Understanding worldwide youth attitudes towards smoke-free policies: an analysis of the Global Youth Tobacco Survey.

BACKGROUND: Smoke-free policies (SFPs) in public places are increasing globally, but developing countries are lagging behind. Understanding youth attitudes towards SFPs can inform SFP initiatives. METHODS: A multilevel logistic regression analysis of data collected from youth aged 13-15 years (2000-2006) who completed the Global Youth Tobacco Survey (GYTS) in 115 countries, primarily in the developing world, was conducted. The analysis examined relationships between support for SFPs and individual-level measures related to smoking status, and exposure to secondhand smoke (SHS), controlling for demographic and environmental factors of interest and country-level policy factors. RESULTS: In all, 77.3% of 356,395 youth in 115 countries favoured SFPs, including majorities of non-smokers (78.7%) and smokers (63.6%). In the multivariable analysis knowledge of smoke harm was the strongest predictor of favouring SFPs (OR 2.42, 95% CI 2.27 to 2.67). Exposure to countermarketing (OR 1.40, 95% CI 1.25 to 1.57) and school anti-smoking education (OR 1.22, 95% CI 1.13 to 1.31) were also positively associated. Current smoking (OR 0.48, 95% CI 0.41 to 0.53), susceptibility to smoking (OR 0.46, 95% CI 0.40 to 0.52) and exposure to tobacco promotion were negatively associated. Significant country-level variation was observed. The presence of any national smoke-free legislation in a country was positively associated with youth favouring such policies. CONCLUSIONS: The majority of youth worldwide support, yet lack, smoke-free policies in public places, while being regularly exposed to SHS. Youth support of SFPs is most positively associated with knowledge of the harmful effects of tobacco smoke. Redoubling education efforts represents an opportunity to establish smoke-free environments and improve health of children in developing countries.

Improving Breast Cancer Control via the Use of Community Health Workers in South Africa: A Critical Review.

Breast cancer is a growing concern in low- and middle-income countries (LMCs). We explore community health worker (CHW) programs and describe their potential use in LMCs. We use South Africa as an example of how CHWs could improve access to breast health care because of its middle-income status, existing cancer centers, and history of CHW programs. CHWs could assume three main roles along the cancer control continuum: health education, screening, and patient navigation. By raising awareness about breast cancer through education, women are more likely to undergo screening. Many more women can be screened resulting in earlier-stage disease if CHWs are trained to perform clinical breast exams. As patient navigators, CHWs can guide women through the screening and treatment process. It is suggested that these roles be combined within existing CHW programs to maximize resources and improve breast cancer outcomes in LMCs.

The Boston Health Care for the Homeless Program: a public health framework.

During the past 25 years, the Boston Health Care for the Homeless Program has evolved into a service model embodying the core functions and essential services of public health. Each year the program provides integrated medical, behavioral, and oral health care, as well as preventive services, to more than 11 000 homeless people. Services are delivered in clinics located in 2 teaching hospitals, 80 shelters and soup kitchens, and an innovative 104-bed medical respite unit. We explain the program's principles of care, describe the public health framework that undergirds the program, and offer lessons for the elimination of health disparities suffered by this vulnerable population.

Implementing the cities readiness initiative: lessons learned from Boston.

The federally funded Cities Readiness Initiative (CRI) requires seamless federal, state, and local public health coordination to provide antibiotics to an entire city population within 48 hours of an aerosolized release of anthrax. We document practical lessons learned from the development and implementation of the Boston CRI plan. Key themes center on heightened emphasis on security, a new mass protection model of dispensing, neighborhood-centric clinic site selection, online training of Medical Reserve Corps volunteers, and the testing of operations through drills and exercises. Sharing such lessons can build national preparedness.

Regionalization of local public health systems in the era of preparedness.

Post-9/11, preparedness planning has catalyzed intrastate regionalization of local public health resources throughout the United States. Investigating this trend unveils several regionalization themes, relevant in other sectors of government, which are applicable to local public health. In this review article, we begin by briefly examining the lessons learned from regionalization for police and fire services, drawing comparisons to public health. Then we provide a brief history of the accelerating regionalization of local public health services sparked by the current attention to emergency preparedness. In particular, we offer case studies from Massachusetts and the National Capital Region to highlight examples of regionalization outcomes related to networking, coordination, standardization, and centralization of public health services. The impact of social capital on preparedness is also explored. Finally, we summarize research needs for the future.

