Engaging adolescents in chronic disease prevention research: insights from researchers about establishing and facilitating a youth advisory group

Our comment discusses our experience establishing a youth advisory group focused on chronic disease prevention research. The comment highlights three key learnings: the need for researchers to adapt their working style, the importance of redefining the power dynamics, and disrupting traditional research structures to align with co-researcher engagement models.

Harnessing education and lifestyle change to support transitional health for returning citizens: a feasibility study protocol

BACKGROUND

Exercise and healthy eating are known to reduce chronic disease risk; however, formerly incarcerated individuals (i.e., returning citizens) face significant social barriers when attempting to engage with existing community-based physical activity and nutrition programs. Given the high disease burden and unique educational needs of returning citizens, this proposed work fills an important gap in the support services currently offered to this population.

METHODS

This article describes a process for evaluating the feasibility and acceptability of a physical activity and nutrition intervention tailored to the needs of returning citizens via a partnership between an academic research organization and a community-based reentry program for returning citizens. Staff from the community-based reentry program will train four returning citizens as group fitness instructors and work with a nutritionist to design a 16-week nutrition education curriculum. Reentry program staff will enroll up to 15 formerly incarcerated adults (aged 18 +) in the exercise and nutrition program. Participants will take part in weekly nutrition classes led by the nutritionist and weekly group exercise classes led by a peer instructor. Research staff will evaluate program success in four domains: reach, preliminary effectiveness, implementation, and maintenance.

RESULTS

This feasibility study will allow us to design and test a program that can eventually be evaluated in a large, randomized trial. It also addresses the multitude of social determinants that impact the health of returning citizens and builds a framework for program sustainability. Individuals recruited as fitness trainers will acquire skills and certifications that may be used to sustain physical fitness activities within the reentry program.

CONCLUSIONS

This feasibility study will test our ability to address social determinants that impact the health of returning citizens through a peer-led physical activity and nutrition programming. In the long term, study results may inform development and implementation of reentry programming and policy on a wider scale.

The health and economic benefits of sugar taxation and vegetables and fruit subsidy scenarios in Canada

A tax on sugar-sweetened beverages (SSB) has been implemented in various jurisdictions. Though research confirmed this tax to reduce sugar consumption and to prevent chronic diseases, it also revealed concerns: one concern relates to the small proportion of sugar in the diet coming from SSBs; and another concern relates to the disproportional tax burden to low-income groups. To inform public health decision makers on alternatives, we examined three 'real world' taxation and subsidy scenarios in Canada: 1) a CAD$0.75/100 g tax on SSBs; 2) a CAD$0.75/100 g tax on free sugar in all foods; and 3) a 20% subsidy on vegetables and fruit (V&F). Using national survey data and a proportional multi-state life table-based Markov model, we simulated the changes in disability-adjusted life years, healthcare costs, tax revenue, intervention costs, and incremental cost-effectiveness ratio for five income quintiles after implementing the three scenarios, over a lifetime of the 2015 Canadian adult population. The first, second and third scenario would prevent 28,921, 262,348 and 551 cases of type 2 diabetes, respectively. They would avert 752,353, 12,167,113, and 29,447 disability-adjusted life years and save CAD$12,942 million, 149,927 million, and 442 million in health care costs, respectively, over a lifetime. Combining the second and third scenarios would lead to the largest health and economic benefits. Although the lowest income quintile would bear a higher sugar tax burden (0.81% of income, CAD$120/person/year), this would be compensated by a coinciding subsidy on V&F (1.30% of income, CAD$194/person/year). These findings support policies that include a tax on all free sugar in foods and a subsidy on V&F as an effective means to reduce chronic diseases and health care costs. Although the sugar tax was financially regressive, the V&F subsidy could compensate for the tax burden of the disadvantaged groups and improve health and economic equity.

The case for citizen science in public health policy and practice: a mixed methods study of policymaker and practitioner perspectives and experiences

BACKGROUND

Citizen science (CS) is increasingly being utilised to involve the public in public health research, but little is known about whether and how CS can address the needs of policy and practice stakeholders in health promotion and chronic disease prevention.

METHODS

Using a mixed methods approach we conducted an online survey (n = 83) and semi-structured interviews (n = 21) with policy and practice stakeholders across Australia to explore how CS approaches are perceived and applied in chronic disease prevention, how CS aligns with existing approaches to community engagement, and how the uptake of CS can be supported within policy and practice settings.

RESULTS

Most participants had heard of CS, and while few had experience of using CS, there was widespread support for this approach, with many seeing it as complementary to other community engagement approaches. CS was seen as providing: (a) a robust framework for engagement; (b) access to rich data; (c) opportunities for more meaningful engagement; and (d) a mutually beneficial approach for stakeholders and community members. However, stakeholders identified a need to weigh benefits against potential risks and challenges including competing organisational priorities, resourcing and expertise, data quality and rigour, governance, and engagement.

CONCLUSIONS

To expand the use of CS, stakeholders identified the need for increased awareness, acceptance, and capacity for CS within public health organisations, greater access to supporting tools and technology, and evidence on processes, feasibility and impacts to enhance the visibility and legitimacy of CS approaches.

Impact of a financial incentive scheme on purchase of fruits and vegetables from unorganised retailers in rural India: a cluster-randomised controlled trial

Background

Inadequate intake of fruits and vegetables is prevalent in rural areas of India, where around 65% of the population reside. Financial incentives have been shown to increase the purchase of fruits and vegetables in urban supermarkets, but their feasibility and effectiveness with unorganised retailers in rural India is unclear.

Methods

A cluster-randomised controlled trial of a financial incentive scheme involving ∼20% cashback on purchase of fruits and vegetables from local retailers was conducted in six villages (3535 households). All households in three intervention villages were invited to participate in the scheme which ran for three months (February-April 2021), while no intervention was offered in control villages. Self-reported (pre-intervention and post-intervention) data on purchase of fruits and vegetables were collected from a random sub-sample of households in control and intervention villages.

Findings

A total of 1109 households (88% of those invited) provided data. After the intervention, the weekly quantity of self-reported fruits and vegetables purchased were (i) 18.6 kg (intervention) and 14.2 kg (control), baseline-adjusted mean difference 4 kg (95% CI: -6.4 to 14.4) from any retailer (primary outcome); and (ii) 13.1 kg (intervention) and 7.1 kg (control), baseline-adjusted mean difference 7.4 kg (95% CI: 3.8-10.9) from local retailers participating in the scheme (secondary outcome). There was no evidence of differential effects of the intervention by household food security or by socioeconomic position, and no unintended adverse consequences were noted.

Interpretation

Financial incentive schemes are feasible in unorganised food retail environments. Effectiveness in improving diet quality of the household likely hinges on the percentage of retailers willing to participate in such a scheme.

