We have a lot to learn yet : a postcolonial lens in health promotion

Health promotion progresses a social justice and empowerment agenda and thus emphasises working with people to increase their control over their health. Certainly, Australia has experienced much success in this endeavour and is internationally recognised as a leader. However, health promotion has failed Indigenous Australians; a fact that is echoed in the health outcomes that ironically provide us with the “moral imperative” to act. Further investigation has also revealed health promotion’s foundation in colonial imaginings. Thus, this paper calls for the culture of health promotion to be examined as a risk factor for poor Indigenous health. To complement this call, this paper presents findings of an ethnographic study of Indigenous health promotion practice, undertaken from a postcolonial and critical whiteness framework. These findings provide a narrative of strength and innovative approaches, highlighting the value of Indigenous knowledge. These findings also contradict the biomedical tendency to construct culture as illness-producing. More broadly, this study’s findings entail important lessons for health promotion to consider, if it is to move beyond the rhetoric, to truly increase people’s control over their health.

Socio-demographic characteristics, modifiable lifestyle factors, and health as predictors of mental health in midlife and older Australian women: a multilevel investigation

Background Poor mental health is a significant cause of morbidity and mortality, yet debate continues about factors most likely to predict poor mental health outcomes. Objective This cohort study examines the influence of modifiable lifestyle factors, menopausal symptoms, and physical health on the mental health of midlife and older Australian women. Methods: Random sampling was used to recruit women aged 40-55, from rural and urban areas of Queensland, Australia. Overall, 340 women completed mailed surveys on socio-demographic characteristics, midlife symptoms (Greene Climacteric Scale©), modifiable lifestyle factors, and mental health (SF-12©) in 2001, 2004 and 2011. Hierarchical repeated-measure models were used to explore the correlates of poor mental health over time. Results The mean age [SD] at baseline was 55 [2.7] years, most were married (73%, n=248) and 18% were pre-menopausal. The model suggested that variance in mental health widened and showed a non-linear increase with age. Decrements in mental health were associated with an increase in midlife symptoms (Greene psychological scale, P <0.01; Greene somatic scale, P <0.05), time (P <0.01), poor physical health (P <0.01) and individual variance (P <0.01). Socio-demographics and lifestyle factors had little influence on mental health over time. Conclusion Findings suggest that while women’s mental health may decline during midlife, the effect is temporary; in older women, physical health and individual factors seem to be increasingly significant. This research highlights the importance of active health promotion as a means of enhancing both physical and mental health in midlife women.

Integration of science and monitoring of river ecosystem health to guide investments in catchment protection and rehabilitation

1. Stream ecosystem health monitoring and reporting need to be developed in the context of an adaptive process that is clearly linked to identified values and objectives, is informed by rigorous science, guides management actions and is responsive to changing perceptions and values of stakeholders. To be effective, monitoring programmes also need to be underpinned by an understanding of the probable causal factors that influence the condition or health of important environmental assets and values. This is often difficult in stream and river ecosystems where multiple stressors, acting at different spatial and temporal scales, interact to affect water quality, biodiversity and ecosystem processes. 2. In this article, we describe the development of a freshwater monitoring programme in South East Queensland, Australia, and how this has been used to report on ecosystem health at a regional scale and to guide investments in catchment protection and rehabilitation. We also discuss some of the emerging science needs to identify the appropriate scale and spatial arrangement of rehabilitation to maximise river ecosystem health outcomes and, at the same time, derive other benefits downstream. 3. An objective process was used to identify potential indicators of stream ecosystem health and then test these across a known catchment land-use disturbance gradient. From the 75 indicators initially tested, 22 from five indicator groups (water quality, ecosystem metabolism, nutrient cycling, invertebrates and fish) responded strongly to the disturbance gradient, and 16 were subsequently recommended for inclusion in the monitoring programme. The freshwater monitoring programme was implemented in 2002, funded by local and State government authorities, and currently involves the assessment of over 120 sites, twice per year. This information, together with data from a similar programme on the region's estuarine and coastal marine waters, forms the basis of an annual report card that is presented in a public ceremony to local politicians and the broader community. 4. Several key lessons from the SEQ Healthy Waterways Programme are likely to be transferable to other regional programmes aimed at improving aquatic ecosystem health, including the importance of a shared common vision, the involvement of committed individuals, a cooperative approach, the need for defensible science and effective communication. 5. Thematic implications: this study highlights the use of conceptual models and objective testing of potential indicators against a known disturbance gradient to develop a freshwater ecosystem health monitoring programme that can diagnose the probable causes of degradation from multiple stressors and identify the appropriate spatial scale for rehabilitation or protection. This approach can lead to more targeted management investments in catchment protection and rehabilitation, greater public confidence that limited funds are being well spent and better outcomes for stream and river ecosystem health.