A statewide public health approach to improving organ donation: the Massachusetts Organ Donation Initiative.

Despite the growing disparity between organ supply and demand in the United States, few initiatives have attempted to close the gap through systematic population-based public health endeavors. We examined the evolution, implementation, and outcomes of the Massachusetts Organ Donation Initiative, a statewide effort that included a unique partnership among organ procurement organizations, major teaching hospitals, and the state's department of public health. Lessons from this initiative have contributed to growing national efforts for increasing organ supply and have provided insights for addressing this continuing public health challenge.

The first decade of the Massachusetts Tobacco Control Program.

This article provides a comprehensive overview of the first decade of the Massachusetts Tobacco Control Program (MTCP). Born after Massachusetts passed a 1992 ballot initiative raising cigarette excise taxes to fund the program, MTCP greatly reduced statewide cigarette consumption before being reduced to a skeletal state by funding cuts. The article describes the program's components and goals, details outcomes, presents a summary of policy accomplishments, and reviews the present status of MTCP in the current climate of national and state fiscal crises. The first decade of the MTCP offers many lessons learned for the future of tobacco control.

A public health approach to reducing morbidity and mortality among homeless people in Boston.

Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.

Using public health data systems to understand and eliminate cancer disparities.

Identifying and eliminating social disparities in cancer depend upon the availability and ready use of public health surveillance data at the national, state and local levels. As an example of advancing a statewide research agenda in cancer disparities, we present descriptive statistics from major public health surveillance data systems in Massachusetts. Disparities highlighted include higher breast cancer mortality rates among African-American women than women of other racial groups, lower rates of colorectal and cervical cancer screening among Asian-American residents, and striking gradients in cancer risk factor prevalence and screening by income and education. Challenges in utilizing public health surveillance data include lack of information in many domains of social inequity beyond race/ethnicity, uneven quality, and lack of stable, reportable data for smaller populations. Opportunities to maximize the usefulness of cancer registry data include application of geographic information systems and linkage with other data systems tracking information on health services outcomes and clinical trial participation. Analyses of surveillance data can spark advances not only in community-based participatory research but also in programs and policies that may ultimately eliminate disparities along the cancer continuum.

Physical exposures during pregnancy and congenital cardiovascular malformations.

Congenital cardiovascular malformations (CCM) cause substantial neonatal morbidity and mortality. Known risk factors for CCM explain only 10-20% of all cases. Few studies have examined mothers' physical exposures during pregnancy and the risk of CCM in their offspring. This study examined the association between exposures to extreme temperatures, prolonged standing, and heavy lifting during early pregnancy and risk of CCM in offspring. Using a case-control study design, 502 cases and 1066 controls were drawn from the population of all liveborn infants born between January 1988 and June 1991 to mothers living in 14 counties in New York State. Cases were identified from a population-based registry of congenital malformations. Controls were randomly selected from birth certificate records. Interviews were conducted by telephone, using a structured questionnaire. Exposure estimates were based on women's self-reports of conditions in the residence and workplace. Eighty-three per cent of the mothers were white, and 66% were between 25 and 34 years old. After adjusting all results for known risk factors and confounding variables, we found no significant increased risk of CCM in subjects whose mothers reported being exposed during early pregnancy to extreme heat (OR = 1.13, 95% CI 0.59, 2.19), nor to extreme cold (OR = 1.19, 95% CI 0.66, 2.15). Mothers who reported ever using a hot tub, hot bath, or sauna during early pregnancy had no increased risk of CCM in their offspring (OR = 0.88, 95% CI 0.65, 1.18). Performing heavy lifting during early pregnancy did not increase the risk of CCM in offspring (OR = 0.80, 95% CI 0.57, 1.11). Prolonged standing during early pregnancy was not associated with an increased risk of CCM in children (OR = 1.03, 95% CI 0.82, 1.28). Thus if these maternal exposures have an adverse effect, it is unlikely to involve CCMs.