Prevalence, trends and distribution of lifestyle cancer risk factors in Uganda: a 20-year systematic review.

BACKGROUND: Cancer is becoming an important public health problem in Uganda. Cancer control requires surveillance of lifestyle risk factors to inform targeted interventions. However, only one national Non-Communicable Disease (NCD) risk factor survey has been conducted in Uganda. This review assessed the prevalence, trends and distribution of lifestyle risk factors in Uganda. METHODS: The review identified studies up to January 2019 by searching Medline, Embase, CINAL and Cochrane databases. Further literature was identified from relevant websites and journals; scanning reference lists of relevant articles; and citation searching using Google Scholar. To be eligible, studies had to have been conducted in Uganda, and report prevalence estimates for at least one lifestyle cancer risk factor. Narrative and systematic synthesis was used to analyse the data. RESULTS: Twenty-four studies were included in the review. Overall, unhealthy diet (88%) was the most prevalent lifestyle risk factor for both males and females. This was followed by harmful use of alcohol (range of 14.3% to 26%) for men, and being overweight (range of 9% to 24%) for women. Tobacco use (range of 0.8% to 10.1%) and physical inactivity (range of 3.7% to 4.9%) were shown to be relatively less prevalent in Uganda. Tobacco use and harmful use of alcohol were more common in males and more prevalent in Northern region, while being overweight (BMI > 25 kg/m2) and physical inactivity were more common in females and more prevalent in Central region. Tobacco use was more prevalent among the rural populations compared to urban, while physical inactivity and being overweight were more common in urban than in rural settings. Tobacco use has decreased overtime, while being overweight increased in all regions and for both sexes. CONCLUSION: There is limited data about lifestyle risk factors in Uganda. Apart from tobacco use, other lifestyle risk factors seem to be increasing and there is variation in the prevalence of lifestyle risk factors among the different populations in Uganda. Prevention of lifestyle cancer risk factors requires targeted interventions and a multi-sectoral approach. Most importantly, improving the availability, measurement and comparability of cancer risk factor data should be a top priority for future research in Uganda and other low-resource settings.

European-wide policymaking at the urban level: a qualitative study.

BACKGROUND: Inter-urban area (UA) health inequalities can be as dramatic as those between high and low-income countries. Policies need to focus on the determinants of health specific to UAs to effect change. This study therefore aimed to determine the degree to which policymakers from different countries could make autonomous health and wellbeing policy decisions for their urban jurisdiction area. METHODS: We conducted a cross-sectional, qualitative interview study with policymakers recruited from eight European countries (N = 37). RESULTS: The reported autonomy among policymakers varied considerably between countries, from little or no autonomy and strict adherence to national directives (e.g. Slovak Republic) to a high degree of autonomy and ability to interpret national guidelines to local context (e.g. Norway). The main perceived barriers to implementation of local policies were political, and the importance of regular and effective communication with stakeholders, especially politicians, was emphasized. Having qualified health professionals in positions of influence within the UA was cited as a strong driver of the public health (PH) agenda at the UA level. CONCLUSION: Local-level policy development and implementation depends strongly on the degree of autonomy and independence of policymakers, which in turn depends on the organization, structure and financial budget allocation of PH services. While high levels of centralization in small, relatively homogenous countries may enhance efficient use of resources, larger, more diverse countries may benefit from devolution to smaller geographical regions.

The effectiveness of omega-3 supplementation in reducing ADHD associated symptoms in children as measured by the Conners' rating scales: A systematic review of randomized controlled trials.

Omega-3 supplements are considered to have anti-inflammatory effects which may be beneficial as inflammation has been linked to ADHD. The aim of this review is to examine the effectiveness of omega-3 supplementation at reducing ADHD symptoms in children and adolescents. Medline, Cinahl+, PsycINFO, Cochrane and Embase were searched for trials investigating the effects of omega-3 supplementation in children and adolescents with ADHD. The primary outcome measure was a mean difference in Conners' rating scale (CRS) between the intervention and placebo group. Search terms used include ADHD, omega-3, fish oils, eicosapentaenoic acid, docosahexaenoic acids, alpha-linolenic acid and Conners' rating scale. Randomized controlled trials examining the efficacy of omega-3 supplementation in children and adolescents as measured by CRS were included. Studies using a combination of polyunsaturated fatty acids or any other rating scale were excluded. Seven trials were included in this review, totalling 926 participants. We found no evidence of publication bias or heterogeneity between trials. Overall, there was a slightly greater reduction in CRS score in favour of the experiment group. One study found a greater reduction in score in favour of the placebo group. Neither findings were statistically significant. There is little supportive evidence to validate the claim of omega-3 supplementation to reduce the degree of ADHD symptoms experienced by children and adolescents. Both experiment and control groups saw similar reductions in Conners rating scale score.