Reproductive Health as a Human Right: A Matter of Access or Provision?

This article seeks to understand why, despite over three decades of claiming women's reproductive health as a human right, we have seen little progress in reducing their health inequalities and poor health outcomes. I argue that one reason for this lack of progress may be due to a failure to clearly articulate the responsibilities of key actors, crucially states, in ensuring that women have access to, and provision of, services required to realize their reproductive rights. What is needed, this article suggests, is a framework that can translate decades of rights language into action and specifically identify the provisions required to address women's health.

The educational pipeline for health care professionals : understanding the source of racial differences

The underrepresentation of blacks in the healthcare professions may have direct implications for the health outcomes of minority patients, underscoring the importance of understanding movement through the educational pipeline into professional healthcare careers by race. We jointly model individuals' postsecondary decisions including enrollment, college type, degree completion, and choosing a healthcare occupation requiring an advanced degree. We estimate the parameters of the model with maximum likelihood using data from the NLS-72. Our results emphasize the importance of pre-collegiate factors and of jointly examining the full chain of educational decisions in understanding the sources of racial disparities in professional healthcare occupations.

The effects of rurality on mental and physical health

The effects of rurality on physical and mental health are examined in analyses of a national dataset, the Community Tracking Survey, 2000-2001, that includes individual level observations from household interviews. We merge it with county level data reflecting community resources and use econometric methods to analyze this multi-level data. The statistical analysis of the impact of the choice of definition on outcomes and on the estimates and significance of explanatory variables in the model is presented using modern econometric methods, and differences in results for mental health and physical health are evaluated. © 2010 Springer Science+Business Media, LLC.

The benefits and challenges of conducting an overview of systematic reviews in public health: a focus on physical activity

Introduction The ultimate aim of Cochrane systematic reviews is to inform policy and practice decisions for better health outcomes. However, due to the increasing numbers of scientific publications, wading through the available evidence of both individual studies and systematic reviews can be challenging and overwhelming even for avid authors and readers. This paper briefly describes the first overview (a systematic review of reviews) of the Cochrane Public Health Group (CPHG) in development and proposes a way forward for the methodologies under consideration.

Health education and the control of intestinal worm infections in China : a new vision

Background: The transmission of soil-transmitted helminths (STHs) is associated with poverty, poor hygiene behaviour, lack of clean water and inadequate waste disposal and sanitation. Periodic administration of benzimidazole drugs is the mainstay for global STH control but it does not prevent re-infection, and is unlikely to interrupt transmission as a stand-alone intervention. Findings: We reported recently on the development and successful testing in Hunan province, PR China, of a health education package to prevent STH infections in Han Chinese primary school students. We have recently commenced a new trial of the package in the ethnically diverse Xishuangbanna autonomous prefecture in Yunnan province and the approach is also being tested in West Africa, with further expansion into the Philippines in 2015. Conclusions: The work in China illustrates well the direct impact that health education can have in improving knowledge and awareness, and in changing hygiene behaviour. Further, it can provide insight into the public health outcomes of a multi-component integrated control program, where health education prevents re-infection and periodic drug treatment reduces prevalence and morbidity.

What predicts mental health in midlife and older women? Results from the Australian Healthy Aging of Women Study

Objectives: Previous research has linked unhealthy lifestyle with a range of negative health outcomes in women. As women age however, they may have fewer performance expectations, but may view their health more positively. Clearly, the experiences of midlife and older women in relation to health and wellbeing need further exploration. The purpose of this study is to examine the factors associated with poor health-related quality of life in midlife (HRQoL) and older Australian women. Methods: The Australian longitudinal Healthy Aging of Women (HOW) study prospectively examines HRQoL, chronic disease and modifiable lifestyle factors midlife and older women as they age. Random sampling was used to select rural and urban based women from South-East Queensland, Australia. Data were collected from 386 women at three time points over the last decade (2001, 2004 and 2011). Results: The average age of women in this study was 65 years (SD = 2.82). Almost three-quarters (73%, n = 248) of the sample were married or living as though married, nine per cent (n = 30) were separated or divorced and a small proportion were had never married (n = 13). Most (86%, n = 291) of the women sample reported being Australian born, around one quarter (34%, n = 114) had completed additional study since leaving school (university degree or diploma). Over half (55%, n = 186) of participants were retired, one quarter (25%, n = 85) were in paid employment and the remained were unemployed (1%, n = 4), unable to work because of illness (2%, n = 6) or worked within the home (17%, n = 56). Using data collected over time we examined the relationship between a range of modifiable lifestyle factors and mental health using structural equation modelling. The overall model exhibited a good fit with the data. Poor sleep quality was associated with reduced mental health while better mental health was reported in women who exercised regularly and satisfied with their currently weight. As hypothesized, past mental health was a significant mediator of current mental health. Conclusions: These findings demonstrate that the mental health of women is complex and needs to be understood not only in terms of current lifestyle but also in relation to previously reported health status.

