André Rougemont

Validation of a French-language version of the MOS 36-Item Short Form Health Survey (SF-36) in young healthy adults

The MOS 36-Item Short Form Health Survey (SF-36) is designed to measure 8 dimensions of health in clinical and general population settings. The main aim of this paper was to examine the reliability and validity of this instrument in young adults. A secondary aim was to document the results of a rapid translation procedure of the instrument, to be compared later to the more thorough official French adaptation. The translated survey was answered in 1992 by 1007 residents of Geneva, Switzerland, 18-44 years old, identified from health insurance rolls (82% response rate). Completion rate for all 8 dimensions of health was 95.5%. The instrument demonstrated excellent covergent (100%) and discriminant (98%) validity against pre-set criteria. Interval scaling of responses could be verified in some, but not all, items. Cronbach alpha (reliability) coefficients ranged from 0.76 to 0.92. Factorial analysis yielded 2 principal components, corresponding to mental and physical health. Thirteen of 16 correlations between health dimensions and principal components were within a pre-established range. Validation by independent clinical variables was also, with few exceptions, consistent with theory. Thus the SF-36 retained excellent psychometric properties even when used in a generally very healthy group. The careful but rapid translation procedure used in this study may be an effective alternative to full-scale cultural adaptations when resources are limited.

Cohort Profile: The Swiss National Cohort—a longitudinal study of 6.8 million people

For many years research on socio-economic inequalities in health in Switzerland was based on crosssectional data. Cross-sectional studies are problematic for several reasons. For example, results may be affected by numerator/denominator bias. Furthermore, occupational information from death certificates was used to describe the socio-economic position of individuals. However, this meant that those who do not work, older men and a substantial proportion of women, had to be excluded. Decennial censuses, conducted at the beginning of December every 10 years, have been done in Switzerland since 1850 (exceptions were 1890 and 1940, which were replaced by a census in 1888 and 1941, respectively). Deaths and causes of death have been registered since 1876, with data stored electronically since 1969. Death registration is anonymous. However, the date of death and birth are available, as well as gender, marital status, place of residence, date of birth of spouse and other variables. The 1990 census for the first time included the exact date of birth, which opened the possibility of linking census and mortality data. Based on the promising results of a pilot study that was done for one Canton at University of Zurich, the project was extended to cover the whole of Switzerland, linking the 1990 census with mortality records up to the end of 1997. The results indicated that linkage was less successful for foreign nationals and young adults, and led to the inclusion of additional data sources, including data on immigrants and emigrants and, importantly, the 2000 census. In 2005, an application by all five University Institutes of Social and Preventive Medicine (ISPMs) to obtain long-term funding for a Swiss National Cohort study (SNC) was successful within the framework of a Swiss National Science Foundation initiative to support longitudinal studies. Approval was obtained from the Ethics Committees of the Cantons of Zurich and Bern and a data centre was established at ISPM Bern.

Epidemiological basis for clinical diagnosis of childhood malaria in endemic zone in West Africa

It is difficult to distinguish childhood malaria from other common febrile disorders by parasite count alone, because of the wide variation in tolerance of parasitaemia among individuals. We postulated that the proportion of febrile episodes among young children that can be attributed to parasitaemia varies according to simple clinical criteria. We studied 1114 children aged 2-9 years, who attended a dispensary in the Republic of Niger, with a case-control approach; each of 557 febrile children was matched with a non-febrile control by sex, age, ethnic group, and day of presentation. Febrile episodes were classified according to three clinical criteria: the presence of a likely non-malarial cause; the duration (less than 3 or more than 3 days before presentation); and the intensity (below 39 degrees C or 39 degrees C and above). There was no evidence for an association between febrile episodes and parasite count during the dry, low-transmission, season. During the rainy, high-transmission, season, by contrast, there was a highly significant relation (p less than 0.0001) between the likelihood of fever and the parasite count; each clinical criterion strengthened the association. There was no association between parasitaemia and low intensity fevers, with an obvious cause, that started 3 or more days before presentation, even in the rainy season; however, the relative risk of a fever that met all three criteria developing in those with vs those without parasitaemia was 27.5. The proportion of febrile cases attributable to detectable parasitaemia (population attributable risk) ranged from 0 to 0.92. Our results suggest that simple clinical criteria may be valuable in the selection of febrile patients for antimalarial treatment. In this geographic area, high fever of short duration and with no other obvious cause that occurs during the rainy season is most likely to be malaria.