A systematic review of the relationship of physical activity and health status in adolescents.

Background: Reduced physical activity is a known risk factor for many illnesses. Research in adolescent populations found increased physical activity levels improves objective health outcomes, but there is conflicting evidence regarding the relationship between physical activity levels and self-reported health status. To synthesise current evidence on the association between physical activity and self-reported health status in adolescents. Secondary objectives are to assess whether the relationship is dose dependant, and the appropriateness of WHO recommendations on adolescents' physical activity. The main databases were searched using keywords for the main outcome of interest (health status, health behaviour and self-perception) and exposure of interest (motor activity, physical activity and exercise), supplemented with manual searches, secondary citation and reference searches. Quality appraisal was carried out using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Eleven studies entered this review. Nine studies reported a significant relationship between increased levels of physical activity and improved self-reported health status, however two did not. Two studies followed up participants and found that the relationship persisted over time. Two papers described a dose-response relationship. Improvements in self-perceived health can be observed even below the current recommended levels of physical activity. The review supports initiatives to encourage adolescents to engage in physical activity as it improves self-reported health status. Sub-optimal levels of physical activity can also be beneficial. Further research should use standardised measurement scales and objectively measured physical activity levels. The roles of gender, income and culture should be further investigated.

Definitions of urban areas feasible for examining urban health in the European Union.

Introduction: As part of the EU-funded project, European Urban Health Indicator System (EURO-URHIS), a definition of urban areas (UAs) and of urban populations was needed to be able to identify comparable UAs in all member states. A literature review on existing definitions, as well as those used by other relevant projects, was performed. A survey of national experts in public health or land planning was also conducted. An algorithm was proposed to find UAs, which were feasible for the focus of EURO-URHIS. No unique general definition of UAs was found. Different fields of research define UAs differently. None of the definitions found were feasible for EURO-URHIS. All of them were found to have critical disadvantages when applied to an urban health project. An ideal definition for this type of project needs to provide a description of the situation without recourse to administrative boundaries yet inform the collection of routine data for urban health monitoring. These requirements were found to contradict each other and were not met in any existing definition. An algorithm was developed for the definition of UAs for the purpose of this study whereby national experts would select regions which are urban as an agglomeration or as a metropolitan area and which are potentially interesting in terms of public health; identify the natural boundaries, where countryside ends and residential or commercial areas of the region begin (e.g. by aerial photos); identify local government boundaries or other official boundaries used for routine data collection purposes which approximate the natural UA as closely as possible and list all administrative areas which are contained in the larger UA. The aggregation of all administrative areas within the original region formed the UA which was used in the project.

Collecting standardised urban health indicator data at an individual level for adults living in urban areas: methodology from EURO-URHIS 2.

Background: An aim of the EURO-URHIS 2 project was to collect standardised data on urban health indicators (UHIs) relevant to the health of adults resident in European urban areas. This article details development of the survey instruments and methodologies to meet this aim. 32 urban areas from 11 countries conducted the adult surveys. Using a participatory approach, a standardised adult UHI survey questionnaire was developed mainly comprised of previously validated questions, followed by translation and back-translation. An evidence-based survey methodology with extensive training was employed to ensure standardised data collection. Comprehensive UK piloting ensured face validity and investigated the potential for response bias in the surveys. Each urban area distributed 800 questionnaires to age-sex stratified random samples of adults following the survey protocols. Piloting revealed lower response rates in younger males from more deprived areas. Almost 19500 adult UHI questionnaires were returned and entered from participating urban areas. Response rates were generally low but varied across Europe. The participatory approach in development of survey questionnaires and methods using an evidence-based approach and extensive training of partners has ensured comparable UHI data across heterogeneous European contexts. The data provide unique information on health and determinants of health in adults living in European urban areas that could be used to inform urban health policymaking. However, piloting has revealed a concern that non-response bias could lead to under-representation of younger males from more deprived areas. This could affect the generalisability of findings from the adult surveys given the low response rates.

The use of locally based aggregate measures in urban health policy making in European urban areas.

Background: National and international policy makers require data at the local level to inform evidence-based policy making and evaluate the impact of policies; however, much data are only published at national level. Data collected at local level could be used to create aggregate measures to help inform health policy. Interviews were conducted with representatives of governmental public health agencies in eight European countries to assess the availability of local data and the extent to which local data was used to help decision making in nine urban areas (UAs). Respondents commented on the barriers to the use of aggregate measures at the local level for health policy decision making. In many of the cities data were available at UA level and in some cases at sub-urban level, however, aggregate measures using local data were rarely used to help inform decision making. The main reasons for this were; poor data quality, a lack of experience in the use of aggregate measures and communication barriers between policy makers and data analysts. A 'top down' approach to decision making also limited the use of local data in the decision making process. Health data are available at urban level within European cities but aggregate measures using these data are rarely used to inform health policy decision making at the local level. Improved communication between local public health data analysts could help increase the use of these data.

