Inequalities in smoking prevalence : a missed opportunity for tobacco control in Pakistan

Background: Pakistan is one of the highest tobacco consuming countries in South Asia and consumption is increasing. To implement equity orientated tobacco control policies, the most vulnerable groups must be identified. We aimed to identify these groups using the Pakistan Demographic and Health Survey (PDHS) 2012–13. Methods: Descriptive statistics, univariate and multivariate analyses were used to explore household and participant characteristics associated with smoking inside the home or tobacco smoking, respectively. Survey weights were used to give nationally representative findings. Results: Data for 12 931 households, 3132 men and 13 538 women were examined. About 58.3% of surveyed households were smoke-free, 39.1% were exposed to indoor tobacco smoke every day, 2.6% less frequently. Significantly more rural households were exposed to indoor tobacco smoke than urban households (45.2% versus 34.9%). Of men, 28.3% reported smoking compared with 1.3% of women. Smoking prevalence was higher in older age groups. Increasing wealth was associated with lower smoking prevalence and indoor smoking. For men, but not women, increasing education was associated with reduced smoking. Conclusions: Inequalities in smoking behaviour impose harm to those who can least afford the financial and health costs. Future tobacco control policies in Pakistan must be sensitive to gender, geography and socio-economic status

Tracking progress of tobacco control in Pakistan against the MPOWER package of interventions : challenges and opportunities

MPOWER is an evidence-based package of the six most effective demand reduction interventions to reduce tobacco use. Global evidence shows that introduction of this package has accelerated and strengthened tobacco control worldwide with over 5 billion people living in 136 countries covered by at least one of these key interventions. This paper comments on how tobacco control laws in a low and middle income country, Pakistan, are meeting the MPOWER package provisions and what the challenges and opportunities for tobacco control are in the country. Pakistan is home to over 24 million tobacco users consuming a variety of tobacco products including 10 million smokeless tobacco users. Pakistan has introduced several laws to meet its international commitments under the framework convention against tobacco control and MPOWER package. However, gaps in existing policies, poor law enforcement, and a conflicting political economy of tobacco in the country pose major challenges for effective tobacco control. The changing political environment with renowned public health activists in current government, an active and independent judiciary, increasing use of social media, and a dynamic civil society offer opportunities to strengthen its efforts for effective policy actions against tobacco use

An examination of who is eligible and who is receiving bariatric surgery in England : secondary analysis of the Health Survey for England dataset

Background: Over 2 million people in England were estimated to be eligible for bariatric surgery in 2006. In 2014, clinical guidelines were updated, widening potential eligibility, meanwhile, obesity prevalence rose. However, numbers receiving surgery decreased, and concerns exist of inequalities in access between population groups. This study is aimed at estimating the number of adults eligible for surgery in England and to compare demographics with those that receive surgery. Methods: BMI and comorbidity status were used to determine eligibility for bariatric surgery within participants of the 2014 Health Survey for England dataset (6938 adults), based on the National Institute of Health and Care Excellence guidelines. Results were scaled up using national population estimates. The demographics of eligible participants were compared against 2014/2015 hospital episode statistics for sex and age group using a chi-squared analysis. Results: Of the total population of England, 7.78% (95% CI 7.1–8.6%), or 3,623,505 people, could have been eligible for bariatric surgery in 2014; nearly a million more than if previous guidelines applied. Eligibility peaked at ages 45–54, with most in the 35–64 age group (58.9%). 58.4% of those eligible were women. Patients receiving surgery were far more likely to be female than male (76.1%) and the distribution skewed towards younger ages when compared with those eligible. Conclusion: Bariatric surgery may benefit many people in England; significant investment is required so that service provision is adequate for demand. Differences between demographics of those eligible and receiving surgery may be explainable; however, the potential health inequality should be investigated

A review of the use of health examination data from the Health Survey for England in government policy development and implementation

Background Information is needed at all stages of the policy making process. The Health Survey for England (HSE) is an annual cross-sectional health examination survey of the non-institutionalised general population in England. It was originally set up to inform national policy making and monitoring by the Department of Health. This paper examines how the nurse collected physical and biological measurement data from the HSE have been essential or useful for identification of a health issue amenable to policy intervention; initiation, development or implementation of a strategy; choice and monitoring of targets; or assessment and evaluation of policies. Methods Specific examples of use of HSE data were identified through interviews with senior members of staff at the Department of Health and the Health and Social Care Information Centre. Policy documents mentioned by interviewees were retrieved for review, and reference lists of associated policy documents checked. Systematic searches of Chief Medical Officer Reports, Government ‘Command Papers’, and clinical guidance documents were also undertaken. Results HSE examination data have been used at all stages of the policy making process. Data have been used to identify an issue amenable to policy-intervention (e.g. quantifying prevalence of undiagnosed chronic kidney disease), in strategy development (in models to inform chronic respiratory disease policy), for target setting and monitoring (the 1992 blood pressure target) and in evaluation of health policy (the effect of the smoking ban on second hand smoke exposure). Conclusions A health examination survey is a useful part of a national health information system