Funding

This research has been funded by the Drivers of Food Choice (DFC) Competitive Grants Program, which is funded by the UK Government's Department for International Development and the Bill & Melinda Gates Foundation, and managed by the University of South Carolina, Arnold School of Public Health, USA; however, the views expressed do not necessarily reflect the UK Government's official policies.

Effects of a digital diabetes prevention program on cardiovascular risk among individuals with prediabetes

OBJECTIVE

To examine changes in cardiovascular disease (CVD) risk outcomes of overweight/obese adults with prediabetes.

METHODS

Using data from a randomized control trial of digital diabetes prevention program (d-DPP) with 599 participants. We applied the atherosclerotic CVD (ASCVD) risk calculator to predict 10-year CVD risk for d-DPP and small education (comparison) groups. Between-group risk changes at 4 and 12 months were compared using a repeated measures linear mixed-effect model. We examined within-group differences in proportion of participants over time for specific CVD risk factors using generalized estimating equations.

RESULTS

We found no differences between baseline 10-year ASCVD risk. Relative to the comparison group, the d-DPP group experienced greater reductions in predicted 10-year ASCVD risk at each follow-up visit and a significant group difference at 4 months (-0.96%; 95% confidence interval: -1.58%, -0.34%) (but not at 12 months). Additionally, we observed that the d-DPP group experienced a decreased proportion of individuals with hyperlipidemia (18% and 16% from baseline to 4 and 12 months), high-risk total cholesterol (8% from baseline to 12 months), and being insufficiently active (26% and 22% from baseline to 4 and 12 months at follow-up time points.

CONCLUSIONS

Our findings suggest that a digitally adapted DPP may promote the prevention of cardiometabolic disease among overweight/obese individuals with prediabetes. However, given the lack of maintenance of effect on ASCVD risk at 12 months, there may also be a need for additional interventions to sustain the effect detected at 4 months.

The value of the Nutrition and Obesity Policy Research and Evaluation Network in advancing the evidence base for effective nutrition and obesity policy: assessment using the Consolidated Framework for Collaborative Research

INTRODUCTION

Addressing nutrition disparities and preventing obesity require multi-level interventions, including policies that address the nutrition environment and other social determinants of health. The Nutrition and Obesity Policy Research Evaluation Network (NOPREN) was established in 2009 to conduct transdisciplinary research and accelerate the translation and implementation of science-based policy interventions. This study examined NOPREN's collaborative practices and identified opportunities to improve network impact.

METHODS

Using a mixed-methods approach, we combined quantitative survey data (n = 106) and in-depth, qualitative interviews (n = 18) to evaluate the experiences of NOPREN members and understand the extent to which NOPREN was achieving its goals.

RESULTS

Using the Consolidated Framework for Collaborative Research (CFCR), quantitative and qualitative results were organized into 11 themes. We find that NOPREN's structure and standardized processes facilitate connections to individuals and resources, foster relationships, and support effective cross-sector collaborations. Areas of improvement include capacity building and a more intentional approach towards recruitment of a diverse membership.

CONCLUSION

A collaborative research network can build synergy across sectors and accelerate knowledge transfer. These findings will be used to inform the network's strategic priorities to maximize impact. Findings may also inform similar collaborative efforts for addressing complex public health problems.

Protocol for a Mixed-Methods Process Evaluation of BetterBrains: A Person-Centered Online Intervention to Delay Cognitive Decline in Adults at Risk of Dementia

BACKGROUND

The BetterBrains Randomized Controlled Trial (RCT) will evaluate the effectiveness of an online, person-centered, risk factor management, coaching intervention in community-dwelling, healthy adults at risk of cognitive decline. Multi-component interventions are challenging to evaluate due to program complexity and personalization to individual needs and contexts. This paper describes a multi-level process evaluation conducted alongside the BetterBrains RCT.

OBJECTIVE

To understand how and why the BetterBrains intervention was effective or ineffective at reducing cognitive decline in healthy adults whilst considering the context in which it was implemented.

METHODS

1,510 non cognitively-deteriorated community-dwelling adults aged 40-70 years old at risk of cognitive decline will be recruited and randomly assigned to the intervention or control group. All BetterBrains intervention participants, coaches, and the research team will be included in the evaluation. A mixed-methods design will be used, guided by The Framework for Implementation Fidelity and the program logic model. Data will be sourced from interviews, focus groups, surveys, BetterBrains coach notes, participant weekly check-in surveys, and audio recordings of intervention coaching sessions. Quantitative data will be analyzed via descriptive and inferential statistics and qualitative data will be analyzed using content and thematic analysis.

RESULTS

The process evaluation will provide information about contextual and influencing factors related to the implementation of BetterBrains and the RCT outcomes.

CONCLUSION

Understanding how BetterBrains was implemented and its associated impacts will inform the translation of the program into community and clinical settings, providing easy access to online, personalized dementia prevention services.

Changes in health behaviours in adults at-risk of chronic disease: primary outcomes from the My health for life program

Background

Chronic disease is the leading cause of premature death globally, and many of these deaths are preventable by modifying some key behavioural and metabolic risk factors. This study examines changes in health behaviours among men and women at risk of diabetes or cardiovascular disease (CVD) who participated in a 6-month lifestyle intervention called the My health for life program.

Methods

The My health for life program is a Queensland Government-funded multi-component program designed to reduce chronic disease risk factors amongst at-risk adults in Queensland, Australia. The intervention comprises six sessions over a 6-month period, delivered by a trained facilitator or telephone health coach. The analysis presented in this paper stems from 9,372 participants who participated in the program between July 2017 and December 2019. Primary outcomes included fruit and vegetable intake, consumption of sugar-sweetened drinks and take-away, alcohol consumption, tobacco smoking, and physical activity. Variables were summed to form a single Healthy Lifestyle Index (HLI) ranging from 0 to 13, with higher scores denoting healthier behaviours. Longitudinal associations between lifestyle indices, program characteristics and socio-demographic characteristics were assessed using Gaussian Generalized Estimating Equations (GEE) models with an identity link and robust standard errors.

Results

Improvements in HLI scores were noted between baseline (Md = 8.8; IQR = 7.0, 10.0) and 26-weeks (Md = 10.0; IQR = 9.0, 11.0) which corresponded with increases in fruit and vegetable consumption and decreases in takeaway frequency (p < .001 for all) but not risky alcohol intake. Modelling showed higher average HLI among those aged 45 or older (β = 1.00, 95% CI = 0.90, 1.10, p < .001) with vocational educational qualifications (certificate/diploma: β = 0.32, 95% CI = 0.14, 0.50, p < .001; bachelor/post-graduate degree β = 0.79, 95% CI = 0.61, 0.98, p < .001) while being male, Aboriginal or Torres Strait Islander background, or not currently working conferred lower average HLI scores (p < .001 for all).

Conclusions

While participants showed improvements in dietary indicators, changes in alcohol consumption and physical activity were less amenable to the program. Additional research is needed to help understand the multi-level barriers and facilitators of behaviour change in this context to further tailor the intervention for priority groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14056-1.