Understanding causal relationships between the built and social environment, health and associated behaviours and risk factors

Introduction: Built environment interventions designed to reduce non-communicable diseases and health inequity, complement urban planning agendas focused on creating more ‘liveable’, compact, pedestrian-friendly, less automobile dependent and more socially inclusive cities.However, what constitutes a ‘liveable’ community is not well defined. Moreover, there appears to be a gap between the concept and delivery of ‘liveable’ communities. The recently funded NHMRC Centre of Research Excellence (CRE) in Healthy Liveable Communities established in early 2014, has defined ‘liveability’ from a social determinants of health perspective. Using purpose-designed multilevel longitudinal data sets, it addresses five themes that address key evidence-base gaps for building healthy and liveable communities. The CRE in Healthy Liveable Communities seeks to generate and exchange new knowledge about: 1) measurement of policy-relevant built environment features associated with leading non-communicable disease risk factors (physical activity, obesity) and health outcomes (cardiovascular disease, diabetes) and mental health; 2) causal relationships and thresholds for built environment interventions using data from longitudinal studies and natural experiments; 3) thresholds for built environment interventions; 4) economic benefits of built environment interventions designed to influence health and wellbeing outcomes; and 5) factors, tools, and interventions that facilitate the translation of research into policy and practice. This evidence is critical to inform future policy and practice in health, land use, and transport planning. Moreover, to ensure policy-relevance and facilitate research translation, the CRE in Healthy Liveable Communities builds upon ongoing, and has established new, multi-sector collaborations with national and state policy-makers and practitioners. The symposium will commence with a brief introduction to embed the research within an Australian health and urban planning context, as well as providing an overall outline of the CRE in Healthy Liveable Communities, its structure and team. Next, an overview of the five research themes will be presented. Following these presentations, the Discussant will consider the implications of the research and opportunities for translation and knowledge exchange. Theme 2 will establish whether and to what extent the neighbourhood environment (built and social) is causally related to physical and mental health and associated behaviours and risk factors. In particular, research conducted as part of this theme will use data from large-scale, longitudinal-multilevel studies (HABITAT, RESIDE, AusDiab) to examine relationships that meet causality criteria via statistical methods such as longitudinal mixed-effect and fixed-effect models, multilevel and structural equation models; analyse data on residential preferences to investigate confounding due to neighbourhood self-selection and to use measurement and analysis tools such as propensity score matching and ‘within-person’ change modelling to address confounding; analyse data about individual-level factors that might confound, mediate or modify relationships between the neighbourhood environment and health and well-being (e.g., psychosocial factors, knowledge, perceptions, attitudes, functional status), and; analyse data on both objective neighbourhood characteristics and residents’ perceptions of these objective features to more accurately assess the relative contribution of objective and perceptual factors to outcomes such as health and well-being, physical activity, active transport, obesity, and sedentary behaviour. At the completion of the Theme 2, we will have demonstrated and applied statistical methods appropriate for determining causality and generated evidence about causal relationships between the neighbourhood environment, health, and related outcomes. This will provide planners and policy makers with a more robust (valid and reliable) basis on which to design healthy communities.

Health consequences of exposure to brominated flame retardants : a systematic review

Background Brominated flame retardants (BFRs), are chemicals widely used in consumer products including electronics, vehicles, plastics and textiles to reduce flammability. Experimental animal studies have confirmed that these compounds may interfere with thyroid hormone homeostasis and neurodevelopment but to date health effects in humans have not been systematically examined. Objectives To conduct a systematic review of studies on the health impacts of exposure to BFRs in humans, with a particular focus on children. Methods A systematic review was conducted using the Medline and EMBASE electronic databases up to 1 February 2012. Published cohort, cross-sectional, and case-control studies exploring the relationship between BFR exposure and various health outcomes were included. Results In total, 36 epidemiological studies meeting the pre-determined inclusion criteria were included. Plausible outcomes associated with BFR exposure include diabetes, neurobehavioral and developmental disorders, cancer, reproductive health effects and alteration in thyroid function. Evidence for a causal relationship between exposure to BFRs and health outcomes was evaluated within the Bradford Hill framework. Conclusion Although there is suggestive evidence that exposure to BFRs is harmful to health, further epidemiological investigations particularly among children, and long-term monitoring and surveillance of chemical impacts on humans are required to confirm these relationships.

