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Rocke K, Howitt C, Hambleton I. Understanding the relationship between built environment features and physical activity in the Caribbean: A scoping review. DIALOGUES IN HEALTH 2023; 2:100088. [PMID: 38515496 PMCID: PMC10953899 DOI: 10.1016/j.dialog.2022.100088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/30/2022] [Accepted: 11/30/2022] [Indexed: 03/23/2024]
Abstract
Background Transforming the urban infrastructure to become safe, inclusive and sustainable remains a challenge in most developing settings. The Caribbean has high burdens of physical inactivity and non-communicable diseases. Therefore, understanding the role of the built environment (BE) in modifying individual activity is important for informing the design of community interventions to improve levels of physical activity (PA). Anecdotally, there is limited evidence on the BE in the Caribbean, however evidence from other Small Island Developing States (SIDS) and from Latin America (LA) may offer useful information given their similar urbanization profiles and shared geo-collaborative histories. Objective Our review identifies and characterizes individual features of the BE and examines their relationships with PA outcomes. Methods We systematically searched a range of multi-discipline research databases, including studies from SIDS and LA that objectively measured BE features as an exposure and PA as an outcome between 2010 and 2021. Grey literature was not considered for this review. We characterized BE measures into 9 neighbourhood design domains using the Walkability for Health framework, and mapped gaps in the published evidence. We performed a narrative summary of BE-PA relationships, focusing on association strength and direction of effect. Results Fifty-one studies from published scientific literature in Brazil, Colombia, Mexico, Chile, and Singapore were included that described 306 BE-PA relationships. The BE was mostly characterized by number of and proximity to spaces for social interaction, green spaces, increasing housing density or street connectivity, and mixed residential and commercial land use. BE-PA relationships, although inconsistent, largely promoted PA. Conclusion Although the review is suggestive of the benefits of the benefits of BE interventions for promoting active commuting and leisurely PA, translational research is needed to understand whether results can be successfully adapted for SIDS, which often have an urban structure defined by a single urban centre with connections to outlying communities.
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Affiliation(s)
- Kern Rocke
- The George Alleyne Chronic Disease Research Centre, Caribbean Health Research Institute, The University of the West Indies, Barbados
- Faculty of Medical Sciences, The University of the West Indies, Cave Hill Campus, Barbados
| | - Christina Howitt
- The George Alleyne Chronic Disease Research Centre, Caribbean Health Research Institute, The University of the West Indies, Barbados
| | - Ian Hambleton
- The George Alleyne Chronic Disease Research Centre, Caribbean Health Research Institute, The University of the West Indies, Barbados
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Bartels CA, Lambert EV, Young MEM, Kolbe-Alexander T. If You Build It Will They Come? Park Upgrades, Park Use and Park-Based Physical Activity in Urban Cape Town, South Africa-The SUN Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2574. [PMID: 36767941 PMCID: PMC9916099 DOI: 10.3390/ijerph20032574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 06/18/2023]
Abstract
The development and upgrade of recreational public spaces are key government strategies to increase opportunities for physical activity (PA) and enhance social interaction and community cohesion. This study aimed to evaluate differences in park use and park-based PA in recently upgraded/developed parks (intervention, n = 4) against established parks (control, n = 4) and in regional parks in high- and low-income settings (n = 2). Additionally, associations between target area features, park use and PA were identified. Direct observation of park use and attributes was conducted using the System for Observing Play and Recreation in Communities (SOPARC) over four months. Despite more park users in intervention parks (2519 vs. 1432), control park visitors were 48% more likely to be engaged in PA (p < 0.001). Similarly, while high-income park users attracted more visitors (2135 vs. 1111), they were 79% less likely to be engaged in any PA compared with low-income park visitors. The likelihood of both use of and PA by gender and age differed by features. Active recreation features in intervention parks attracted more users than the same features in control parks. In this study, upgraded or newly developed parks attracted more visitors but not necessarily overall greater levels of physical activity.