Variable Eating Patterns: A Potential Novel Risk Factor for Systemic Inflammation in Women

BACKGROUND

The timing and regularity of eating patterns could play a role in systemic inflammation, as circadian clocks responsible for daily rhythms of inflammatory signaling are entrained by food intake.

PURPOSE

To evaluate associations of intra-weekly and weekday-weekend differences in eating timing patterns with high-sensitivity C-reactive protein (hsCRP).

METHODS

A community-based sample of 103 U.S. women from the American Heart Association Go Red for Women Strategically Focused Research Network completed a meal-timing questionnaire and provided a blood sample for measurement of hsCRP. Differences in weekday versus weekend eating start time, eating end time, and nightly fasting duration were calculated as eating jetlag metrics. Intra-weekly variability in eating timing patterns was defined by the standard deviation (SD) of these variables. Multivariable linear regression models were used to evaluate cross-sectional associations of eating timing variability metrics with hsCRP.

RESULTS

Each additional 30-min difference in weekday-weekend eating end time was related to 13% higher hsCRP (p = .023). Similarly, every 30-min increase in eating end time SD, reflecting greater variability in timing of last eating occasion, was associated with 29% higher hsCRP. Per 1-hr weekday-weekend difference in nightly fasting duration, there was a 45% elevation in hsCRP (p = .003). Every 30-min increase in nightly fasting duration SD, representing greater variability in span of the daily fasting/eating periods, was associated with 46% higher hsCRP.

CONCLUSIONS

Variable eating timing patterns were associated with higher hsCRP. Intervention studies are needed to determine whether stabilizing the timing of eating occasions may represent a novel strategy to reduce chronic inflammation.

A decision-making model to optimize the impact of community-based health programs

Hospitals and clinics are increasingly interested in building partnerships with community-based organizations to address the social determinants of health. Choosing among community-based health programs can be complex given that programs may have different effectiveness levels and implementation costs. This study develops a decision-making model that can be used to evaluate multiple key factors that would be relevant in resource allocation decisions related to a set of community-based health programs. The decision-making model compares community-based health programs by considering funding limitations, program duration, and participant retention until program completion. Specifically, the model allows decision makers to select the optimal mix of community-based health programs based on the profiles of the population given the above constraints. The model can be used to improve resource allocation in communities, ultimately contributing to the long-term goal of strengthening cross-sector partnerships and the integration of services to improve health outcomes.

Who or what is to blame? Examining sociodemographic relationships to beliefs about causes, control, and responsibility for cancer and chronic disease prevention in Alberta, Canada

BACKGROUND

Beliefs about causes and responsibility for chronic diseases can affect personal behaviour and support for healthy policies. In this research we examined relationships between socio-demographics (sex, age, education, employment, political alignment, perceived health, household income, household size) and perceptions of causes and responsibility for health behaviour, chronic disease correlates, and attitudes about cancer prevention and causes.

METHODS

Using data from the 2016 Chronic Disease Prevention survey in which participants (N = 1200) from Alberta, Canada responded to items regarding how much they believed personal health behaviours, prevention beliefs, and environmental factors (i.e., healthy eating, physical activity, alcohol, smoking, and where a person lives or works) are linked to getting cancer. Participants also responded to questions about causes and responsibility for obesity, alcohol, and tobacco (i.e., individual or societal). Relationships were examined using multinomial logistic regression on socio-demographics and survey items of interest.

RESULTS

Men (compared to women) were less likely to link regular exercise, or drinking excessive alcohol, to reducing or increasing cancer risk. Similarly, men were less likely to link environmental factors to cancer risk, and more likely to agree that cancer was not preventable, and that treatment is more important than prevention. Finally, men were more likely to believe that alcohol problems are an individual's fault. Left and central voters were more likely to believe that society was responsible for addressing alcohol, tobacco, and obesity problems compared to right voters. Those with less than post-secondary education were less likely to believe that regular exercise, maintaining a healthy body weight, or eating sufficient fruits and vegetables were linked to cancer - or that society should address obesity - compared to those with more education. Households making above the median income (versus below) were more likely to link a balanced diet with cancer and were less likely to think that tobacco problems were caused by external circumstances.

CONCLUSIONS

These results provide insight into the importance of health literacy, message framing, and how socio-demographic factors may impact healthy policy. Men, those with less education, and those with less income are important target groups when promoting health literacy and chronic disease prevention initiatives.

A qualitative exploration of two risk calculators using video-recorded NHS health check consultations

BACKGROUND

The aim of the study was to explore practitioner-patient interactions and patient responses when using QRISK®2 or JBS3 cardiovascular disease (CVD) risk calculators. Data were from video-recorded NHS Health Check (NHSHC) consultations captured as part of the UK RIsk COmmunication (RICO) study; a qualitative study of video-recorded NHSHC consultations from 12 general practices in the West Midlands, UK. Participants were those eligible for NHSHC based on national criteria (40-74 years old, no existing diagnoses for cardiovascular-related conditions, not on statins), and practitioners, who delivered the NHSHC.

METHOD

NHSHCs were video-recorded. One hundred twenty-eight consultations were transcribed and analysed using deductive thematic analysis and coded using a template based around Protection Motivation Theory.

RESULTS

Key themes used to frame the analysis were Cognitive Appraisal (Threat Appraisal, and Coping Appraisal), and Coping Modes (Adaptive, and Maladaptive). Analysis showed little evidence of CVD risk communication, particularly in consultations using QRISK®2. Practitioners often missed opportunities to check patient understanding and encourage risk- reducing behaviour, regardless of the risk calculator used resulting in practitioner verbal dominance. JBS3 appeared to better promote opportunities to initiate risk-factor discussion, and Heart Age and visual representation of risk were more easily understood and impactful than 10-year percentage risk. However, a lack of effective CVD risk discussion in both risk calculator groups increased the likelihood of a maladaptive coping response.

CONCLUSIONS

The analysis demonstrates the importance of effective, shared practitioner-patient discussion to enable adaptive coping responses to CVD risk information, and highlights a need for effective and evidence-based practitioner training.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population

BACKGROUND

The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population.

METHODS

This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed.

RESULTS

There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease.

CONCLUSION

Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

A community-based positive psychology group intervention to promote physical activity among people with metabolic syndrome: Proof of concept results to inform a pilot randomized controlled trial protocol

Background

Community-based physical activity interventions can offset the burden of developing chronic diseases. Positive psychology (PP) interventions may improve health behaviors, but little is known about their effectiveness in community-based prevention settings. A multilevel PP-based intervention has never been studied in people at risk for chronic diseases.

Purpose

The aim of the trial is to demonstrate feasibility, acceptability, and improve physical activity. The purpose is to describe the theory, design, and rationale of the randomized controlled trial (RCT) phase of an iteratively developed physical activity intervention for metabolic syndrome. The feasibility results of the proof-of-concept phase are presented.

