Christopher A. Birt

Estimating the cardiovascular mortality burden attributable to the European Common Agricultural Policy on dietary saturated fats

OBJECTIVE To estimate the burden of cardiovascular disease within 15 European Union countries (before the 2004 enlargement) as a result of excess dietary saturated fats attributable to the Common Agricultural Policy (CAP). METHODS A spreadsheet model was developed to synthesize data on population, diet, cholesterol levels and mortality rates. A conservative estimate of a reduction in saturated fat consumption of just 2.2 g was chosen, representing 1% of daily energy intake. The fall in serum cholesterol concentration was then calculated, assuming that this 1% reduction in saturated fat consumption was replaced with 0.5% monounsaturated and 0.5% polyunsaturated fats. The resulting reduction in cardiovascular and stroke deaths was then estimated, and a sensitivity analysis conducted. FINDINGS Reducing saturated fat consumption by 1% and increasing monounsaturated and polyunsaturated fat by 0.5% each would lower blood cholesterol levels by approximately 0.06 mmol/l, resulting in approximately 9800 fewer coronary heart disease deaths and 3000 fewer stroke deaths each year. CONCLUSION The cardiovascular disease burden attributable to CAP appears substantial. Furthermore, these calculations were conservative estimates, and the true mortality burden may be higher. The analysis contributes to the current wider debate concerning the relationship between CAP, health and chronic disease across Europe, together with recent international developments and commitments to reduce chronic diseases. The reported mortality estimates should be considered in relation to the current CAP and any future reforms.

Quality of and access to green space in relation to psychological distress: results from a population-based cross-sectional study as part of the EURO-URHIS 2 project

Background Psychological distress (PD) (mental ill-health) has a frequency between 5 and 25% in urban populations, and there is mounting evidence that access to green space might reduce its occurrence. Evidence suggests that the quality of green space is as important as accessibility in promoting mental well-being. A pilot study for EURO-URHIS 2 allowed investigation of access to green space in relation to PD in a deprived urban population in the UK. Methods An adult urban health indicator questionnaire, including the GHQ-12 and validated questions on access to and quality of green space, was sent to a stratified random sample of 1680 adults drawn from one general practice list in Sandwell, UK. Multivariable logistic regression was used to determine associations between attributes of green space and PD adjusting for age, sex and levels of deprivation. Results There were 578 (35%) completed responses. The reported prevalence of PD [n = 131 (22.7%)] was significantly greater than national England and Wales estimates. As well as accessibility (OR = 0.58; 95% CI = 0.35, 0.96) and sufficiency (OR = 0.12; 95% CI = 0.39, 0.89) of green spaces, having the ability to use them for relaxation and recreation were significantly associated with reduced PD [OR = 0.13 (0.42, 0.94) and OR = 0.11 (0.34, 0.80), respectively]. In addition, a dose-response relationship between number of positive green space attributes and PD was identified (P < 0.05). Conclusion This population-based study in a deprived urban UK population demonstrates an association, and some dose-response relationship, between access to and quality of green spaces with reduced PD. The cross-sectional design and use of subjective measures limit interpretation of causality. More knowledge is needed on how UK planning affects green spaces and the potential mental health consequences.

The Developing Role of Systems of Competences in Public Health Education and Practice

In recent decades there have been attempts in many professions to define the competences of their practitioners. Over the last quarter century attempts have been made to apply this to public health; initiatives in several countries have been devised to meet the perceived needs of public health education and training (e.g., the United States), of public health practice (e.g., the United Kingdom), etc. The achievements and some of the failings of US and UK initiatives are reviewed.Since 2006 The Association of Schools of Public Health in the European Region (ASPHER) has been working on a system of public health competences suited and adapted to the needs of both public health education and training, and practice. After much work and several stages of development, a third series of competence lists (for public health practitioners generally, for MPH-related education, and for employment purposes) will soon be published. ASPHER believes that for sustainability of a competences project, the competences proposed must be seen as relevant by all public health practitioners and stakeholders, including those engaged in education and training, service work, and public health research. Accordingly, all these stakeholders need to be involved in the preparation of lists of competences.Sustainability will also require an ongoing system and structure for permanent review of existing public health competences, and of the need for definition of new ones. Possible directions towards the achievement of this are indicated. A generally accepted system of core competences could contribute most to the establishment of a clearly identifiable public health profession across Europe, equipped to address current and future health needs of its peoples.All three experiences described share similar challenges, and on a continuing basis these will of necessity need to be addressed in the future: the assessment of whether competences have been achieved or not; the evaluation of whether lists of competences are genuinely appropriate both to population health challenges and to the development and management of systems of intervention as experienced in practice; identification of appropriate means to take account of geographical, regional and national disparities within one common competence system.

