The Middle-Out Perspective: an approach to formalise 'normal practice' in public health advocacy.

AIMS: The middle-out perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle-out (rather than the top-down or bottom-up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. We argue that public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. The article aims to demonstrate this argument. METHODS: This article introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke-free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes. RESULTS: These case studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda. CONCLUSION: Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health.

Current issues in the impacts of transport on health.

Introduction or background: Transport affects health in many ways. Benefits include access to education, employment, goods, services and leisure, and opportunities for incorporating physical activity into daily living. There are major inequalities: benefits generally accrue to wealthier people and harms to the more deprived, nationally and globally. Sources of data: Health on the Move 2; Journal of Transport and Health. Areas of agreement: Benefits of travel for access and physical activity. Harms include health impacts of air and noise pollution; injuries and fatalities from falls or collisions; sedentary behaviour with motorized transport; community severance (barrier effect of busy roads and transport infrastructure); global climate change; impacts on inequalities; transport's role in facilitating spread of communicable diseases. Areas of controversy include: Biofuels; cycle safety; driving by older people. Growing points and areas for research include: Effects of default 20 mph speed limits; impacts of autonomous vehicles on health and inequalities.

Explanatory factors for health inequalities across different ethnic and gender groups: data from a national survey in England.

BACKGROUND: The objective of this study was to examine the relative contribution of factors explaining ethnic health inequalities (EHI) in poor self-reported health (pSRH) and limiting long-standing illness (LLI) between Health Survey for England (HSE) participants. METHOD: Using HSE 2003-2006 data, the odds of reporting pSRH or of LLI in 8573 Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Irish and Pakistani participants was compared with 28,470 White British participants. The effects of demographics, socioeconomic position (SEP), psychosocial variables, community characteristics and health behaviours were assessed using separate regression models. RESULTS: Compared with White British men, age-adjusted odds (OR, 95% CI) of pSRH were higher among Bangladeshi (2.05, 1.34 to 3.14), Pakistani (1.77, 1.34 to 2.33) and Black Caribbean (1.60, 1.18 to 2.18) men, but these became non-significant following adjustment for SEP and health behaviours. Unlike Black Caribbean men, Black African men exhibited a lower risk of age-adjusted pSRH (0.66, 0.43 to 1.00 (p=0.048)) and LLI (0.45, 0.28 to 0.72), which were significant in every model. Likewise, Chinese men had a lower risk of age-adjusted pSRH (0.51, 0.26 to 1.00 (p=0.048)) and LLI (0.22, 0.10 to 0.48). Except in Black Caribbean women, adjustment for SEP rendered raised age-adjusted associations for pSRH among Pakistani (2.51, 1.99 to 3.17), Bangladeshi (1.85, 1.08 to 3.16), Black Caribbean (1.78, 1.44 to 2.21) and Indian women (1.37, 1.13 to 1.66) insignificant. Adjustment for health behaviours had the largest effect for South Asian women. By contrast, Irish women reported better age-adjusted SRH (0.70, 1.51 to 0.96). CONCLUSIONS: SEP and health behaviours were major contributors explaining EHI. Policies to improve health equity need to monitor these pathways and be informed by them.

Changes in waist circumference among adolescents in England from 1977-1987 to 2005-2007.

OBJECTIVE: To assess change in abdominal obesity in adolescents in England. STUDY DESIGN: Health Survey for England (HSE), annual cross-sectional surveys of nationally representative samples in England. METHODS: This study included 1770 children aged 11-16 years in HSE 2005-2007 with valid waist circumference (WC) measurements. WC and body mass index (BMI) were expressed as standard deviation scores (z scores) against the growth references used for British children. RESULTS: Mean WC z scores were substantially higher than mean BMI z scores for both sexes: WC 1.0 [95% confidence interval (CI) 0.93-1.1], BMI 0.54 (95% CI 0.44-0.63) for boys; WC 1.3 (95% CI 1.2-1.4), BMI 0.48 (95% CI 0.40-0.56) for girls (both P < 0.001). Mean WC z score was higher for girls than boys (P < 0.001). Between 1997 and 2005-2007, WC increased for both boys (P < 0.01) and girls (P < 0.001), but BMI did not (P > 0.05). Only children in the lowest WC decile had an increase in WC z score less than +1 standard deviation compared with the 1977-1987 baseline. BMI z score increased across the top nine deciles of the BMI distribution by 0.4 (2nd-4th deciles) to 0.9 (top decile). CONCLUSIONS: WC in adolescents has increased substantially, and probably more than BMI. The whole population has become fatter.

Persistent regional variation in treatment of hypertension.