Methods

Participants are adult primary care patients at community health centers with metabolic syndrome and low physical activity (target n = 64). The 8-week group intervention consists of weekly physical activity goal-setting and self-monitoring, positive psychology activities, and neighborhood walks. Participants rate feasibility and acceptability of sessions. Pre-post-intervention, and 24 weeks later, participants complete accelerometers, questionnaires, and biometrics.

Feasibility results

Eight participants enrolled and seven completed. The median number of group sessions attended was 7 out of 8. Average ease and usefulness of sessions were rated as 7.0 (±0.5)/10 and 8.1 (±1.0)/10, respectively, indicating feasibility and acceptability. Average pre-post physical activity increased by 2152 steps and 29.25 min of MVPA/week.

Discussion

This proof-of-concept trial demonstrated high feasibility and acceptability, with increased physical activity. These positive findings suggest that the RCT phase will show high feasibility, acceptability, and initial impact on physical activity.

Chronic disease prevention evaluation in Ontario's public health system: a qualitative needs assessment

OBJECTIVES

Building evaluation capacity for chronic disease prevention (CDP) is a critical step in ensuring the effectiveness of CDP programming over time. In this article, we highlight the findings of the qualitative arm of a mixed-methods needs assessment designed to assess the gaps and areas of strength within Ontario's public health system with respect to CDP evaluation.

METHODS

We conducted 29 interviews and focus groups with representatives from 25 public health units (PHUs) and analyzed the data using thematic analysis. We sought to understand what gaps and challenges exist in the Ontario public health system around CDP evaluation.

RESULTS

Challenges facing Ontario's PHUs in CDP evaluation include variation and centralization of capacity to evaluate, as well as competing priorities limiting the development of evaluative thinking. Participating PHUs identified the need for evaluation capacity building (ECB) strategies grounded in an understanding of the unique contexts in which they work and a desire for guidance in conducting a complex and thoughtful evaluation. Moving forward, PHUs noted a desire for a strong system of knowledge sharing and consultation across the public health system, including through strengthening existing partnerships with community collaborators.

CONCLUSION

These results support the case for ECB strategies that are adaptive and context-sensitive and equip PHUs with the skills required to evaluate complex CDP programming.

Health literacy and its effect on chronic disease prevention: evidence from China's data

BACKGROUND

Improving health literacy is an important public health goal in many countries. Although many studies have suggested that low health literacy has adverse effects on an individual's health outcomes, confounding factors are often not accounted. This paper examines the interplay between health literacy and chronic disease prevention.

METHODS

A population-based sample of 8194 participants aged 15-69 years old in Ningbo were used from China's 2017 National Health Literacy Surveillance Data. We use multivariate regression analysis to disentangle the relationship between health literacy and chronic disease prevention.

RESULTS

We find the association between health literacy and the occurrence of the first chronic condition is attenuated after we adjust the results for age and education. This might arise because having one or more chronic conditions is associated with better knowledge about chronic diseases, thus improve their health literacy. More importantly, we find health literacy is associated with a reduction in the likelihood of having a comorbid condition. However, this protective effect is only found among urban residents, suggesting health literacy might be a key factor explaining the rural-urban disparity in health outcomes.

CONCLUSION

Our findings highlight the important role of health literacy in preventing comorbidities instead of preventing the first chronic condition. Moreover, family support could help improve health literacy and result in beneficial effects on health.

Development of a computational modeling laboratory for examining tobacco control policies: Tobacco Town

A key focus of recent policy efforts to curb tobacco product usage has been the role of place-specifically the density of retail and advertising and the resulting spatial pattern of access and exposure for consumers. Policies can alter the environment by reducing density or shifting distribution of tobacco retail and thus limiting access and exposure. Since little empirical evidence exists for the potential impact of these policies across potentially heterogeneous places, we develop and apply an original spatial computational model to simulate place-based retail tobacco control policies. The model is well-grounded in theory and available empirical evidence. We apply the model in four representative settings to demonstrate the utility of this approach as a policy laboratory, to develop general insights on the relationship between retailer density, retail interventions, and tobacco costs incurred by consumers, and to provide a framework to guide future modeling and empirical studies. Our results suggest that the potential impact on costs of reducing tobacco retailer density are highly dependent on context. Projected impacts are also influenced by assumptions made about agent (smoker) purchasing decision-making processes. In the absence of evidence in this area, we tested and compared three alternative decision rules; these interact with environmental properties to produce different results. Agent properties, namely income and cigarettes per day, also shape purchasing patterns before and after policy interventions. We conclude that agent-based modeling in general, and Tobacco Town specifically, hold much potential as a platform for testing and comparing the impact of various retail-based tobacco policies across different communities. Initial modeling efforts uncover important gaps in both data and theory and can provide guidance for new empirical studies in tobacco control.

Practitioner perspectives on building capacity for evidence-based public health in state health departments in the United States: a qualitative case study

BACKGROUND

Public health agencies are responsible for implementing effective, evidence-based public health programs and policies to reduce the burden of chronic diseases. Evidence-based public health can be facilitated by modifiable administrative evidence-based practices (A-EBPs) (e.g., workforce development, organizational climate), yet little is known about how practitioners view A-EBPs. Thus, the purpose of this qualitative study was to understand state health department practitioners' perceptions about how A-EBPs are implemented and what facilitators and barriers exist to using A-EBPs.

METHODS

Chronic disease prevention and health promotion program staff who were members of the National Association of Chronic Disease Directors were recruited to participate in telephone interviews using a snowball sampling technique. Interviews were transcribed verbatim, and transcripts were analyzed using a common codebook and the a priori method in NVivo.

RESULTS

Twenty seven interviews were conducted with practitioners in four states (5-8 interviews per state). All practitioners felt that their work unit culture is positive and that leadership encouraged and expected staff to use evidence-based processes. Participants discussed the provision of trainings and technical assistance as key to workforce development and how leaders communicate their expectations. Access to evidence, partnerships, and funding restrictions were the most commonly discussed barriers to the use of A-EBPs and EBDM.

CONCLUSIONS

Results of this study highlight practitioners' perspectives on promoting evidence-based public health in their departments. Findings can inform the development and refinement of resources to improve A-EBP use and organizational and leadership capacity of state health departments.