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Affiliation(s)
- Clare A. Bartels
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS), Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Estelle V. Lambert
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS), Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
| | - Marié E. M. Young
- Department of Sport, Recreation and Exercise Science, Faculty of Community and Health Science, University of the Western Cape, Cape Town 7535, South Africa
| | - Tracy Kolbe-Alexander
- Research Centre for Health through Physical Activity, Lifestyle and Sport (HPALS), Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7700, South Africa
- School of Health and Medical Sciences, University of Southern Queensland, Ipswich, QLD 4305, Australia
- Centre for Health Research, University of Southern Queensland, Ipswich, QLD 4305, Australia
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Cunningham-Myrie C, Theall KP, Younger-Coleman N, Wiggan J, McFarlane S, Francis D, Bennett N, Tulloch-Reid M, Ferguson TS, Davidson T, Govia I, Guthrie-Dixon N, Aiken W, Grant A, Webster-Kerr K, Wilks R. Who moves in vulnerable Caribbean neighborhoods? Positive deviance for physical activity: Findings from the Jamaica health and Lifestyle Survey 2017 (JHLS III). Prev Med Rep 2022; 30:101998. [PMID: 36189127 PMCID: PMC9519374 DOI: 10.1016/j.pmedr.2022.101998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 09/17/2022] [Accepted: 09/20/2022] [Indexed: 11/26/2022] Open
Abstract
Decreased physical activity (PA) has been associated with residents living in neighborhoods perceived as being disordered or having high crime levels. What is unknown are the characteristics of individuals who engage in moderate to vigorous levels of PA (MVPA) despite living in these vulnerable neighborhoods, or who may be referred to as positive deviants (PD). We examined the factors associated with PD for PA among Jamaicans. Between 2016 and 2017 the Jamaica Health and Lifestyle Survey, a cross-sectional nationally representative survey (n = 2807), was conducted on individuals aged 15 years and older. Regression analyses were performed to identify associations with PD, defined using engagement in MVPA among persons living in vulnerable neighborhoods (N = 1710). Being female (odds ratio [OR]a = 0.64 (0.48, 0.86); p = 0.003), obese while living in an urban area (ORa = 0.39; 95 % CI = 0.26, 0.59; p < 0.0001), unemployed (ORa = 0.53; 95 % CI = 0.39, 0.73; p < 0.0001), or a student (ORa = 0.62; 95 % CI = 0.39, 0.98); p = 0.041) was associated with a significantly lower likelihood of PD, while having a personal medical history of at least one chronic disease significantly increased likelihood (ORa = 1.43; 95 % CI = 1.08, 1.90; p = 0.014). Taking a PD approach may be one angle to consider in trying to determine what is working and for whom, so that this may be harnessed in policy, prevention and intervention programming to increase PA.
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Affiliation(s)
- C Cunningham-Myrie
- Department of Community Health & Psychiatry, University of the West Indies, Mona, Kingston, Jamaica
| | - K P Theall
- Departments of Social, Behavioral, and Population Sciences and Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - N Younger-Coleman
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - J Wiggan
- Ministry of Health & Wellness, Jamaica
| | - S McFarlane
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - D Francis
- School of Health and Human Performance, Georgia College and State University, Milledgeville, GA, USA
| | - N Bennett
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - M Tulloch-Reid
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - T S Ferguson
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | | | - I Govia
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - N Guthrie-Dixon
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
| | - W Aiken
- Department of Surgery, Radiology, Anaesthesia & Intensive Care, University of the West Indies, Mona, Kingston, Jamaica
| | - A Grant
- Ministry of Health & Wellness, Jamaica
| | | | - R Wilks
- Caribbean Institute for Health Research, University of the West Indies, Mona, Jamaica
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Guariguata L, Unwin N, Garcia L, Woodcock J, Samuels TA, Guell C. Systems science for developing policy to improve physical activity, the Caribbean. Bull World Health Organ 2021; 99:722-729. [PMID: 34621090 PMCID: PMC8477427 DOI: 10.2471/blt.20.285297] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/27/2022] Open
Abstract
The World Health Organization (WHO) Global Action Plan on Physical Activity recommends adopting a systems approach to implementing and tailoring actions according to local contexts. We held group model-building workshops with key stakeholders in the Caribbean region to develop a causal loop diagram to describe the system driving the increasing physical inactivity in the region and envision the most effective ways of intervening in that system to encourage and promote physical activity. We used the causal loop diagram to inform how the WHO Global Action Plan on Physical Activity might be adapted to a local context. Although the WHO recommendations aligned well with our causal loop diagram, the diagram also illustrates the importance of local context in determining how interventions should be coordinated and implemented. Some interventions included creating safe physical activity spaces for both sexes, tackling negative attitudes to physical activity in certain contexts, including in schools and workplaces, and improving infrastructure for active transport. The causal loop diagram may also help understand how policies may be undermined or supported by key actors or where policies should be coordinated. We demonstrate how, in a region with a high level of physical inactivity and low resources, applying systems thinking with relevant stakeholders can help the targeted adaptation of global recommendations to local contexts.