What does a single determination of malaria parasite density mean? A longitudinal survey in Mali

Summary Temporal variations of blood parasite density were evaluated in a longitudinal study of young, asymptomatic men in a village with endemic malaria in Mali (West Africa). Our main intention was to challenge the value of a single measure of parasite density for the diagnosis of malaria, and to define the level of endemicity in any given area. Parasitaemia and body temperature were recorded three times a day in the wet season (in 39 subjects on 12 days) and in the dry season (in 41 subjects on 13 days). Two thousand nine hundred and fifty seven blood smears (98.5% of the expected number) were examined for malaria parasites. We often found 100‐fold or greater variations in parasite density within a 6‐hour period during individual follow‐up. All infected subjects had frequent negative smears. Although fever was most likely to occur in subjects with a maximum parasite density exceeding 10000 parasites/mm3 (P = 0.009), there was no clear relationship between the timing of these two events. Examples of individual profiles for parasite density and fever are presented. These variations (probably due to a ‘sequestration‐release’ mechanism, which remains to be elucidated) lead us to expect a substantial impact on measurements of endemicity when only a single sample is taken. In this study, the percentage of infected individuals varied between 28.9% and 57.9% during the dry season and between 27.5% and 70.7% during the wet season. The highest rates were observed at midday, and there were significant differences between days. Thus, high parasite density sometimes associated with fever can no longer be considered as the gold standard in the diagnosis of malaria. Other approaches, such as decision‐making processes involving clinical, biological and ecological variables must be developed, especially in highly endemic areas where Plasmodium infection is the rule rather than the exception and the possible causes of fever are numerous.

HYPOHAPTOGLOBINAEMIA AS AN EPIDEMIOLOGICAL AND CLINICAL INDICATOR FOR MALARIA: Results of Two Studies in a Hyperendemic Region in West Africa

Hypohaptoglobinaemia is a common phenomenon in tropical countries, where it is probably due to malaria-induced haemolysis. Two studies were carried out in a hyperendemic zone of West Africa to test its specificity and usefulness as an epidemiological indicator for measuring malaria endemicity. The first study evaluated the prevalence of hypohaptoglobinaemia before and after courses of antimalarial chemotherapy of varying duration. The second monitored haptoglobin levels in an untreated population during a whole year to compare its seasonal variations with those of several classic indicators of malaria. These studies suggest that in regions where malaria is endemic the prevalence of hypohaptoglobinaemia could be as useful an indicator as the parasitic index but would be much easier to establish and to monitor.

The protective effect of taking care of grandchildren on elders’ mental health? Associations between changing patterns of intergenerational exchanges and the reduction of elders’ loneliness and depression between 1993 and 2007 in Taiwan

BackgroundThe 20th century’s rapid industrialization and urbanization brought important social changes to Taiwan, including an increased number of elders living alone, which has increased risk of depression for the elderly. This study aimed to evaluate the changing pattern regarding the effect of intergenerational exchanges on elders’ depressive symptoms from 1993 to 2007.MethodsData from the second-, fourth- and sixth-wave surveys of the Study of Health and Living Status of the Middle-Aged and Elderly in Taiwan were analyzed. This study collected elders’ individual sociodemographic characteristics, their self-reported health status and their intergenerational exchanges, including living with partners or with their children and their provision of care for their grandchildren. Information about elders’ depression was evaluated using the 5-item Epidemiological Studies Depression Scale (CES-D).Changes in elders’ intergenerational exchanges and depressive symptoms were compared during these study periods (chi-square test). Then, logistic regression was performed to determine how significantly elders’ intergenerational exchanges were associated with their depressive symptoms across the three years 1993, 1999 and 2007.ResultsThe prevalence of elders living with partners decreased from 1993 to 2007 by 19%, and that of living with their children decreased from 1993 to 2007 by 7%. Conversely, the percentage of elders providing care for grandchildren dramatically increased, from 9% in 1993 to 21% in 2007. Elderly people had significantly fewer depressive symptoms in 2007 than in 1993.After adjusting for confounders, those living without a partner, living without children or providing no grandchild care had a greater risk of feeling lonely and being depressed. However, during the period 1993 to 2007, the impact on elders’ depression and loneliness of co-residing with a partner or with children decreased at the same time that the impact of their provision of grandchild care increased. In 2007, elders who provided no grandchild care were significantly more likely to feel lonely and sad as well as to have high CES-D scores; these strong associations were not found in 1993 and 1999.ConclusionsThis study illustrates how taking care of grandchildren protects against depression and loneliness in elderly Taiwanese. We argue the need, in an aging society, for improving intergenerational interaction and recommend careful evaluation of the interaction between population policies and those of social welfare, such as child care.