Public health capacity building—not only the property of the medical profession

In this issue of the Journal, Westerling1 provides a comprehensive overview of the work performed by the Public Health (PH) Section of the European Union of Medical Specialists (UEMS), as this relates to the further development and harmonization of medical specialization in PH within the EU. He makes some very important points, many of which effectively have been overlooked and ignored, including by the European Commission, for much too long. His points regarding the harmonization of specialist training, the need for uniformly high standards of PH practice across the EU, as well as for high quality of education and training of PH specialists, and concerning the urgent need to define the core content of the specialty, are all well made. However, although all this is splendid stuff, he deludes himself if he believes that this remains a matter only for the medical profession: PH in the 21st century has become multi-disciplinary. Over the years, the contribution of the medical profession to PH has been impressive; indeed, PH to a large extent owes its mere existence to the enormous contributions made to it by distinguished members of the medical profession, and during the 20th century medical postgraduate specialization in PH contributed significantly to the development of the specialty. However, nowadays there are new types of educational investments that are required for PH capacity building, at both academic and service levels of PH education and training; moreover, nowadays these involve students and trainees from a variety of backgrounds, only one of which may be medicine. In the UK for example, trainees are now selected for higher PH training from both medical and non-medical backgrounds (the non-medical entrants have usually distinguished themselves in professions related in one way or another to health services). All UK trainees, both medical and non-medical, undergo identical …

Why investigate urban health indicators

Globally, the majority of people now live in urban areas.1 The European Urban Health Indicator System projects parts 1 and 2 (EURO-URHIS 1 and 2) have been developing tools to help policy-makers determine the health, and ways to improve the health, of urban dwellers. The focus of policy-makers should not just be on a narrow health perspective but also on the need to improve the environment, social status and quality of life of urban populations by all means possible. Descriptive studies at urban and sub-urban level which measure the extent of problems and monitor progress, and population-based interventions, are essential to ensure the sustainability of healthy urbanization and the wellbeing of urban citizens. Multidisciplinary, trans-sectoral research into evidence-based policy-making, i.e. from bench to populations, is the only way to bring about real health gain for the global urban resident. ‘Health is wealth’ must be the rallying cry for all urban policy-makers. In 1978, the United Nations (UN) recognized that the urban environment was a global challenge and created the Human Settlements Programme, or UN-Habitat, for sustainable settlement development and adequate shelter for all. Thirty years later, the urban population has now exceeded the rural population and become poorest subset of the World’s population.2 The movement of populations into urban areas (UAs) is due in part to the drive to achieve better general socioeconomic, cultural and environmental conditions. However, it has led to an expansion of urban environments known as ‘urban sprawl’. UAs can be split into many different zones depending on the functionality and density of the infrastructure and environment, e.g. urban heart or ‘city centre’, industrial and commercial zones, and suburban areas which are mostly residential or mixed function.3,4 The resultant variation in urban environments means it is often difficult to define the ‘city’ …

Do academic competencies relate to 'real life' public health practice? A report from two exploratory workshops