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Affiliation(s)
- Leonor Guariguata
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Avalon Jemmott's Lane, Bridgetown, St Michael, BB11115, Barbados
| | - Nigel Unwin
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Avalon Jemmott's Lane, Bridgetown, St Michael, BB11115, Barbados
| | - Leandro Garcia
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, England
| | - James Woodcock
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, England
| | - T Alafia Samuels
- Caribbean Institute for Health Research, University of the West Indies, Kingston, Jamaica
| | - Cornelia Guell
- European Centre for Environment and Human Health, University of Exeter Medical School, Truro, England
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Fontán-Vela M, Rivera-Navarro J, Gullón P, Díez J, Anguelovski I, Franco M. Active use and perceptions of parks as urban assets for physical activity: A mixed-methods study. Health Place 2021; 71:102660. [PMID: 34454253 DOI: 10.1016/j.healthplace.2021.102660] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/23/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022]
Abstract
Parks are potential key urban assets for improved population health; however, their use is not equal among all social groups. Individual and contextual factors could influence residents' perceptions of parks and how they interact with and, eventually, benefit from them. The use of complementary methodologies provides a deeper understanding of the relationship between park use, physical activity (PA), and residents' perceptions. Thus, we designed a mixed-methods study to analyze differences in park use and PA, and the perceptions of parks as urban assets for PA. We selected six parks from three neighborhoods in Madrid (Spain) with different neighborhood socioeconomic status (NSES) for systematic social observation. We registered park users by age, PA level (low, medium, and high), gender, and NSES using the System for Observing Play and Recreation in Communities (SOPARC) audit tool adapted for iOS software (iSOPARC). We also conducted 37 semi-structured interviews and 29 focus groups to analyze residents' perceptions of parks as urban assets for PA in the same neighborhoods. We adopted a convergent-parallel design to analyze both quantitative and qualitative data, and to describe the convergence and divergence areas between them. Parks within the high-NSES were more visited, showing a higher proportion of people performing high PA (11.9%) as compared to residents of the middle (9.3%) and low-NSES (3.2%). Female visitors showed lower PA levels compared to men, especially for parks within high-NSES. The following issues were reported as influence urban park use and perceptions: park maintenance and area perception, works constraints, insecurity and crime, differential perceptions by age, and the availability of organized activities in the parks. Residents from high-NSES reported fewer barriers to park use compared to residents from the other areas, who reported limitations such as less leisure time due to job constrains or perceived insecurity in parks. Senior participants reported that having parks with organized activities and a design oriented towards different age-groups are valuable. Our study shows consistency between the fewer and less intense use of parks registered in the middle and low-NSES neighborhoods, and the more barriers for PA reported in this areas during the qualitative analysis. Mixed-methods provided an insight of the potential causes leading to the differences in park use and PA within cities, which is essential in terms of environmental justice and health equity. Thus, a mixed-methods comprehensive approach to public health problems can help designing public policies addressing relevant factors related to urban health inequities.