Is There a Benefit to Patients Using Wearable Devices Such as Fitbit or Health Apps on Mobiles? A Systematic Review

Wearable devices have become a standard health care intervention with emerging health care technologies. These devices are designed to promote healthy behaviors and decrease risk for chronic disease like cardiovascular disease and diabetes. The purpose of this study was to provide evidence of the benefit of wearable devices in chronic disease outcomes among adults. Systematic search of PubMed, Web of Science, World Health Organization international clinical trials registry platform, BMC ISRCTN registry, and the Institute of Electrical and Electronics Engineers was performed based upon the PRISMA guideline. Included articles were randomized controlled trials or quasi-experimental studies with health outcomes published in English up to October 2018. Studies focusing on adults were selected. Three investigators reviewed the selected publications and made agreement on final selection. Of a total of 550 publications extracted, 6 studies met the final criteria. There was little indication that wearable devices provide a benefit for health outcomes. Of the 6 studies examined, only one study showed a significant reduction for weight loss among participants who used wearable devices. No significant reduction was discovered in cholesterol or blood pressure. Among the 6 studies, only one study examined hemoglobin A1c, and it showed a significant reduction in older patients with type 2 diabetes. The current literature evaluating wearable devices indicates little benefit of the devices on chronic disease health outcomes. Wearable devices play a role as a facilitator in motivating and accelerating physical activity, but current data do not suggest other consistent health benefits.

Lessons Learned in Promoting Evidence-Based Public Health: Perspectives from Managers in State Public Health Departments

Evidence-based public health (EBPH) practice, also called evidence-informed public health, can improve population health and reduce disease burden in populations. Organizational structures and processes can facilitate capacity-building for EBPH in public health agencies. This study involved 51 structured interviews with leaders and program managers in 12 state health department chronic disease prevention units to identify factors that facilitate the implementation of EBPH. Verbatim transcripts of the de-identified interviews were consensus coded in NVIVO qualitative software. Content analyses of coded texts were used to identify themes and illustrative quotes. Facilitator themes included leadership support within the chronic disease prevention unit and division, unit processes to enhance information sharing across program areas and recruitment and retention of qualified personnel, training and technical assistance to build skills, and the ability to provide support to external partners. Chronic disease prevention leaders’ role modeling of EBPH processes and expectations for staff to justify proposed plans and approaches were key aspects of leadership support. Leaders protected staff time in order to identify and digest evidence to address the common barrier of lack of time for EBPH. Funding uncertainties or budget cuts, lack of political will for EBPH, and staff turnover remained challenges. In conclusion, leadership support is a key facilitator of EBPH capacity building and practice. Section and division leaders in public health agencies with authority and skills can institute management practices to help staff learn and apply EBPH processes and spread EBPH with partners.

The effect of culinary interventions (cooking classes) on dietary intake and behavioral change: a systematic review and evidence map

Background

Culinary interventions (cooking classes) have been used to improve the quality of dietary intake and change behavior. The aim of this systematic review is to investigate the effects of culinary interventions on dietary intake and behavioral and cardiometabolic outcomes.

Methods

We conducted a systematic review of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus for comparative studies that evaluated culinary interventions to a control group or baseline values. The intervention was defined as a cooking class regardless of its length or delivery approach. Studies included populations of children, healthy adults or adults with morbidities. The risk of bias was assessed using the Cochrane Risk of Bias tool and the Newcastle-Ottawa Scale. Outcomes were pooled using the random-effects model and descriptive statistics and depicted in an evidence map. Simple logistic regression was used to evaluate factors associated with intervention success.

Results

We included 30 studies (6 were randomized, 7381 patients, average follow up 25 weeks). Culinary interventions were not associated with a significant change in body mass index (− 0.07 kg/m², 95% CI: -1.53, 1.40), systolic (− 5.31 mmHg, 95% CI: -34.2, 23.58) or diastolic blood pressure (− 3.1 mmHg, 95% CI: -23.82, 17.62) or LDL cholesterol (− 8.09 mg/dL, 95% CI: -84.43, 68.25). Culinary interventions were associated with improved attitudes, self-efficacy and healthy dietary intake in adults and children. We were unable to demonstrate whether the effect of a culinary intervention was modified by various characteristics of the intervention such as its delivery or intensity. Interventions with additional components such as education on nutrition, physical activity or gardening were particularly effective.

Conclusions

Culinary interventions were not associated with a significant change in cardiometabolic risk factors, but were associated with improved attitudes, self-efficacy and a healthier dietary intake in adults and children.

Electronic supplementary material

The online version of this article (10.1186/s40795-019-0293-8) contains supplementary material, which is available to authorized users.

A qualitative study of cardiovascular disease risk communication in NHS Health Check using different risk calculators: protocol for the RIsk COmmunication in NHS Health Check (RICO) study

BACKGROUND

NHS Health Check is a national cardiovascular disease (CVD) risk assessment programme for 40-74 year olds in England, in which practitioners should assess and communicate CVD risk, supported by appropriate risk-management advice and goal-setting. This requires effective communication, to equip patients with knowledge and intention to act. Currently, the QRISK®2 10-year CVD risk score is most common way in which CVD risk is estimated. Newer tools, such as JBS3, allow manipulation of risk factors and can demonstrate the impact of positive actions. However, the use, and relative value, of these tools within CVD risk communication is unknown. We will explore practitioner and patient CVD risk perceptions when using QRISK®2 or JBS3, the associated advice or treatment offered by the practitioner, and patients' responses.

METHODS

RIsk COmmunication in NHS Health Check (RICO) is a qualitative study with quantitative process evaluation. Twelve general practices in the West Midlands of England will be randomised to one of two groups: usual practice, in which practitioners use QRISK®2 to assess and communicate CVD risk; intervention, in which practitioners use JBS3. Twenty Health Checks per practice will be video-recorded (n = 240, 120 per group), with patients stratified by age, gender and ethnicity. Post-Health Check, video-stimulated recall (VSR) interviews will be conducted with 48 patients (n = 24 per group) and all practitioners (n = 12-18), using video excerpts to enhance participant recall/reflection. Patient medical record reviews will detect health-protective actions in the first 12-weeks following a Health Check (e.g., lifestyle referrals, statin prescription). Risk communication, patient response and intentions for health-protective behaviours in each group will be explored through thematic analysis of video-recorded Health Checks (using Protection Motivation Theory as a framework) and VSR interviews. Process evaluation will include between-group comparisons of quantitatively coded Health Check content and post-Health Check patient outcomes. Finally, 10 patients with the most positive intentions or behaviours will be selected for case study analysis (using all data sources).

DISCUSSION

This study will produce novel insights about the utility of QRISK®2 and JBS3 to promote patient and practitioner understanding and perception of CVD risk and associated implications for patient intentions with respect to health-protective behaviours (and underlying mechanisms). Recommendations for practice will be developed.

TRIAL REGISTRATION

ISRCTN ISRCTN10443908 . Registered 7th February 2017.

Postmenopausal health interventions: Time to move on from the Women's Health Initiative?