Obesity in international migrant populations

Purpose of Review: This review examines the risk of obesity in migrant groups—specifically migrants from countries with lower prevalence of obesity to countries with higher prevalence of obesity. We examine obesity prevalence within migrant groups compared with native populations and the evidence on factors that might shape obesity risk in these migrant groups. Recent Findings: Migrants may arrive in new countries with a health advantage including generally a healthier body weight. Genetic and epi-genetic factors, as well as body size preference, socio-economic factors, and stress exposure, may play a role in increasing unhealthy weight gain in migrant populations. This unhealthy weight gain leads to similar or greater obesity risk in migrant populations compared with native populations 10–15 years after migration. Summary: Meeting the challenge of prevention and treatment of obesity in diverse populations will require greater attention to minority groups in research in the future

Experiences of young smokers in quitting smoking in twin cities of Pakistan : a phenomenological study

Background: Smoking is highly prevalent in Pakistan claiming the lives of over 100,000 individuals every year. A significant proportion of smokers (24.7%) make an attempt to quit each year but 97.4% fail to quit successfully. Little is known about the reasons for, and experiences of, failed quit attempts. This study was carried out to explore the experiences of young male smokers in quitting smoking in the twin cities of Pakistan Method: A qualitative study was carried out using a phenomenological approach in Rawalpindi and Islamabad. A total of 11 participants were interviewed. All study participants were male and had made at least one quit attempt. Study participants were a mix of smokers who failed to quit smoking, intermittent smokers and successful quitters. Streubert’s (1991) method of phenomenology was followed during data analysis. Results: The experiences of smokers while smoking “the smoking phase” have major effects on their journey towards quitting smoking. The smoking phase consists of three major stages: contact with initial smoking stimuli, the journey from first puff to enjoying smoking and then finally smoking becoming part of life. However, the journey towards quitting smoking is not as simple as the journey towards becoming a smoker. Instead, smokers get trapped in three overlapping cycles of smoking and quit attempts: smoking & forced quitting, smoking & intentional quitting, and smoking & intermittent smoking before successful quitting. Breaking the cycle is not easy in the presence of trapping factors (addiction, high availability, easy affordability, conducive social setup and low perceived risks of smoking). Three factors play a major role in breaking these cycles which are strong will power, continuous peer support and avoidance of smokers’ company. Conclusion: A young smoker, during his experience of quitting smoking gets entrapped in several overlapping cycles of smoking & quit attempts before successful quitting. There are known entrapping factors as well as factors which help in breaking these cycles. Targeted interventions are needed to facilitate smoking cessation among young smokers in Pakistan

Public health research in the UK to understand and mitigate the impact of COVID-19 and COVID-19 response measures

This paper reflects concerns that funding and attention should be expanded from the important focus on those suffering and dying from COVID-19, and the safety and resources of healthcare professionals, to address wider questions on the (unequal) health and well-being impacts of COVID-19 and associated response measures. While immediate priorities such as those outlined in the WHO research agenda are undoubtedly important, additional urgent questions must be addressed. These include questions focused on (1) the non-virus impacts of preparing health and social care systems to cope with COVID-19 and (2) the health effects mediated by the educational, economic and social injuries sustained during the pandemic. Long-term, sustained and co-ordinated interdisciplinary research funding will be needed to address the long-lasting impacts of COVID-19 and its response measures