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Affiliation(s)
- Mario Fontán-Vela
- Universidad de Alcalá, Facultad de Medicina y Ciencias de La Salud, Departamento de Cirugía, Ciencias Médicas y Sociales, Grupo de Investigación en Epidemiología y Salud Pública, Alcalá de Henares, Madrid, Spain; Preventive Medicine Department, Infanta Leonor University Hospital, 28031, Madrid, Spain
| | - Jesús Rivera-Navarro
- Universidad de Alcalá, Facultad de Medicina y Ciencias de La Salud, Departamento de Cirugía, Ciencias Médicas y Sociales, Grupo de Investigación en Epidemiología y Salud Pública, Alcalá de Henares, Madrid, Spain; Department of Sociology and Communication, University of Salamanca, 37007, Salamanca, Spain
| | - Pedro Gullón
- Universidad de Alcalá, Facultad de Medicina y Ciencias de La Salud, Departamento de Cirugía, Ciencias Médicas y Sociales, Grupo de Investigación en Epidemiología y Salud Pública, Alcalá de Henares, Madrid, Spain; School of Global, Urban and Social Studies, RMIT University, Melbourne, Australia.
| | - Julia Díez
- Universidad de Alcalá, Facultad de Medicina y Ciencias de La Salud, Departamento de Cirugía, Ciencias Médicas y Sociales, Grupo de Investigación en Epidemiología y Salud Pública, Alcalá de Henares, Madrid, Spain
| | - Isabelle Anguelovski
- Catalan Institution for Research and Advanced Studies (ICREA), Universitat Autònoma de Barcelona (UAB), Institute for Environmental Sciences and Technology (ICTA), Barcelona Laboratory for Urban Environmental Justice and Sustainability, Medical Research Institute Hospital Del Mar (IMIM), 08003, Barcelona, Spain
| | - Manuel Franco
- Universidad de Alcalá, Facultad de Medicina y Ciencias de La Salud, Departamento de Cirugía, Ciencias Médicas y Sociales, Grupo de Investigación en Epidemiología y Salud Pública, Alcalá de Henares, Madrid, Spain; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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Craig LS, Cunningham-Myrie CA, Hotchkiss DR, Hernandez JH, Gustat J, Theall KP. Social determinants of multimorbidity in Jamaica: application of latent class analysis in a cross-sectional study. BMC Public Health 2021; 21:1197. [PMID: 34162349 PMCID: PMC8220124 DOI: 10.1186/s12889-021-11225-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/07/2021] [Indexed: 11/10/2022] Open
Abstract
Background Non-communicable disease (NCD) multimorbidity is associated with impaired functioning, lower quality of life and higher mortality. Susceptibility to accumulation of multiple NCDs is rooted in social, economic and cultural contexts, with important differences in the burden, patterns, and determinants of multimorbidity across settings. Despite high prevalence of individual NCDs within the Caribbean region, exploration of the social epidemiology of multimorbidity remains sparse. This study aimed to examine the social determinants of NCD multimorbidity in Jamaica, to better inform prevention and intervention strategies. Methods Latent class analysis (LCA) was used to examine social determinants of identified multimorbidity patterns in a sample of 2551 respondents aged 15–74 years, from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008. Multimorbidity measurement was based on self-reported presence/absence of 11 chronic conditions. Selection of social determinants of health (SDH) was informed by the World Health Organization’s Commission on SDH framework. Multinomial logistic regression models were used to estimate the association between individual-level SDH and class membership. Results Approximately one-quarter of the sample (24.05%) were multimorbid. LCA revealed four distinct profiles: a Relatively Healthy class (52.70%), with a single or no morbidity; and three additional classes, characterized by varying degrees and patterns of multimorbidity, labelled Metabolic (30.88%), Vascular-Inflammatory (12.21%), and Respiratory (4.20%). Upon controlling for all SDH (Model 3), advancing age and recent healthcare visits remained significant predictors of all three multimorbidity patterns (p < 0.001). Private insurance coverage (relative risk ratio, RRR = 0.63; p < 0.01) and higher educational attainment (RRR = 0.73; p < 0.05) were associated with lower relative risk of belonging to the Metabolic class while being female was a significant independent predictor of Vascular-Inflammatory class membership (RRR = 2.54; p < 0.001). Material circumstances, namely housing conditions and features of the physical and neighbourhood environment, were not significant predictors of any multimorbidity class. Conclusion This study provides a nuanced understanding of the social patterning of multimorbidity in Jamaica, identifying biological, health system, and structural determinants as key factors associated with specific multimorbidity profiles. Future research using longitudinal designs would aid understanding of disease trajectories and clarify the role of SDH in mitigating risk of accumulation of diseases.