Menopause is a critical period during which, without timely interventions, increased risks of cardiovascular and metabolic diseases, osteoporosis, sexual dysfunction and premature cognitive decline will contribute to diminished quality-of-life in women. Hormone therapy (HT) used to be the standard of care for managing vasomotor symptoms and prevention of chronic diseases until publication of the Women's Health Initiative (WHI) in 2002. Concerned about risks highlighted in WHI publications, many symptomatic women promptly ceased HT which resulted in increased vasomotor symptoms, osteoporosis-related-fractures and insomnia. Data from post-hoc WHI analyses and newer clinical trials consistently show reductions in coronary heart disease and mortality when estrogen therapy is initiated soon after menopause, whereas administration in later years and/or in combination with progesterone carries increased risks. However, no validated primary preventive strategies are available for younger postmenopausal women (<60 years), highlighting the need to re-evaluate the use of estrogen alone for which the risk-benefit balance appears positive. In contrast, in older women (>60 years), risks associated with oral HT exceed benefits; however transdermal estrogen may offer a safer alternative and should be further evaluated. Alternative therapies such as phytoestrogens and non-hormonal prescriptions may be beneficial for older women or those who are unsuitable for HT. Long-term head-to-head comparisons of HT with alternative interventions are warranted to confirm their efficacy for chronic disease prevention.

Advocacy coalition impacts on healthy public policy-oriented learning in Alberta, Canada (2009-2016): A difference-in-differences analysis

Since 2009, the Alberta Policy Coalition for Chronic Disease Prevention (APCCP) has pursued policy, systems, and environmental change strategies engaging policy elites to promote healthy public policy for chronic disease prevention in Alberta, Canada. Employing Advocacy Coalition Framework (ACF) vocabulary to facilitate our analysis, we examined whether concerted advocacy by the APCCP shifted elites' belief system structures over an eight year period compared to the general public as a baseline, by fostering healthy public policy-oriented learning. As data for the study, we employed a trend design series of cross-sectional Chronic Disease Prevention Surveys in Alberta, Canada between 2009 and 2016, comparing policy elite responses in 2009 (n = 183) and 2016 (n = 174) with general public responses in 2010 (n = 1203) and 2016 (n = 1200). Drawing on four scales developed in a published exploratory factor analysis, we examined changes in elite versus public beliefs with respect to (i) behavioral etiology, (ii) socio-ecological etiology, (iii) individual responsibility, and (iv) societal responsibility. Each scale was analyzed for reliability using Cohen's alpha (α), tested for sample mean (μ) value differences with analysis of variance (ANOVA) (p < .05), and compared between groups over time using difference-in-differences analysis. Cohen's alphas above approximately 0.700 indicated acceptable scale reliability (0.692≤α ≤ 0.879). ANOVA testing indicated significant group mean difference for every scale but societal responsibility among elites (μ₂₀₀₉ = 13.2, μ₂₀₁₆ = 13.7; p = .06). Standardized beta coefficients (β) presented significant differences between elites and the public for three of four scales, excepting behavioral etiology (β = -0.009, p = .746). In ACF terms, transformation of elites' policy core beliefs is necessary, but not sufficient, for major policy change such as healthy public policy. Spanning provincial policy communities relevant to whole-of-government intervention for chronic disease prevention, our results provide evidence to support the plausibility of long term socio-ecological strategies aiming to foster policy-oriented learning among elites by advocacy coalitions like the APCCP.

Bringing health into transportation and land use scenario planning: Creating a National Public Health Assessment Model (N-PHAM)

There is mounting evidence linking land development and transportation investments to physical activity with resulting implications for chronic disease prevention. Links between the physical environment and health have traditionally focused on harmful exposures such as air pollution, noise, and traffic injury. Given limited funds and competition for how and where investments are made, there is a need to prioritize and target resources to maximize health benefits that can include activity related chronic disease prevention. The ability to apply this evidence to decision making has been limited by the complexity and inconsistency of research methods, and lack of a direct connection with the planning contexts in which decisions are made. Scenario planning tools provide a method to apply evidence with spatial planning decisions at a range of geographic scales. The US Environmental Protection Agency commissioned the development of a National Public Health Assessment Model (N-PHAM). This project utilized built and natural environment data at the block-group level and large population surveys to model the relationships of the environment with several health outcomes for a range of age and income groups. N-PHAM is the first health assessment tool that can connect to multiple existing scenario planning platforms utilizing nationally available data and can be consistently applied nationally. Such tools can empower communities to choose investments that have the greatest potential to improve public health and quality of life, reduce health care costs, and address environmental justice related disparities.

Protocol for the CHORD project (community health outreach to reduce diabetes): a cluster-randomized community health worker trial to prevent diabetes

BACKGROUND

Type 2 diabetes mellitus (DM) affects 9.4% of US adults and children, while another 33.9% of Americans are at risk of DM. Health care institutions face many barriers to systematically delivering the preventive care needed to decrease DM incidence. Community health workers (CHWs) may, as frontline public health workers bridging clinic and community, help overcome these challenges. This paper presents the protocol for a pragmatic, cluster-randomized trial integrating CHWs into two primary care clinics to support DM prevention for at-risk patients.

METHODS

The trial will randomize 15 care teams, stratified by practice site (Bellevue Hospital and Manhattan VA), totaling 56 primary care physicians. The study cohort will consist of ~ 2000 patients who are 18-75 years of age, actively enrolled in a primary care team, able to speak English or Spanish, and have at least one glycosylated hemoglobin (HbA1c) result in the prediabetic range (5.7-6.4%) since 2012. Those with a current DM diagnosis or DM medication prescription (other than metformin) are ineligible. The intervention consists of four core activities - setting health goals, health education, activation for doctor's appointments, and referrals to DM prevention programs - adjustable according to the patient's needs and readiness. The primary outcome is DM incidence. Secondary outcomes include weight loss, HbA1C, and self-reported health behaviors. Clinical variables and health behaviors will be obtained through electronic medical records and surveys, respectively. Implementation outcomes, namely implementation fidelity and physicians' perspectives about CHW integration into the clinic, will be assessed using interviews and CHW activity logs and analyzed for the influence of moderating organizational factors.

DISCUSSION

This is the first rigorous, pragmatic trial to test the effectiveness of integrating CHWs into primary care for DM prevention reaching a population-based sample. Our study's limitations include language-based eligibility and the use of HbA1c as a measure of DM risk. It will measure both clinical and implementation outcomes and potentially broaden the evidence base for CHWs and patient-centered medical home implementation. Further, the intervention's unique features, notably patient-level personalization and referral to existing programs, may offer a scalable model to benefit patients at-risk of DM.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03006666 (Received 12/27/2016).

Enhancing evidence-based diabetes and chronic disease control among local health departments: a multi-phase dissemination study with a stepped-wedge cluster randomized trial component

BACKGROUND

The rates of diabetes and prediabetes in the USA are growing, significantly impacting the quality and length of life of those diagnosed and financially burdening society. Premature death and disability can be prevented through implementation of evidence-based programs and policies (EBPPs). Local health departments (LHDs) are uniquely positioned to implement diabetes control EBPPs because of their knowledge of, and focus on, community-level needs, contexts, and resources. There is a significant gap, however, between known diabetes control EBPPs and actual diabetes control activities conducted by LHDs. The purpose of this study is to determine how best to support the use of evidence-based public health for diabetes (and related chronic diseases) control among local-level public health practitioners.

