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.

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.

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.

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.

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.

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.

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.

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.

Prevalence and determinants of secondhand smoke exposure among women in Bangladesh, 2011.

BACKGROUND AND OBJECTIVES: The population of Bangladesh is highly susceptible to secondhand smoke (SHS) exposure due to high smoking rates and low awareness about the harmful effects of SHS. This study aims to determine the prevalence of SHS exposure and highlight the essential determinants in developing successful strategies to prevent adverse health effects in Bangladesh. METHODS: The analysis is based on the Bangladesh Demographic Health Survey 2011, in which 17,749 women in the reproductive age group (12-49 years) were included. The information regarding SHS exposure at home was derived from the question: "How often does anyone smoke inside your house?" The variable was recoded into 3 groups: daily exposure, low exposure (exposed weekly, monthly, or less than monthly), and no SHS exposure. We performed descriptive and bivariable analyses and multinomial logistic regression. RESULTS: A total of 46.7% of the women reported high exposure to SHS at home. According to the multinomial logistic regression model, relatively lower education and lower wealth index were significantly associated with daily SHS exposure at home. The exposure differed significantly between the divisions of Bangladesh. Having children at home (vs. not) and being Islamic (compared to other religious affiliations) were protective factors. CONCLUSIONS: The study indicates that women from socioeconomically disadvantaged households are more likely to experience daily exposure to SHS at home. Therefore, especially these groups have to be targeted to reduce tobacco consumption. In addition to aspects of legislation, future strategies need to focus educational aspects to improve the population's health status in Bangladesh.

Meta-analysis of the association between second-hand smoke exposure and ischaemic heart diseases, COPD and stroke.

BACKGROUND: Second-hand smoke (SHS) is the most important contaminant of indoor air in first world countries. The risks associated with SHS exposure are highly relevant, because many people are regularly, and usually involuntarily, exposed to SHS. This study aims to quantify the effects of SHS exposure. Therefore, its impact on ischaemic heart diseases (IHD), chronic obstructive pulmonary diseases (COPD) and stroke will be considered. METHODS: A systematic literature review was conducted to identify articles dealing with the association between SHS and the three outcomes IHD, COPD and stroke. Overall, 24 articles were included in a meta-analysis using a random effects model. Effect sizes stratified for sex and for both sexes combined were calculated. RESULTS: The synthesis of primary studies revealed significant effect sizes for the association between SHS exposure and all three outcomes. The highest RR for both sexes combined was found for COPD (RR = 1.66, 95 % CI: 1.38-2.00). The RR for both sexes combined was 1.35 (95 % CI: 1.22-1.50) for stroke and 1.27 (95 % CI: 1.10-1.48) for IHD. The risks were higher in women than in men for all three outcomes. CONCLUSIONS: This is the first study to calculate effect sizes for the association between SHS exposure and the disease outcomes IHD, COPD, and stroke at once. Overall, the effect sizes are comparable with previous findings in meta-analyses and therefore assumed to be reliable. The results indicate the high relevance of public health campaigns and legislation to protect non-smokers from the adverse health effects attributable to SHS exposure.

High HIV prevalence and risk of infection among rural-to-urban migrants in various migration stages in China: a systematic review and meta-analysis.

BACKGROUND: Rural-to-urban migrants represent 17% of the total Chinese population and are considered a potential high-risk bridging population of HIV infection between urban and rural China. METHOD: Based on a systematic review and meta-analysis, this study determined HIV prevalence among rural-to-urban migrants in different stages of migration. This review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: We identified 54 studies reporting 59 HIV prevalence levels among rural-to-urban migrants in China. Overall, 53.4% (95% confidence interval, 33.5%-72.4%) of urban patients with HIV have migratory background. The floating-out population showed a higher HIV prevalence (0.15% [0.06%-0.34%]) than did the Chinese population (0.057%; odds ratio, 2.63 [1.35-5.14]). The floating-in population showed a higher HIV prevalence (0.38% [0.29%-0.50%]), corresponding to 6.70 (6.05-7.41) times greater odds of HIV infection. Higher prevalence levels were observed among female migrants (0.69% [0.51%-0.93%]), reflecting a much higher odds of HIV infection (12.18 [11.11-13.35]). Infection risk among returning migrants (0.18% [0.12%-0.29%]) was 3.16 (2.06-4.84) times higher than the overall Chinese population. Chinese internal migrants contribute to a substantial amount of the overall HIV epidemic in China. CONCLUSION: Migrants are at greater risk for HIV infection than the general Chinese population and likely to facilitate the geographical spread of HIV in China. Targeted strategies for health promotion and HIV prevention for migrants in China should be developed.

Quantifying the burden of disease due to premature mortality in Hong Kong using standard expected years of life lost.