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Affiliation(s)
- Leslie S Craig
- Department of Medicine, School of Medicine, Tulane University, New Orleans, LA, USA.
| | | | - David R Hotchkiss
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Julie H Hernandez
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Jeanette Gustat
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Katherine P Theall
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
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Craig LS, Hotchkiss DR, Theall KP, Cunningham-Myrie C, Hernandez JH, Gustat J. Prevalence and patterns of multimorbidity in the Jamaican population: A comparative analysis of latent variable models. PLoS One 2020; 15:e0236034. [PMID: 32702046 PMCID: PMC7377400 DOI: 10.1371/journal.pone.0236034] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 06/26/2020] [Indexed: 01/15/2023] Open
Abstract
Background Evidence suggests that the single-disease paradigm does not accurately reflect the individual experience, with increasing prevalence of chronic disease multimorbidity, and subtle yet important differences in types of co-occurring diseases. Knowledge of multimorbidity patterns can aid clarification of individual-level burden and needs, to inform prevention and treatment strategies. This study aimed to estimate the prevalence of multimorbidity in Jamaica, identify population subgroups with similar and distinct disease profiles, and examine consistency in patterns identified across statistical techniques. Methods Latent class analysis (LCA) was used to examine multimorbidity patterns in a sample of 2,551 respondents aged 15–74 years, based on data from the nationally representative Jamaica Health and Lifestyle Survey 2007/2008 and self-reported presence/absence of 11 chronic conditions. Secondary analyses compared results with patterns identified using exploratory factor analysis (EFA). Results Nearly one-quarter of the sample (24.1%) were multimorbid (i.e. had ≥2 diseases), with significantly higher burden in females compared to males (31.6% vs. 16.1%; p<0.001). LCA revealed four distinct classes, including a predominant Relatively Healthy class, comprising 52.7% of the sample, with little to no morbidity. The remaining three classes were characterized by varying degrees and patterns of multimorbidity and labelled Metabolic (30.9%), Vascular-Inflammatory (12.2%), and Respiratory (4.2%). Four diseases determined using physical assessments (obesity, hypertension, diabetes, hypercholesterolemia) were primary contributors to multimorbidity patterns overall. EFA identified three patterns described as “Vascular” (hypertension, obesity, hypercholesterolemia, diabetes, stroke); “Respiratory” (asthma, COPD); and “Cardio-Mental-Articular” (cardiovascular disease, arthritis, mental disorders). Conclusion This first study of multimorbidity in the Caribbean has revealed a high burden of co-existing conditions in the Jamaican population, that is predominantly borne by females. Consistency across methods supports the validity of patterns identified. Future research into the causes and consequences of multimorbidity patterns can guide development of clinical and public health strategies that allow for targeted prevention and intervention.
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Affiliation(s)
- Leslie S. Craig
- Department of Medicine, School of Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - David R. Hotchkiss
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Katherine P. Theall
- Department of Global Community Health and Behavioral Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Colette Cunningham-Myrie
- Department of Community Health and Psychiatry, University of the West Indies, Mona, Jamaica
- * E-mail:
| | - Julie H. Hernandez
- Department of Health Policy and Management, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
| | - Jeanette Gustat
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Louisiana, United States of America
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Le Gouais A, Govia I, Guell C. Challenges for creating active living infrastructure in a middle-income country: a qualitative case study in Jamaica. ACTA ACUST UNITED AC 2020. [DOI: 10.1080/23748834.2020.1767950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Anna Le Gouais
- MRC Epidemiology Unit & Centre for Diet and Activity Research (CEDAR), School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Ishtar Govia
- Caribbean Institute for Health Research (CAIHR), The University of the West Indies, Mona, Jamaica
| | - Cornelia Guell
- European Centre for Environment and Human Health, University of Exeter Medical School, Truro, UK
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