METHODS/DESIGN

This paper describes the methods for a two-phase study with a stepped-wedge cluster randomized trial that will evaluate dissemination strategies to increase the uptake of public health knowledge and EBPPs for diabetes control among LHDs. Phase 1 includes development of measures to assess practitioner views on and organizational supports for evidence-based public health, data collection using a national online survey of LHD chronic disease practitioners, and a needs assessment of factors influencing the uptake of diabetes control EBPPs among LHDs within one state in the USA. Phase 2 involves conducting a stepped-wedge cluster randomized trial to assess effectiveness of dissemination strategies with local-level practitioners at LHDs to enhance capacity and organizational support for evidence-based diabetes prevention and control. Twelve LHDs will be selected and randomly assigned to one of the three groups that cross over from usual practice to receive the intervention (dissemination) strategies at 8-month intervals; the intervention duration for groups ranges from 8 to 24 months. Intervention (dissemination) strategies may include multi-day in-person workshops, electronic information exchange methods, technical assistance through a knowledge broker, and organizational changes to support evidence-based public health approaches. Evaluation methods comprise surveys at baseline and the three crossover time points, abstraction of local-level diabetes and chronic disease control program plans and progress reports, and social network analysis to understand the relationships and contextual issues that influence EBPP adoption.

TRIAL REGISTRATION

ClinicalTrial.gov, NCT03211832.

Moderate mental illness as a predictor of chronic disease prevention and screening

Background

Primary care plays a pivotal role in the provision of both mental health care and chronic disease prevention and screening (CDPS). Unfortunately, moderate mental illness (MMI) is associated with poorer general health outcomes. Part of this burden of illness may be due to reduced CDPS uptake. The Building on the Existing Tools to Improve Chronic Disease Prevention in Primary Care (BETTER) trial recruited 777 participants ages 40–65 from 32 family practice panels, of whom 135 (18.2%) had elevated GAD scores, 118 (16.4%) had elevated PHQ scores, and 264 (34.0%) had electronic medical record (EMR)-documented MMI. We hypothesized that patients with screen-positive or chart-documented MMI are 1) eligible for more CDPS actions, and 2) able to complete a lower proportion of CDPS actions than patients unaffected by MMI.

Methods

This study was a secondary analysis of data from the BETTER trial. Participants were stratified by both EMR-documented MMI and screen-positive evidence of MMI (using the General Anxiety Disorders (GAD-7) and Patient Health Questionnaire (PHQ-9) instruments for anxiety and depression screening, respectively). The primary outcome was the proportion of CDPS actions for which the patient was eligible completed at follow-up, using a composite index.

Results

After adjusting for age, gender, and social support, patients with evidence of MMI had a lower composite index than patients without evidence of MMI (p < 0.05). The lower composite index is primarily due to higher eligibility for CDPS at baseline; ability to complete CDPS was not statistically different.

Conclusions

Patients affected by MMI are eligible for more CDPS actions than their unaffected counterparts. Although they are able to complete a similar number of CDPS actions, they are not able to eliminate their baseline CDPS gap. Primary care teams need to be aware of this increased CDPS eligibility for patients with MMI and ensure best practices in CDPS supports are available to this patient population. Further study is needed to determine the ideal suite of targeted supports.

Scaling up complex interventions: insights from a realist synthesis

Preventing chronic diseases, such as cancer, cardiovascular disease and diabetes, requires complex interventions, involving multi-component and multi-level efforts that are tailored to the contexts in which they are delivered. Despite an increasing number of complex interventions in public health, many fail to be ‘scaled up’. This study aimed to increase understanding of how and under what conditions complex public health interventions may be scaled up to benefit more people and populations.

A realist synthesis was conducted and discussed at an in-person workshop involving practitioners responsible for scaling up activities. Realist approaches view causality through the linkages between changes in contexts (C) that activate mechanisms (M), leading to specific outcomes (O) (CMO configurations). To focus this review, three cases of complex interventions that had been successfully scaled up were included: Vibrant Communities, Youth Build USA and Pathways to Education. A search strategy of published and grey literature related to each case was developed, involving searches of relevant databases and nominations from experts. Data extracted from included documents were classified according to CMO configurations within strategic themes. Findings were compared and contrasted with guidance from diffusion theory, and interpreted with knowledge users to identify practical implications and potential directions for future research.

Four core mechanisms were identified, namely awareness, commitment, confidence and trust. These mechanisms were activated within two broad scaling up strategies, those of renewing and regenerating, and documenting success. Within each strategy, specific actions to change contexts included building partnerships, conducting evaluations, engaging political support and adapting funding models. These modified contexts triggered the identified mechanisms, leading to a range of scaling up outcomes, such as commitment of new communities, changes in relevant legislation, or agreements with new funding partners.

This synthesis applies and advances theory, realist methods and the practice of scaling up complex interventions. Practitioners may benefit from a number of coordinated efforts, including conducting or commissioning evaluations at strategic moments, mobilising local and political support through relevant partnerships, and promoting ongoing knowledge exchange in peer learning networks. Action research studies guided by these findings, and studies on knowledge translation for realist syntheses are promising future directions.

Exploring the unanticipated effects of multi-sectoral partnerships in chronic disease prevention

Multi-sectoral partnerships are important parts of many public health efforts to address chronic diseases, such as cancer, diabetes, and cardiovascular disease. Despite the potential value of multi-sectoral approaches, uncertainty exists regarding their effects on individuals, organizations, communities and populations. This article reports on a study that examined the unanticipated effects (both positive and negative) of the Public Health Agency of Canada's (the Agency) Multi-sectoral Partnerships initiative, which supports more than 30 multi-sectoral partnership projects across Canada. Thirteen semi-structured interviews were conducted with staff from organizations participating in 3 diverse partnership projects as part of the Agency's multi-sectoral partnerships initiative. Multiple unanticipated effects were identified and organized into 4 themes: (1) insights about the flexibility and responsiveness of government; (2) access to new and valuable resources (people, skills, expertise); (3) opportunity to build new capacities; and (4) understanding realistic timelines for partnership activities and outcomes. While these effects were unanticipated for study participants, they resonate with insights from the literature on multi-sectoral partnerships. These results raise a number of questions for consideration as partnership initiatives continue to evolve, including the types of training that partners might need; the individual and organizational capacities required for partnership approaches; and the evaluation techniques that might be most useful to capture the non-linear effects of partnership approaches.

Smoking cessation practice among family doctors in Lithuania: a Survey

OBJECTIVES

Relatively low proportion of ex-smokers and high rates of smoking-related diseases are estimated in Lithuania. The aim of this survey was to assess the extent of smoking cessation assistance among family doctors in Lithuania, and to identify factors associated with cessation interventions.

MATERIALS AND METHODS

Data were collected using a questionnaire addressing family doctors' cessation assistance practice; knowledge of smoking epidemiology and health effects; knowledge of cessation assistance guidelines; smoking status; and attendance on Courses/Conferences on Smoking and smoking cessation Assistance (CCSA). The study included 718 family doctors in Lithuania in 2014.