Protection of neuromuscular sensory endings by the WldS gene

The compartmental hypothesis of neurodegeneration proposes that the neurone, long recognized to consist of morphologically and functionally distinct compartments, also houses distinct degeneration mechanisms for the soma, axon and nerve endings. Support for this hypothesis is provided by the phenomenon of the WldS (for Wallerian Degeneration, slow) mouse, a mutant in which axons survive several weeks after transection, rather than degenerating within 24-48 hours as in wild type mice, by virtue of expression of a chimeric Nmnat1/Ube4b protein. In this thesis I used the WldS-mouse to re-examine and extend the theory of compartmental neurodegeneration by focusing specifically on sensory axons and endings; and finally by considering a fourth compartment, the dendrites. The first part of this thesis reports that Ia afferent axons and their annulospiral endings are robustly protected from degeneration in WldS mice. Homozygous or heterozygous WldS mice crossbred with transgenic mice expressing fluorescent protein in neurones were sacrificed at various times after sciatic nerve transection. Fluorescence microscopy of whole mount preparations of lumbrical muscles in these mice revealed excellent preservation of annulospiral endings on muscle spindles for at least 10 days after axotomy. No significant difference was detected in the protection with age or gene copy-number in contrast to the protection of motor nerve terminals, which degenerate rapidly in heterozygote and aged homozygote WldS mice. In an attempt to explain the difference in motor and sensory protection by WldS, examination of three hypotheses was undertaken: a) differences in protein expression, tested by western blot and immunohistochemistry; b) differences in the degree of neuronal branching, tested through examination of g-motor axons and endings which have a degree of branching intermediate to motor and sensory neurons; and c) differences in the activity in the disconnected stumps, through primary culture of the saphenous and phrenic nerve, selected because they comprise largely pure sensory and motor axons respectively. The data suggest that none of these hypotheses provides a sufficient explanation for the difference between sensory and motor protection by WldS. The last part of this thesis attempts to extend the theory of compartmental degeneration. I examine a system for investigation of WldS-mediated protection of dendrites. In preliminary experiments retinal explants from transgenic mice expressing YFP in a subset of retinal ganglion-cell neurones were cultured. The dendritic arbours of these cells were shown to be amenable for repeated visualization and accessible to injury and monitoring of degeneration. Overall the data in this thesis suggest that the level of WldS -mediated protection conferred to an axon or axonal endings varies between different neuronal types. This has implications for the potential applications of WldS research to clinical problems. Specifically, the data imply that sensory neuropathies may benefit more than motor neuropathies from treatments based on the protective effects of WldS. These findings in sensory neurones also challenge some of the assumptions made about WldS- mediated protection of neurones, for example the extent of the age-effect on axonal endings. Further investigation of WldS-mediated protection in the CNS could give renewed impetus to attempts to discover targets for treatment in common neurodegenerative diseases. Finally, a system for investigation of dendritic degeneration has been piloted, suggesting that molecules involved in the degeneration of dendrites or in protection from this degeneration may be amenable to investigation in this system, prospectively extending the compartmental hypothesis of neuronal degeneration

How and to what extent did the Coventry City of Culture 'City Host' volunteer programme effect the volunteers' mental wellbeing?:A qualitative study

Abstract Background A team of volunteers, known as City Hosts, were recruited to support UK City of Culture 2021 awarded to Coventry. City Hosts held various roles facilitating cultural event delivery and promoting a positive experience for visitors. This study aimed to (i) understand how and to what extent the volunteering programme impacted volunteer subjective wellbeing, and (ii) explore the mechanisms of change and intermediate outcomes between volunteering and subjective wellbeing. Methods This qualitative study comprised inductive and deductive analysis of data collected through semi-structured interviews, conducted between December 2021–May 2022 with City Hosts. This was complimented with secondary qualitative analysis of free text responses within Monitoring and Evaluation data collected from City Hosts in surveys conducted in August and November 2021, and April 2022. Results Approximately 180 City Hosts responded to the free text questions in each survey and 27 completed interviews. Analysis of data collected from City Hosts suggested positive wellbeing impacts from volunteering and supported theorised pathways to improved wellbeing. Strengths of the City Host programme included (i) facilitating the full range of mechanisms of change that mediate improved volunteer wellbeing, particularly promoting social connections and developing a strong role and group identity and (ii) flexibility around what volunteers do, how much, and how often. Conclusions This study offers lessons for others designing volunteering programmes who wish to promote wellbeing among associated volunteers. We also offer evidence that exposure to culture may be one mechanism by which volunteering can improve wellbeing

Assessment of cardiovascular risk in a slum population in Kenya : use of World Health Organisation/International Society of Hypertension (WHO/ISH) risk prediction charts - secondary analyses of a household survey

Objectives Although cardiovascular disease (CVD) is of growing importance in low- and middle-income countries (LMICs), there are conflicting views regarding CVD as a major public health problem for the urban poor, including those living in slums. We examine multivariable risk prediction in a slum population and assess the number of cardiovascular related deaths within 10 years of application of the tool. Setting We use data from the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) population (residents of two slum communities) between May 2008 and April 2009. Design This is a secondary data analysis from a cross-sectional survey. We use the WHO/International Society of Hypertension (WHO/ISH) cardiovascular risk prediction tool to examine 10-year risk of major CVD events in a slum population. CVD deaths in the cohort, reported up until June 2018 and identified through verbal autopsy are also presented. Participants 3063 men and women aged over 40 years with complete data for variables needed for the WHO/ISH risk prediction tool were eligible to take part. Results The majority of study members (2895, 94.5%) were predicted to have ‘low’ risk (20% were identified as dying of CVD. Conclusions This study shows that there is a low risk profile of CVD in this slum population in Nairobi, Kenya, in comparison to results from application of multivariable risk prediction tools in other LMIC populations. This has implications for health service planning in these contexts