Public health (PH) organizations in different parts of the world (such as North America1,2) have recently been seeking to define competencies relevant to PH practice. The Association of Schools of PH in the European Region (ASPHER) has initiated a programme to produce a European PH competency framework.3,4 ASPHER invited all member schools to participate in brainstorming workshops which yielded a provisional list of competencies.3 These were discussed and supplemented with more competencies at two European conferences (at Aarhus University, Denmark, in April 2008, and at Ecole des Hautes Etudes de Sante Publique (EHESP), Paris, France, in October 2008), with the participation of representatives of national health systems as well as of schools of PH (SsPH); the conferences aimed at further development of the lists based on continuing dialogue between SsPH and PH stakeholders. Typically, competencies are general descriptions of the knowledge or skills needed by an individual, or a group, to perform a specific activity in an organization. A European cross-country PH competency framework has many potential applications, including standard setting and curriculum development in PH education and training, benchmarking for completion of training and of specific roles, as well as an aid to job description construction. As well as promoting a structured and systematic approach to personal professional development, such a framework could be used to identify needs for PH capacity building, and to facilitate professional collaboration and mobility, exchange of ideas and PH employment opportunities throughout Europe. Moreover, the development process itself, aiming at agreed-upon lists …

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

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

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

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

Collecting standardized urban health indicator data at an individual level for school-aged children living in urban areas: methods from EURO-URHIS 2.

Background Measuring health and its determinants in urban populations is essential to effectively develop public health policies maximizing health gain within this context. Adolescents are important in this regard given the origins of leading causes of morbidity and mortality develop pre-adulthood. Comprehensive, accurate and comparable information on adolescent urban health indicators from heterogeneous urban contexts is an important challenge. EURO-URHIS 2 aimed to develop standardized tools and methodologies collecting data from adolescents across heterogenous European urban contexts. Questionnaires were developed including (i) comprehensive assessment of urban health indicators from 7 pre-defined domains, (ii) use of previously validated questions from a literature review and other European surveys, (iii) translation/back-translation into European languages and (iv) piloting. Urban area-specific data collection methodologies were established through literature review, consultation and piloting. School-based surveys of 14-16-year olds (400-800 per urban area) were conducted in 13 European countries (33 urban areas). Participation rates were high (80-100%) for students from schools taking part in the surveys from all urban areas, and data quality was generally good (low rates of missing/spoiled data). Overall, 13 850 questionnaires were collected, coded and entered for EURO-URHIS 2. Dissemination included production of urban area health profiles (allowing benchmarking for a number of important public health indicators in young people) and use of visualization tools as part of the EURO-URHIS 2 project. EURO-URHIS 2 has developed standardized survey tools and methodologies for assessing key measures of health and its determinants in adolescents from heterogenous urban contexts and demonstrated the utility of this data to public health practitioners and policy makers.

Differences in adults’ health and health behaviour between 16 European urban areas and the associations with socio-economic status and physical and social environment

Background With a growing proportion of the European population living in urban areas (UAs), exploring health in urban areas becomes increasingly important. The objective of this study is to assess the magnitude of differences in health and health behaviour between adults living in urban areas (UAs) across Europe. We also explored whether and to what extent such differences can be explained by socio-economic status (SES) and physical or social environment. Data were obtained from a cross-sectional questionnaire survey, performed between as part of the European Urban Health Indicator System Part 2 (EURO-URHIS 2) project. Using multi-level logistic regression analysis, UA differences in psychological distress, self-assessed health, overweight and obesity, daily smoking, binge drinking and physical exercise were assessed. Median Odds Ratios (MORs) were calculated to estimate the extent to which the observed variance is attributable to UA, individual-level SES (measured by perceived financial strains, education level and employment status) and/or characteristics of physical and social environment. The dataset included 14 022 respondents in 16 UAs within 9 countries. After correction for age and gender, all MORs, except that for daily smoking, indicated statistically significant UA health differences. SES indicators (partly) explained UA differences in psychological distress, decreasing the MOR from 1.43 [95% credible interval (Cr.I.) 1.27-1.67, baseline model], to 1.25 (95% Cr.I. 1.14-1.40, SES model): a reduction of 42%. Accounting for the quality of green areas reduced the MOR for psychological distress by an additional 40%, to 1.15 (95% Cr.I. 1.05-1.28). Our study showed large differences in health and health behaviour between European UAs. Reducing socio-economic disadvantage and improving the quality of the neighbourhoods green spaces may reduce UA differences in psychological distress.