BACKGROUND: To complement available information on mortality in a population Standard Expected Years of Life Lost (SEYLL), an indicator of premature mortality, is increasingly used to calculate the mortality-associated disease burden. SEYLL consider the age at death and therefore allow a more accurate view on mortality patterns as compared to routinely used measures (e.g. death counts). This study provides a comprehensive assessment of disease and injury SEYLL for Hong Kong in 2010. METHODS: To estimate the SEYLL, life-expectancy at birth was set according to the 2004 Global Burden of Disease study at 82.5 and 80 years for females and males, respectively. Cause of death data for 2010 were corrected for misclassification of cardiovascular and cancer causes. In addition to the baseline estimates, scenario analyses were performed using alternative assumptions on life-expectancy (Hong Kong standard life-expectancy), time-discounting and age-weighting. To estimate a trend of premature mortality a time-series analysis from 2001 to 2010 was conducted. RESULTS: In 2010 524,706.5 years were lost due to premature death in Hong Kong with 58.3% of the SEYLL attributable to male deaths. The three overall leading single causes of SEYLL were "trachea, bronchus and lung cancers", "ischaemic heart disease" and "lower respiratory infections" together accounting for about 29% of the overall SEYLL. Further, self-inflicted injuries (5.6%; ranked 5) and liver cancer (4.9%; ranked 7) were identified as important causes not adequately captured by classical mortality measures. Scenario analyses highlighted that by using a 3% time-discount rate and non-uniform age-weights the SEYLL dropped by 51.6%. Using Hong Kong's standard life-expectancy values resulted in an overall increase of SEYLL by 10.8% as compared to the baseline SEYLL. Time-series analysis indicates an overall increase of SEYLL by 6.4%. In particular, group I (communicable, maternal, perinatal and nutritional) conditions showed highest increases with SEYLL-rates per 100,000 in 2010 being 1.4 times higher than 2001. CONCLUSIONS: The study stresses the mortality impact of diseases and injuries that occur in earlier stages of life and thus presents the SEYLL measure as a more sensitive indicator compared to classical mortality indicators. SEYLL provide useful additional information and supplement available death statistics.

Spousal violence against women and its association with women's mental health in Pakistan.

In Pakistan, the issue of spousal violence is under-researched and still not considered a public health problem. To assess the association of spousal violence with women's mental health, a hospital-based cross-sectional survey was conducted through a structured interview schedule with 373 randomly selected ever-married women of reproductive age in eight randomly selected hospitals in the cities of Lahore and Sialkot, Pakistan. After controlling for sociodemographic variables, women's experiences of past and current psychological, physical, and sexual violence remained significantly associated with women's poor mental health. The situation warrants urgent action to mitigate the violence-induced damages done to women's mental health.

Mapping urban malaria and diarrhea mortality in Accra, Ghana: evidence of vulnerabilities and implications for urban health policy.

Historic increase in urban population numbers in the face of shrinking urban economies and declining social services has meant that a large proportion of the urban population lives in precarious urban conditions, which provide the grounds for high urban health risks in low income countries. This study aims to identify, investigate, and contrast the spatial patterns of vulnerability and risk of two major causes of mortality, viz malaria and diarrhea mortalities, in order to optimize resource allocation for effective urban environmental management and improvement in urban health. A spatial cluster analysis of the observed urban malaria and diarrhea mortalities for the whole city of Accra was conducted. We obtained routinely reported mortality data for the period 1998-2002 from the Ghana Vital Registration System (VRS), computed the fraction of deaths due to malaria and diarrhea at the census cluster level, and analyzed and visualized the data with Geographic Information System (GIS, ArcMap 9.3.1). Regions of identified hotspots, cold spots, and excess mortalities were observed to be associated with some socioeconomic and neighborhood urban environmental conditions, suggesting uneven distribution of risk factors for both urban malaria and diarrhea in areas of rapid urban transformation. Case-control and/or longitudinal studies seeking to understand the individual level factors which mediate socioenvironmental conditions in explaining the observed excess urban mortalities and to establish the full range of risk factors might benefit from initial vulnerability mapping and excess risk analysis using geostatistical approaches. This is key to evidence-based urban health policy reforms in rapidly urbanizing areas in low income economies.

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.

A spatial epidemiological analysis of self-rated mental health in the slums of Dhaka.

BACKGROUND: The deprived physical environments present in slums are well-known to have adverse health effects on their residents. However, little is known about the health effects of the social environments in slums. Moreover, neighbourhood quantitative spatial analyses of the mental health status of slum residents are still rare. The aim of this paper is to study self-rated mental health data in several slums of Dhaka, Bangladesh, by accounting for neighbourhood social and physical associations using spatial statistics. We hypothesised that mental health would show a significant spatial pattern in different population groups, and that the spatial patterns would relate to spatially-correlated health-determining factors (HDF). METHODS: We applied a spatial epidemiological approach, including non-spatial ANOVA/ANCOVA, as well as global and local univariate and bivariate Moran's I statistics. The WHO-5 Well-being Index was used as a measure of self-rated mental health. RESULTS: We found that poor mental health (WHO-5 scores < 13) among the adult population (age ≥15) was prevalent in all slum settlements. We detected spatially autocorrelated WHO-5 scores (i.e., spatial clusters of poor and good mental health among different population groups). Further, we detected spatial associations between mental health and housing quality, sanitation, income generation, environmental health knowledge, education, age, gender, flood non-affectedness, and selected properties of the natural environment. CONCLUSIONS: Spatial patterns of mental health were detected and could be partly explained by spatially correlated HDF. We thereby showed that the socio-physical neighbourhood was significantly associated with health status, i.e., mental health at one location was spatially dependent on the mental health and HDF prevalent at neighbouring locations. Furthermore, the spatial patterns point to severe health disparities both within and between the slums. In addition to examining health outcomes, the methodology used here is also applicable to residuals of regression models, such as helping to avoid violating the assumption of data independence that underlies many statistical approaches. We assume that similar spatial structures can be found in other studies focussing on neighbourhood effects on health, and therefore argue for a more widespread incorporation of spatial statistics in epidemiological studies.

Primary health care physicians' response to the victims of spousal violence against women in Pakistan.

In this article we investigates the primary care physicians' response to the victims of spousal violence in Pakistan. By drawing upon the data collected by in-depth interviews from 24 physicians from Lahore and Sialkot, in this research we documented their knowledge, attitudes, and behavior treating the victims of violence. Data revealed that the physicians lacked competence, training, and resources to provide comprehensive care to the victims and relied on a reductionist biomedical model. While identifying some barriers that inhibited the physicians' ability to help the victims, in this article we offer some recommendations for the improvement of physicians' response to spousal violence within Pakistan's cultural context.

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.