viability and sustainability of volunteer-dependent services including the need to acknowledge and plan for the economic vulnerability of so-called volunteer recruits.