OBJECTIVES: To assess regional variation within England in the proportion of people with survey-defined hypertension who were on treatment, and hypothesize if this was due to chance or confounding. STUDY DESIGN: Data from three annual, cross-sectional health examination surveys, the Health Survey for England. METHODS: Nationally representative random samples of the free-living general population were visited by an interviewer and a nurse. Blood pressure was measured with an automated monitor using a standardized protocol (2005: n = 5321, 2006: n = 10,213, 2007: n = 4848). Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, and/or taking prescribed medication to lower blood pressure. RESULTS: In London, a higher proportion of participants with survey-defined hypertension were on anti-hypertensive medication in each separate year's sample compared with the rest of England [2005-2007 average: 61% men, 66% women in London; 43% men, 55% women in England (P for London vs rest of England <0.001 for each sex)]. Regression analysis showed that this regional effect [odds ratio (OR) 1.47 95% confidence interval (CI) 1.94-2.47, P = 0.031] was no longer significant after adjustment for demographic and socio-economic factors (OR 1.37, 95% CI 0.94-1.98, P = 0.101), but was strengthened (OR 1.69, 95% CI 1.09-2.60, P = 0.018) by including longstanding illness, diabetes, cardiovascular disease and health behaviours in the model. CONCLUSIONS: The proportion of hypertensive patients on anti-hypertensive medication was consistently above the national average in London, and this was associated with personal characteristics. Comorbidities increased the effect, even after adjustment for personal characteristics. This result may be due to greater population mobility in London, with more people having new patient health checks. Understanding this variation could enhance treatment nationally and internationally.

A review of health impact assessment frameworks.

BACKGROUND: Consideration of health impacts of non-health sector policies has been encouraged in many countries, with health impact assessment (HIA) increasingly used worldwide for this purpose. HIA aims to assess the potential impacts of a proposal and make recommendations to improve the potential health outcomes and minimize inequalities. Although many of the same techniques can be used, such as community consultation, engagement or profiling, HIA differs from other community health approaches in its starting point, purpose and relationship to interventions. Many frameworks have been produced to aid practitioners in conducting HIA. OBJECTIVE: To review the many HIA frameworks in a systematic and comparative way. STUDY DESIGN: Systematic review. METHOD: The literature was searched to identify published frameworks giving sufficient guidance for those with the necessary skills to be able to undertake an HIA. RESULTS: Approaches to HIA reflect their origins, particularly those derived from Environmental Impact Assessment (EIA). Early HIA resources tended to use a biomedical model of health and examine projects. Later developments were designed for use with policy proposals, and tended to use a socio-economic or environmental model of health. There are more similarities than differences in approaches to HIA, with convergence over time, such as the distinction between 'narrow' and 'broad' focus HIA disappearing. Consideration of health disparities is integral to most HIA frameworks but not universal. A few resources focus solely on inequalities. The extent of community participation advocated varies considerably. CONCLUSION: It is important to select an HIA framework designed for a comparable context, level of proposal and available resources.

The epidemiology of fractures in England.

INTRODUCTION: Fractures are a considerable public health burden in the United Kingdom but information on their epidemiology is limited. OBJECTIVE: This study aims to estimate the true annual incidence and lifetime prevalence of fractures in England, within both the general population and specific groups, using a self-report methodology. METHODS: A self-report survey of a nationally representative general population sample of 45,293 individuals in England, plus a special boost sample of 10,111 drawn from the ethnic minority population. RESULTS: The calculated fracture incidence is 3.6 fractures per 100 people per year. Lifetime fracture prevalence exceeds 50% in middle-aged men, and 40% in women over the age of 75 years. Fractures occur with reduced frequency in the non-white population: this effect is seen across most black and minority ethnic groups. CONCLUSIONS: This study suggests that fractures in England may be more common than previously estimated, with an overall annual fracture incidence of 3.6%. Age-standardised lifetime fracture prevalence is estimated to be 38.2%. Fractures are more commonplace in the white population.

What happens to medical students who complete an honours year in public health and epidemiology?

BACKGROUND: Around one-third of medical students in the UK take an intercalated honours degree in addition to their basic undergraduate course. The honours year has been reported to have a major influence on subsequent career choice; honours students show greater interest in research and laboratory medicine careers and less in general practice and public health.1,2 AIMS: To examine the career choice of Nottingham medical students who completed an honours year in public health and epidemiology (including general practice). METHODS: Postal questionnaire and telephone follow-up of a cohort of 266 students who entered the honours year in Public Health and Epidemiology between 1973 and 1993. RESULTS: Career information was available on 203 students; 78% (195) of those are currently employed in medicine. 44% were working in general practice (expected 40-45%) and 8% in public health medicine (expected 2%). Overall 19% (expected 4-11%) had chosen academic careers including nine of the 15 choosing an academic career in public health. The majority (60%) reported that the honours year had influenced their career choice, while 55% reported that the year had increased their likelihood of choosing an academic career. CONCLUSIONS: The honours year does encourage entry into academic and research careers in general and the type of honours year department strongly influences the subsequent choice of specialty.

Malaria in Brent: successful treatment in the community.

40 cases of malaria seen in an 18 month period were reviewed. The clinical diagnosis was made by the general practitioner or casualty officer in 85%, and 45% of these were treated and discharged without further referral. In an area where a high awareness of malaria exists, uncomplicated Plasmodium vivax infection can be treated safely in the community. Primaquine should be given for the exo-erythrocyte stage and patients screened for glucose-6-phosphate dehydrogenase deficiency before this.