Developing a European urban health indicator system: results of EURO-URHIS 1.

Introduction: More than half of the world's population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUA's, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

Population Impact Analysis: a framework for assessing the population impact of a risk or intervention.

BACKGROUND: To describe an organizing framework, Population Impact Analysis, for applying the findings of systematic reviews of public health literature to estimating the impact on a local population, with the aim of implementing evidence-based decision-making. METHODS: A framework using population impact measures to demonstrate how resource allocation decisions may be influenced by using evidence-based medicine and local data. An example of influenza vaccination in the over 65s in Trafford to reduce hospital admissions for chronic obstructive pulmonary disease (COPD) is used. RESULTS: The number of COPD admissions due to non-vaccination of the over 65 in Trafford was 16.4 (95% confidence interval: 13.5; 19.5) and if vaccination rates were taken up to 90%, 11.5 (95% confidence interval: 9.3; 13.8) admissions could have been prevented. A total of 705 (95% confidence interval: 611; 861) people would have to be vaccinated against influenza to prevent one hospital admission. CONCLUSIONS: Population Impact Analysis can help the 'implementation' aspect of evidence for population health. It has been developed to support public health policy makers at both local and national/international levels in their role of commissioning services.

Innovations: evidence-based practices: establishing the evidence base for psychiatric services: estimating the impact on the population.

The impact of evidence-based interventions for individual patients is clear, but a broader approach is needed. The authors describe a six-step method for calculating the population impact of introducing a new evidence-based intervention. The steps involve identifying the prevalence of a condition, the proportion of persons in the larger population eligible for the intervention, and the baseline risk that the intervention is meant to address. Obtaining useful results from this mathematical calculation depends on having accurate and robust data about the prevalence of a condition, the size of the targeted population, and the effectiveness of the intervention. Results for different interventions for the same condition and target population can then be compared.

Measuring children and monitoring obesity: surveys of English Primary Care Trusts 2004-06.

BACKGROUND: Child obesity has unclear determinants and consequences. A precautionary approach requires best-guess interventions and large-scale surveillance. This study was to determine the current measurement activities and the information systems required for child obesity surveillance. DESIGN: Questionnaire-based surveys. SETTING: Primary Care Trusts (PCTs) in United Kingdom. PARTICIPANTS: Two hundred and forty-seven (82%) PCTs in 2004 and 240 (79%) in 2006. MAIN MEASURES: Children's ages at which height and weight are routinely measured, the type of personnel taking the measurements, arrangements for recording data, information systems and uses of the data. RESULTS: PCTs measure height/length and weight most commonly at 6 weeks (74%) and 5 years (74%)-also at 6-12 months (58%), 1.5-2.5 years (50%), 2.5-4 years (40%), 11 years (18%) and 7 years (11%). Seventy-seven per cent of PCTs transferred the measurements to a database-26 different information systems were named. Six per cent of PCTs in 2004, rising to 34% in 2006, used the data to produce public health reports. CONCLUSIONS: Body mass index (BMI) surveillance requires new arrangements in 25% of PCTs at school entry and 80% at transfer to senior school. Important aspects of child obesity surveillance not yet addressed are pre-school measurement, longitudinal assessment and the public health requirements of (child) electronic health records.

Helping to prioritise interventions for depression and schizophrenia: use of Population Impact Measures.

BACKGROUND: To demonstrate the potential of Population Impact Measures in helping to prioritise alternative interventions for psychiatry, this paper estimates the number of relapses and hospital readmissions prevented for depression and schizophrenia by adopting best practice recommendations. The results are designed to relate to particular local populations. METHODS: Literature-based estimates of disease prevalence, relapse and re-admission rates, current and best practice treatment rates, levels of adherence with interventions and relative risk reduction associated with different interventions were obtained and calculations made of the Number of Events Prevented in your Population (NEPP). RESULTS: In a notional population of 100,000 adults, going from current to 'best' practice for different interventions, the number of relapses prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 23 (family intervention), 43 (relapse prevention), and 44 (early intervention); and for depression the number of relapses prevented in the next year were 100 (increasing care management), 227 (continuing treatment with antidepressants), 279 (increasing rate of diagnosis), and 325 (Cognitive Behaviour Therapy). Hospital re-admissions prevented in the next year for schizophrenia were 6 (increasing adherence to medication), 36 (relapse prevention) and 40 (early intervention). CONCLUSION: Population Impact measures provide the possibility for a policy-maker to see the impact of a new intervention on the population as a whole, and to compare alternative interventions to best improve psychiatric disease outcomes. The methods are much simpler than others, and have the advantage of being transparent.