Transport and health in China : recent collaborative research relating to vehicle factors and pollution

The nature of the transport system contributes to public health outcomes in a range of ways. The clearest contribution to public health is in the area of traffic crashes, because of their direct impact on individual death and disability and their direct costs to the health system. Other papers in this conference address these issues. This paper outlines some collaborative research between the Centre for Accident Research and Road Safety - Queensland (CARRS-Q) at QUT and Chinese researchers in areas that have indirect health impacts. Heavy vehicle dynamics: The integrity of the road surface influences crash risk, with ruts, pot-holes and other forms of road damage contributing to increased crash risks. The great majority of damage to the road surface from vehicles is caused by heavy trucks and buses, rather than cars or smaller vehicles. In some cases this damage is due to deliberate overloading, but in other cases it is due to vehicle suspension characteristics that lead to occasional high loads on particular wheels. Together with a visiting researcher and his colleagues, we have used both Queensland and Chinese data to model vehicle suspension systems that reduce the level of load, and hence the level of road damage and resulting crash risk(1-5). Toll worker exposure to vehicle emissions: The increasing construction of highways in China has also involved construction of a large number of toll roads. Tollbooth workers are potentially exposed to high levels of pollutants from vehicles, however the extent of this exposure and how it relates to standards for exposure are not well known. In a study led by a visiting researcher, we conducted a study to model these levels of exposure for a tollbooth in China(6). Noise pollution: The increasing presence of high speed roads in China has contributed to an increase in noise levels. In this collaborative study we modelled noise levels associated with a freeway widening near a university campus, and measures to reduce the noise(7). Along with these areas of research, there are many other areas of transport with health implications that are worthy of exploration. Traffic, noise and pollution contribute to a difficult environment for pedestrians, especially in an ageing society where there are health benefits to increasing physical activity. By building on collaborations such as those outlined, there is potential for a contribution to improved public health by addressing transport issues such as vehicle factors and pollution, and extending the research to other areas of travel activity. 1. Chen, Y., He, J., King, M., Chen, W. and Zhang, W. (2014). Stiffness-damping matching method of an ECAS system based on LQG control. Journal of Central South University, 21:439-446. DOI: 10.1007/s1177101419579 2. Chen, Y., He, J., King, M., Feng, Z. and Chang, W. (2013). Comparison of two suspension control strategies for multi-axle heavy truck. Journal of Central South University, 20(2): 550-562. 3. Chen, Y., He, J., King, M., Chen, W. and Zhang, W. (2013). Effect of driving conditions and suspension parameters on dynamic load-sharing of longitudinal-connected air suspensions. Science China Technological Sciences, 56(3): 666-676. DOI: 10.1007/s11431-012-5091-3 4. Chen, Y., He., J., King, M., Chen, W. and Zhang, W. (2013). Model development and dynamic load-sharing analysis of longitudinal-connected air suspensions. Strojniški Vestnik - Journal of Mechanical Engineering, 59(1):14-24. 5. Chen, Y., He, J., King, M., Liu, H. and Zhang, W. (2013). Dynamic load-sharing of longitudinal-connected air suspensions of a tri-axle semi-trailer. Proceedings of Transportation Research Board Annual Conference, Washington DC, 13-17 January 2013, paper no. 13-1117. 6. He, J., Qi, Z., Hang, W., King, M., and Zhao, C. (2011). Numerical evaluation of pollutant dispersion at a toll plaza based on system dynamics and Computational Fluid Dynamics models. Transportation Research Part C, 19(2011):510-520. 7. Zhang, C., He, J., Wang, Z., Yin, R. and King, M. (2013). Assessment of traffic noise level before and after freeway widening using traffic microsimulation and a refined classic noise prediction method. Proceedings of Transportation Research Board Annual Conference, Washington DC, 13-17 January 2013, paper no. 13-2016.

