Gabriel Gulis

Workgroup Report: Drinking-Water Nitrate and Health-Recent Findings and Research Needs

Human alteration of the nitrogen cycle has resulted in steadily accumulating nitrate in our water resources. The U.S. maximum contaminant level and World Health Organization guidelines for nitrate in drinking water were promulgated to protect infants from developing methemoglobinemia, an acute condition. Some scientists have recently suggested that the regulatory limit for nitrate is overly conservative; however, they have not thoroughly considered chronic health outcomes. In August 2004, a symposium on drinking-water nitrate and health was held at the International Society for Environmental Epidemiology meeting to evaluate nitrate exposures and associated health effects in relation to the current regulatory limit. The contribution of drinking-water nitrate toward endogenous formation of N-nitroso compounds was evaluated with a focus toward identifying subpopulations with increased rates of nitrosation. Adverse health effects may be the result of a complex interaction of the amount of nitrate ingested, the concomitant ingestion of nitrosation cofactors and precursors, and specific medical conditions that increase nitrosation. Workshop participants concluded that more experimental studies are needed and that a particularly fruitful approach may be to conduct epidemiologic studies among susceptible subgroups with increased endogenous nitrosation. The few epidemiologic studies that have evaluated intake of nitrosation precursors and/or nitrosation inhibitors have observed elevated risks for colon cancer and neural tube defects associated with drinking-water nitrate concentrations below the regulatory limit. The role of drinking-water nitrate exposure as a risk factor for specific cancers, reproductive outcomes, and other chronic health effects must be studied more thoroughly before changes to the regulatory level for nitrate in drinking water can be considered.

Impact of financial crisis on selected health outcomes in Europe

BACKGROUND A number of health outcomes were affected by previous financial crises, e.g. suicides, homicides and transport accident mortality. Aim of this study was to analyse the effects of the current financial crisis on selected health outcomes at population level in Europe. METHODS A mixed approach of ecologic and time trend design was applied, including correlation analysis. For eight countries, data on the economic situation (unemployment rate and economic growth) and health indicators (overall mortality, suicide and transport accident mortality) was drawn from EUROSTAT database for 2000-10. Spearmans rank correlation was applied to analyse the influence of social protection on the association between exposure and outcome variables. RESULTS The financial crisis had no visible effect on overall mortality in any of the eight countries until 2010. Transport accident mortality decreased in all eight countries, in the range of 18% in Portugal to 52% in Slovenia. In contrast, suicide mortality increased in Germany (+5.3%), Portugal (+5.2%), Czech Republic (+7.6%), Slovakia (+22.7%) and Poland (+19.3%). The effect of unemployment on suicide is higher in countries with lower social spending (Spearmans r = -0.83). DISCUSSION Clear cause-effect relations could not be established owing to the ecological study design and issues concerning data availability. However, there are clear changes in suicide and transport accident mortality after onset of the crisis, and findings are consistent with previous work. As part of this work, a comprehensive framework was developed, which can be applied to analyse health effects of financial crises in more detail.

Intersectoral action for health: The experience of a Danish municipality

Background:The aim was to build up evidence on intersectoral action for health at local government level by identifying both challenges and facilitating factors in collaboration between sectors when developing and implementing an intersectoral health policy in Varde, Denmark. Methods: The study was carried out in 2011 using the case-study method. Approximately 500 pages of documents from the period 2007−2011 were analysed, and semi-structured interviews were carried out with nine key informants. Results: The following challenges were identified: the policy was perceived as an additional task by employees outside the health sector; initially no direct funding was allocated to intersectoral projects; the level of ambition was not balanced between sectors; there was a lack of ownership of the policy; baseline measures were lacking and the policy had no clear objectives. Facilitating factors were considered to be: significant political support; public involvement; use of local media; establishment of a ‘Fund for Health’; establishment of ‘Health Networks’ within sectors; and collaboration with a research group. Conclusions: Important practical lessons can be drawn from this experience for other cities planning to introduce similar formal intersectoral health policies. In order to increase the chance of successful intersectoral action in further development and implementation of the intersectoral health policy in Varde in the future, the challenges and facilitating factors identified in this study should be considered. More evidence is required on the long-term health impacts of such policies.

Health Impact Assessment: HIA

Health impact assessment (HIA) is a combination of procedures, methods and tools used in order to evaluate the potential effects of a policy or project on the health of a population. HIA, therefore, is a multidisciplinary and comprehensive governance tool used by decision-makers in order to build a healthy public policy and reduce health inequalities .

Health impact assessment and evaluation of a Roma housing project in Hungary

An outstanding feature of marginalized Roma communities is their severely substandard living conditions, which contribute to their worse health status compared to the majority. However, health consequences of international and local-level housing initiatives in most cases fail to be assessed prospectively or evaluated after implementation. This paper summarizes the result of a retrospective health impact assessment of a Roma housing project in Hungary in comparison with the outcome evaluation of the same project. Positive impacts on education, in- and outdoor conditions were noted, but negative impacts on social networks, housing expenses and maintenance, neighbourhood satisfaction and no sustained change in health status or employment were identified. Recommendations are made to improve efficiency and sustainability of housing development initiatives among disadvantaged populations.