When providers and community leaders define health priorities: the results of a Delphi survey in the canton of Geneva

The Delphi method was used to determine the health priorities in one Swiss canton. The opinion of various groups concerned, either as health professionals or as representatives of the general population, was gathered to identify the health determinants and health problems perceived as most important, to clarify the reasons for these choices, and to recommend interventions to be undertaken in order to improve the situation in the identified priority areas. Five panels, including health professionals as well as selected leaders of community groups with no direct involvement in health, were given the opportunity to reply to two rounds of questionnaires. There was a high convergence of opinion on health determinants and problems to be given priority between panels and between the first and second round. Priorities identified are mainly physical problems (cardiovascular disease, respiratory and breast cancer, AIDS, injuries due to road accidents, chronic back pain), psychosocial disorders (depression, suicide, violence in the family, stress), and problems of substance abuse (alcohol and tobacco). Unemployment and social isolation were chosen because of their perceived impact on health. Very few interventions were proposed in the medical technical or research areas. This may be due partly to the fact that good quality care is widely available and accessible in Geneva, whereas preventive programmes have not received enough attention in the past. Through the identified priorities and the proposed activities, a new vision of health emerges which gives more importance to psychosocial problems and the social environment. In this context, health promotion is seen as essential, acknowledging that sustained change in individual behaviours can only occur if the social and cultural context is taken into consideration. In conclusion, the results of this survey show that the Delphi method is a useful tool to reach consensus on health priorities and corresponding activities among a variety of actors.

Is the reporting timeliness gap for avian flu and H1N1 outbreaks in global health surveillance systems associated with country transparency

BackgroundThis study aims to evaluate the length of time elapsed between reports of the same incidents related to avian flu and H1N1 outbreaks published by the WHO and ProMED-mail, the two major global health surveillance systems, before and after the amendment of the International Health Regulations in 2005 (IHR 2005) and to explore the association between country transparency and this timeliness gap.MethodsWe recorded the initial release dates of each report related to avian flu or H1N1 listed on the WHO Disease Outbreak News site and the matching outbreak report from ProMED-mail, a non-governmental program for monitoring emerging diseases, from 2003 to the end of June 2009. The timeliness gap was calculated as the difference in days between the report release dates of the matching outbreaks in the WHO and ProMED-mail systems. Civil liberties scores were collected as indicators of the transparency of each country. The Human Development Index and data indicating the density of physicians and nurses were collected to reflect countries’ development and health workforce statuses. Then, logistic regression was performed to determine the correlation between the timeliness gap and civil liberties, human development, and health workforce status, controlling for year.ResultsThe reporting timeliness gap for avian flu and H1N1 outbreaks significantly decreased after 2003. On average, reports were posted 4.09 (SD = 7.99) days earlier by ProMED-mail than by the WHO. Countries with partly free (OR = 5.77) and free civil liberties scores (OR = 10.57) had significantly higher likelihoods of longer timeliness gaps than non-free countries. Similarly, countries with very high human development status had significantly higher likelihoods of longer timeliness gaps than countries with middle or low human development status (OR = 5.30). However, no association between the timeliness gap and health workforce density was found.ConclusionThe study found that the adoption of IHR 2005, which contributed to countries’ awareness of the importance of timely reporting, had a significant impact in improving the reporting timeliness gap. In addition, the greater the civil liberties in a country (e.g., importance of freedom of the media), the longer the timeliness gap.

Utility of the detection of Plasmodium parasites for the diagnosis of malaria in endemic areas

BackgroundIn populations where the prevalence of infection with Plasmodium parasites is high, blood tests that identify Plasmodium parasites in patients with fever may lead to false positive diagnosis of malaria-disease. We characterised the diminishing value of the parasite detection test as a function of the prevalence of infection.MethodsWe computed the ability of the parasite detection test to identify malaria at various levels of prevalence (0% to 90%), assuming plausible estimates of sensitivity (95% and 85%) and specificity (99% and 95%) for the detection of parasites. In each situation, we computed likelihood ratios of malaria (or absence of malaria) for positive and negative parasite detection tests. Likelihood ratios were classified as clinically useful (≥ 10), intermediate (5–10), or unhelpful (<5).ResultsLikelihood ratios of positive tests were strongly related to the prevalence of infection in the general population: a positive test was unhelpful when the prevalence was 20% or more, and useful only when prevalence was 5% or less. The sensitivity and specificity of the test had little influence on these results. Likelihood ratios of negative tests were clinically useful when prevalence was 70% or less, but only for high levels of sensitivity (95%). If sensitivity was low (85%), the negative test was at best of intermediate utility, and was unhelpful if the prevalence of asymptomatic infection exceeded 30%.ConclusionIdentification of Plasmodium parasites supports a diagnosis of malaria only in areas where the prevalence of Plasmodium infection is low. Wherever this prevalence exceeds about 20%, a positive test is clinically unhelpful.

A learner‐centered curriculum in public health at the University of Geneva

Switzerlands first masters program in public health was established in the fall of 1990 at the University of Geneva School of Medicine. The 3‐year program is fully learner centered and community oriented. The process of problem‐based learning (PBL), around which the program is designed, is well accepted by students and staff. In the summer of 1993, the first cohort of students was certified as competent public health specialists who have acquired relevant professional skills as well as a holistic “public health culture.” Throughout the curriculum, students plan, implement, and evaluate projects related to health problems they have encountered in their own employment as health professionals. Individual and group work, discussions and seminars with teachers and other students, and brainstorming sessions with the programs specially trained facilitators allow students to identify and achieve individual educational objectives while working on community‐related health projects. Beyond its internal objectives...