Health consequences of exposure to e-waste : a systematic review

Background The population exposed to potentially hazardous substances through inappropriate and unsafe management practices related to disposal and recycling of end-of-life electrical and electronic equipment, collectively known as e-waste, is increasing. We aimed to summarise the evidence for the association between such exposures and adverse health outcomes. Methods We systematically searched five electronic databases (PubMed, Embase, Web of Science, PsycNET, and CINAHL) for studies assessing the association between exposure to e-waste and outcomes related to mental health and neurodevelopment, physical health, education, and violence and criminal behaviour, from Jan 1, 1965, to Dec 17, 2012, and yielded 2274 records. Of the 165 full-text articles assessed for eligibility, we excluded a further 142, resulting in the inclusion of 23 published epidemiological studies that met the predetermined criteria. All studies were from southeast China. We assessed evidence of a causal association between exposure to e-waste and health outcomes within the Bradford Hill framework. Findings We recorded plausible outcomes associated with exposure to e-waste including change in thyroid function, changes in cellular expression and function, adverse neonatal outcomes, changes in temperament and behaviour, and decreased lung function. Boys aged 8–9 years living in an e-waste recycling town had a lower forced vital capacity than did those living in a control town. Significant negative correlations between blood chromium concentrations and forced vital capacity in children aged 11 and 13 years were also reported. Findings from most studies showed increases in spontaneous abortions, stillbirths, and premature births, and reduced birthweights and birth lengths associated with exposure to e-waste. People living in e-waste recycling towns or working in e-waste recycling had evidence of greater DNA damage than did those living in control towns. Studies of the effects of exposure to e-waste on thyroid function were not consistent. One study related exposure to e-waste and waste electrical and electronic equipment to educational outcomes. Interpretation Although data suggest that exposure to e-waste is harmful to health, more well designed epidemiological investigations in vulnerable populations, especially pregnant women and children, are needed to confirm these associations. Funding Children's Health and Environment Program, Queensland Children's Medical Research Institute, The University of Queensland, Australia.

The impact of frailty and polypharmacy on adverse outcomes in older inpatients

Background Older people are at significant risk of adverse outcomes as a result of changes in physiology, frailty, co-morbidity and polypharmacy.1 Timely identification of high-risk patients may facilitate the optimization of medication and reduce the incidence of adverse outcomes. The aims of this study were to evaluate in older inpatients the relationships between risk factors, including frailty and polypharmacy, and adverse health outcomes. Methods This is a prospective study of 1418 patients, aged 70 and older, admitted to general medical units in 11 acute care hospitals across Australia. The interRAI Acute Care (interRAI AC) assessment tool was used for data collection. Frailty status was measured using a Frailty Index (FI), adding each individual’s deficits and dividing by the total number of deficits considered. Adverse health outcomes included falls in hospital, delirium, in-hospital functional and cognitive decline, discharge to a higher level of care and inpatient mortality. Results Patients had a mean age 81 ± 6.8 years with a median length of hospital stay of 6 days (interquartile range 4 to 11 days); 701 (50%) experienced at least one adverse outcome. Polypharmacy (5-9 drugs per day) was observed in almost half of the study population (n=695, 49%) and hyper-polypharmacy (≥10 drugs) observed in about one-third of patients (n=490, 34.6%). Cognitive impairment was shown to be associated with the lower rate of prescribing. FI had a significant association with all adverse outcomes studied (p = <0.05). In contrast, no association was observed between polypharmacy categories and adverse outcomes except for those on 10 or more drugs where they were more likely to be discharged to a higher level of care (p= 0.014). Conclusions Among older inpatients, frailty status was a significant predictor of adverse outcomes. Lower rates of prescribing to patients with cognitive impairment may underpin the lack of an association between polypharmacy and adverse outcomes in this cohort. References: 1. Olsson IN, Runnamo R, Engfeldt P. Medication quality and quality of life in the elderly, a cohort study.Health Qual Life Outcomes.2011;9:95

The long-term health consequences of child physical abuse, emotional abuse, and neglect : a systematic review and meta-analysis

Background Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes. Methods and Findings A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16–2.04], emotional abuse [OR = 3.06; 95% CI 2.43–3.85], and neglect [OR = 2.11; 95% CI 1.61–2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67–2.20], emotional abuse [OR = 1.41; 95% CI 1.11–1.79], and neglect [OR = 1.36; 95% CI 1.21–1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17–5.32], emotional abuse [OR = 3.37; 95% CI 2.44–4.67], and neglect [OR = 1.95; 95% CI 1.13–3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50–2.10], emotional abuse [OR = 1.75; 95% CI 1.49–2.04], and neglect [OR = 1.57; 95% CI 1.39–1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships. Conclusions This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.