Comparing public-health research priorities in Europe

BackgroundDespite improving trends, countries in Europe continue to face public-health challenges. This study investigated the priorities of stakeholders for research to meet these challenges.MethodsPublic-health research includes population-level and health-system research, but not clinical or biomedical research. The study drew on data from three surveys undertaken through collaboration in SPHERE (Strengthening Public Health Research in Europe). There was participation of ministries in 18 of 28 (64% response) European countries, from 22 of 39 (56% response) member national associations of the European Public Health Association, and from 80 civil society health organisations (53% of members of the European Public Health Alliance)ResultsPublic-health research fields included disease control, health promotion and health services. Ministries of health, rather than ministries of science or education, mostly took responsibility for public-health research: they reported varied but well-defined areas for research in relation to national health plans and programmes. National public health associations reported research priorities across most fields of public health, although with some European regional differences. Civil society health organisations prioritised health promotion research nationally, but also health services research internationally. There was less research reported on methods, such as modelling and economic analysis, wider determinants of health, and public-health interventions.ConclusionSystematic collaboration between stakeholders across European countries would enhance knowledge and promote innovation to address contemporary public-health challenges.

Assessment of population health risks of policies

Assessment of population health risks of policies / , Assessment of population health risks of policies / , کتابخانه دیجیتال جندی شاپور اهواز

Do Bolivian small holder farmers improve and retain knowledge to reduce occupational pesticide poisonings after training on Integrated Pest Management

BackgroundPesticide consumption is increasing in Bolivia as well as pest resistance, pesticide poisonings and pollution of the environment. This survey evaluates the training of small holder farmers on pesticide handling and ecological alternatives to reduce the negative pesticide effects.MethodA baseline survey was performed in 2002 and follow-up surveys in 2004 and 2009. Farmers were selected and trained on Integrated Pest Management (IPM) from 2002 to 2004 in Farmer Field Schools (FFS). After exclusions and drop outs, 23 FFS trained farmers could be compared to 47 neighbor farmers for changes in ‘knowledge, attitude and practice’ (KAP) on IPM and symptoms of poisoning when handling pesticides. Statistical analysis was performed with SPSS version 21.0 using χ2-test, Cochran’s Q test and Student’s T-test.ResultsImprovements were seen in both groups but most significant among the FFS farmers. At baseline no difference were seen between the two groups apart from a more frequent use of personal protection among the FFS farmers. After the training was finished significant differences were seen between FFS farmers and neighbor farmers on all KAP variables, a difference reduced to six of the KAP variables in 2009. No difference was seen in self-reported poisonings after pesticide handling. FFS farmers improved their KAP scores markedly during training and there after retained their knowledge, while neighbor farmers improved during the entire period. Ecological farming without the use of pesticides increased most among the FFS farmers.ConclusionThe study showed a sustained improvement among Farmers Field School trained farmers on personal protection and hygiene when handling pesticides, knowledge and use of IPM and ecological alternatives and a reduction in self-reported symptoms after pesticide handling. Similar though less pronounced improvements was seen among neighbor farmers having had less training and information on pesticide handling and alternatives than the FFS trained farmers. Training of farmers on IPM and good agricultural practices has positive effects, but is scarce in Bolivia as in most low-income countries and must be encouraged to support an improved and sustainable food production and to protect the health of farmers and consumers as well as the environment.

Integrating a quantitative risk appraisal in a health impact assessment: analysis of the novel smoke-free policy in Hungary

BACKGROUND Although the quantification of health outcomes in a health impact assessment (HIA) is scarce in practice, it is preferred by policymakers, as it assists various aspects of the decision-making process. This article provides an example of integrating a quantitative risk appraisal in an HIA performed for the recently adopted Hungarian anti-smoking policy which introduced a smoking ban in closed public places, workplaces and public transport vehicles, and is one of the most effective measures to decrease smoking-related ill health. METHODS A comprehensive, prospective HIA was conducted to map the full impact chain of the proposal. Causal pathways were prioritized in a transparent process with special attention given to those pathways for which measures of disease burden could be calculated for the baseline and predicted future scenarios. RESULTS The proposal was found to decrease the prevalence of active and passive smoking and result in a considerably positive effect on several diseases, among which lung cancer, chronic pulmonary diseases, coronary heart diseases and stroke have the greatest importance. The health gain calculated for the quantifiable health outcomes is close to 1700 deaths postponed and 16,000 life years saved annually in Hungary. CONCLUSION The provision of smoke-free public places has an unambiguously positive impact on the health of the public, especially in a country with a high burden of smoking-related diseases. The study described offers a practical example of applying quantification in an HIA, thereby promoting its incorporation into political decision making.

Public Health Challenges and Priorities for Kazakhstan

The Republic of Kazakhstan is one of the largest and fastest growing post-Soviet economies in Central Asia. Despite recent improvements in health care in response to Kazakhstan 2030 and other state-mandated policy reforms, Kazakhstan still lags behind other members of the Commonwealth of Independent States of the European Region on key indicators of health and economic development. Although cardiovascular diseases are the leading cause of mortality among adults, HIV/AIDS, tuberculosis, and blood-borne infectious diseases are of increasing public health concern. Recent data suggest that while Kazakhstan has improved on some measures of population health status, many environmental and public health challenges remain. These include the need to improve public health infrastructure, address the social determinants of health, and implement better health impact assessments to inform health policies and public health practice. In addition, more than three decades after the Declaration of Alma-Ata, which was adopted at the International Conference on Primary Health Care convened in Kazakhstan in 1978, facilitating population-wide lifestyle and behavioral change to reduce risk factors for chronic and communicable diseases, as well as injuries, remains a high priority for emerging health care reforms and the new public health. This paper reviews the current public health challenges in Kazakhstan and describes five priorities for building public health capacity that are now being developed and undertaken at the Kazakhstan School of Public Health to strengthen population health in the country and the Central Asian Region.