RESULTS

The results show that 23% of family doctors always ask their patients about smoking habits. Although 59% of family doctors always advise smoking patients to quit smoking, only 26% recommend a follow-up appointment, 22% refer for a specialized smoking cessation treatment, 15% prescribe nicotine replacement therapy, and 6% prescribe Varenicline or Bupropion. The study demonstrated limited knowledge of family doctors in relation to epidemiological aspects of tobacco use and effective cessation assistance methods. Cessation assistance is influenced by family doctors' age, smoking status, knowledge of cessation assistance guidelines and CCSA attendance.

CONCLUSIONS

Effective training of family doctors' in smoking epidemiology, health hazards and in smoking cessation assistance is warranted in Lithuania. In addition, coordinated efforts in primary health care institutions are required to improve help for smokers who intend to quit.

The human gut microbiome impacts health and disease

The human gut microbiome can now be characterized in unprecedented detail by an approach based on high-throughput sequencing of total stool DNA, that we name quantitative metagenomics. Central to the approach is a catalog that lists all the genes of intestinal microbes that are known - 9.9 millions, identified by the analysis of 1267 stool samples. Beyond the gene list, genetic units that carry them begun to be known; many of these correspond to bacterial species that were never isolated and cultured yet. Quantitative metagenomics allows developing powerful algorithms to diagnose a disease, monitor patients and identify individuals at risk to progress towards a disease. This lays ground for developing new approaches to better restore and even preserve the health by modulation of the altered microbiome, which contributes to promote or aggravate a disease.

Public health strategies promoting physical activity and healthy eating in Canada: are we changing paradigms?

OBJECTIVES

To compare the extent to which Canadian public health organizations incorporated the Ottawa Charter for Health Promotion action areas in promoting physical activity and healthy eating in 2004 and 2010.

METHODS

Data were available from repeat censuses of all regional, provincial, and national organizations with mandates to promote physical activity [n = 134 (2004); n = 118 (2010)] or healthy eating [n = 137 (2004); n = 130 (2010)]. Eleven strategies to promote these behaviors were grouped according to the five action areas. Descriptive analyses were conducted to document the level of involvement in each action area over time.

RESULTS

The proportion of organizations promoting physical activity and "heavily involved" in creating supportive environments increased from 51 % (2004) to 70 % (2010). The proportion also increased for reorienting health services (29 % to 39 %). The proportion of organizations promoting healthy eating and "heavily involved" in building healthy public policy increased from 47 to 53 %. Individual skill building remained stable for physical activity but declined for healthy eating.

CONCLUSIONS

While developing personal skills remains important in promoting physical activity and healthy eating in Canada, public health organizations increased involvement in structural-level strategies.

Impact of a 3-year multi-centre community-based intervention on risk factors for chronic disease and obesity among free-living adults: the Healthy Alberta Communities study

Background

Healthy Alberta Communities (HAC) was a 3-year community-based intervention to reduce lifestyle-related risk factors for chronic disease and obesity at a population-level. The current paper examines changes in blood pressure (BP) and anthropometric indicators within HAC communities compared to secular trends.

Methods

Between 2006 and 2009, this community-academic partnership sought to create environments supportive of healthier dietary and physical activity behaviours within four diverse communities in Alberta, Canada. Height, weight, waist and hip circumference and BP were measured among 1554 and 1808 community residents at baseline (2006) and follow-up (2009), respectively. A comparison sample was drawn from a representative national survey. Samples were stratified by age and change between pre- and post-intervention was assessed using t-tests. Changes in parameters over time between groups were compared using meta-analysis. The net difference in change in outcomes (change in intervention communities minus change in comparison group) represented the effect of the intervention.

Results

Adjusted systolic (SBP) and diastolic (DBP) BP declined within most age groups in HAC communities from pre- to post-intervention. The net decline in SBP was 1 mmHg in 20–39 year olds (p = 0.006) and 2 mmHg in 40–59 year olds (p = 0.001), while the net decline in DBP was 3 mmHg in 20–39 year olds (p < 0.001), 2 mmHg in 40–59 year olds (p < 0.001) and 3 mmHg in 60–79 year olds (p < 0.001). The net increase in the proportion of individuals with normal BP was 5.9 % (p < 0.001), while the net decline in the proportion of individuals with stage 1 hypertension was 4.5 % (p < 0.001). BMI and body weight were unchanged. There was a significant net increase in waist and hip circumference among 20–39 year olds within intervention communities.

Conclusions

Findings suggest HAC succeeded in shifting the population distribution of BP in a leftward direction. By contrast, anthropometric parameters remained unchanged or worsened within intervention communities. Therefore, while improvements in some clinical risk factors can be achieved through relatively diffuse and shorter-term community-level environmental changes, improvements in others may require interventions of greater intensity and duration. Evaluating the success of community-based interventions based on their efficacy in changing individual-level clinical indicators may, however, underestimate their potential.

Beyond BMI: The Next Chapter in Childhood Obesity Management

Pediatric obesity treatment has traditionally focused on body mass index (BMI) and has had limited success. Recent research has suggested new ways to approach this topic that focuses more on holistic measures of health and inclusion of a larger population of children. This paper discusses new evidence in the prevention of chronic disease and treatment of obesity that has a body positive and mental health lens as well as integrating research from several areas of health, including the prevention of chronic disease. Practical medical and mental health assessments tools are suggested for clinical use. Implications for an individualized, positive treatment future are presented.

Chronicling changes to the chronic disease prevention landscape in Canada's public health system 2004-2010

The collective impact of major shifts in public health infrastructure and numerous new chronic disease prevention (CDP) capacity-building initiatives that have taken place in Canada over the last decade is unknown. The objective of this study was to determine if CDP capacity (i.e., skills and resources) and involvement in CDP programming improved in public health organizations in Canada from 2004 to 2010. Data for this repeated cross-sectional study were drawn from two waves of a national census of organizations mandated to carry out primary prevention of chronic disease and/or promotion of healthy eating, physical activity and tobacco control. Medians for continuous variables and frequencies for categorical variables were compared across time. Neither resources nor level of priority for CDP increased over time. There was little difference in the proportion of organizations with high levels of skills and involvement in core CDP practices (i.e., needs assessment, identification of relevant practices, planning, evaluation). Skills and involvement in CDP risk factor programming showed some gains, some steady states and some losses. Specifically, skill and involvement in tobacco control programming declined markedly while the proportion of organizations involved in healthy eating and physical activity programming increased. Skills to address and involvement in programming related to social determinants of health remained low over time as did involvement in programming addressing multiple risk factors concurrently. The lack of marked improvement in CDP capacity between 2004 and 2010 against a backdrop of initiatives favourable to strengthening the preventive health system in Canada suggests that efforts may have fallen short.