Generating pre-test probabilities: a neglected area in clinical decision making.

OBJECTIVE: To assess the accuracy and variability of clinicians' estimates of pre-test probability for three common clinical scenarios. DESIGN: Postal questionnaire survey conducted between April and October 2001 eliciting pre-test probability estimates from scenarios for risk of ischaemic heart disease (IHD), deep vein thrombosis (DVT), and stroke. PARTICIPANTS AND SETTING: Physicians and general practitioners randomly drawn from College membership lists for New South Wales and north-west England. MAIN OUTCOME MEASURES: Agreement with the "correct" estimate (being within 10, 20, 30, or > 30 percentage points of the "correct" estimate derived from validated clinical-decision rules); variability in estimates (median and interquartile ranges of estimates); and association of demographic, practice, or educational factors with accuracy (using linear regression analysis). RESULTS: 819 doctors participated: 310 GPs and 288 physicians in Australia, and 106 GPs and 115 physicians in the UK. Accuracy varied from about 55% of respondents being within 20% of the "correct" risk estimate for the IHD and stroke scenarios to 6.7% for the DVT scenario. Although median estimates varied between the UK and Australian participants, both were similar in accuracy and showed a similarly wide spread of estimates. No demographic, practice, or educational variables substantially predicted accuracy. CONCLUSIONS: Experienced clinicians, in response to the same clinical scenarios, gave a wide range of estimates for pre-test probability. The development and dissemination of clinical decision rules is needed to support decision making by practising clinicians.

GPs' and physicians' interpretation of risks, benefits and diagnostic test results.

BACKGROUND: Understanding pre-test probability and baseline risks helps to interpret the results of diagnostic tests and the benefits of treatment, but how good is the understanding of these concepts? OBJECTIVES: Our aim was to assess the ability of GPs and consultant physicians to make accurate estimates and understand the application of pre-test probability and baseline risk for two common clinical conditions. METHODS: A two-stage questionnaire survey based on case scenarios of patients with angina and congestive heart failure was carried out of 202 physicians, randomly selected from the members of the Royal College of Physicians in the NW of England, 205 GPs randomly chosen from the practice list of the NW Health Authorities and 128 MRCGP examiners attending an examiners meeting. A total of 115, 106 and 81 members of these groups, respectively, responded to the first stage, and 44, 46 and 64 to the second. The main outcome measures were the stated likelihood of true ischaemic heart disease (IHD) being present and the predicted 1-year mortality; the impact of changing prevalence and baseline risk on these results; and interpretation of different methods of risk presentation. RESULTS: Estimates of pre-test probability of IHD being present ranged from 5 to 100% and of baseline risk of 1-year mortality from 0 to 86%. More GP examiners and consultant physicians understood the impact of increasing age on the test result than did the random sample of GPs. A majority of each group correctly said that increasing age would reduce the number needed to treat (NNT). Presentation of benefit as relative risk reduction was a greater stimulus to starting treatment than the NNT or measures of population impact. CONCLUSION: Clinicians should collect data to allow a better knowledge of the likelihood of disease and of baseline risk in their patient populations. Methods to increase the understanding of the influence of pre-test probability on diagnostic test results and of how to quantify and demonstrate the impact of the benefit of interventions should be explored.

Public health in Primary Care Trusts: a resource needs assessment.

BACKGROUND: This study was commissioned by the UK Health Development Agency to provide a snapshot of how, at the outset of the 2002 NHS reorganisation, Primary Care Trust (PCT) staff and Professional Executive Committee (PEC) members perceived their public health roles and functions, the opportunities and barriers to delivering those roles and functions and the development needs in order to fulfill them. METHODS: Taped group interviews were conducted with PECs of eight PCTs (covering a range of settings, size and stage of organisational development), followed up by structured telephone interviews with 35 frontline staff from four of the PCTs. Analysis was through content analysis and counting of themes including a quantitative assessment of the occurrence of themes and comparison between different categories of participants. RESULTS: PEC members and frontline staff (particularly community based staff) were keen to address a broad public health agenda within the new PCTs, however a number of barriers to the ability of the PCT to fulfill its Public Health role were identified. The most important were lack of resources (staff and staff time) in the context of a host of competing agendas and excessive clinical workloads. There was a clear difference among frontline staff between those who were practice or community based-many practice-based frontline staff did not acknowledge any major public health dimensions to their daily work. A number of detailed suggestions for improvement were made. CONCLUSION: At the start of the 2002 NHS reorganisation, PCTs need to improve their organisational capacity to address the public health if they are to deliver health improvement as envisaged. We make recommendations which should allow PCTs to perform their public health functions more effectively.