The middle-out perspective:an approach to formalise 'normal practice' in public health advocacy

AIMS: The middle-out perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle-out (rather than the top-down or bottom-up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. We argue that public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. The article aims to demonstrate this argument. METHODS: This article introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke-free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes. RESULTS: These case studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda. CONCLUSION: Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health

Meta-Analysis as Early Evidence on the Particulate Emissions Impact of EURO VI on Battery Electric Bus Fleet Transitions

The current generation of Zero Emission Vehicle (ZEV) policies are designed to accelerate the transition away from conventional internal combustion engine (ICE) petrol and diesel vehicle fleets. However, the current focus on zero exhaust emissions and the lack of more detailed guidance regarding Non-Exhaust Emissions (NEEs) may mean that some of the trade-offs in transitioning to, e.g., Battery Electric Vehicle (BEV) fleets may be missed by many in the commercial sector. Here, as part of early work on the scoping of the First Bus EURO VI Diesel Vehicle (E6DV) to BEV fleet upgrades, we estimate E6DV total particulate emissions to be ca. 62–85 and 164–213 mg.veh−1.km−1 for PM2.5 and PM10, respectively, and that the majority, typically 93–97%, are NEEs. We also discuss the complex interaction between E6DV/BEV properties and estimate potential changes resulting from the transition to BEVs as ranging from a decrease of ca. 2–12% to an increase of ca. 12–50% depending on a combination of weight difference, regenerative brake performance and journey type. Finally, we propose metrics that would allow fleet operators more insight into a wider range of emission outcomes at the scoping stage of a fleet upgrade

Ten steps or climbing a mountain: A study of Australian health professionals' perceptions of implementing the baby friendly health initiative to protect, promote and support breastfeeding

Background: The Baby Friendly Hospital (Health) Initiative (BFHI) is a global initiative aimed at protecting, promoting and supporting breastfeeding and is based on the ten steps to successful breastfeeding. Worldwide, over 20,000 health facilities have attained BFHI accreditation but only 77 Australian hospitals (approximately 23%) have received accreditation. Few studies have investigated the factors that facilitate or hinder implementation of BFHI but it is acknowledged this is a major undertaking requiring strategic planning and change management throughout an institution. This paper examines the perceptions of BFHI held by midwives and nurses working in one Area Health Service in NSW, Australia. Methods: The study used an interpretive, qualitative approach. A total of 132 health professionals, working across four maternity units, two neonatal intensive care units and related community services, participated in 10 focus groups. Data were analysed using thematic analysis. Results: Three main themes were identified: ‘Belief and Commitment’; ‘Interpreting BFHI’ and ‘Climbing a Mountain’. Participants considered the BFHI implementation a high priority; an essential set of practices that would have positive benefits for babies and mothers both locally and globally as well as for health professionals. It was considered achievable but would take commitment and hard work to overcome the numerous challenges including a number of organisational constraints. There were, however, differing interpretations of what was required to attain BFHI accreditation with the potential that misinterpretation could hinder implementation. A model described by Greenhalgh and colleagues on adoption of innovation is drawn on to interpret the findings. Conclusion: Despite strong support for BFHI, the principles of this global strategy are interpreted differently by health professionals and further education and accurate information is required. It may be that the current processes used to disseminate and implement BFHI need to be reviewed. The findings suggest that there is a contradiction between the broad philosophical stance and best practice approach of this global strategy and the tendency for health professionals to focus on the ten steps as a set of tasks or a checklist to be accomplished. The perceived procedural approach to implementation may be contributing to lower rates of breastfeeding continuation

Cross-sectional study of asthma and rhinitis symptoms in the context of exposure to air pollution in Nepal

Asthma is common in children worldwide, although its prevalence varies substantially by location. The prevalence of wheeze over a 12-month period ranged from 2.1% to 32.2% in the older age group (13–14 years) and 4.1% to 32.1% in the younger age group (6–7 years) [1]. There is a positive association between current symptoms of asthma in younger and older children with gross national income [2], and it is generally slightly less common in girls than boys in the younger group [1–3]. Exposure to air pollution is associated with asthma exacerbations. Odds ratios for wheeze in the past year and the use of solely an open fire for cooking were 2.17 (95% CI 1.64–2.87) for children aged 6–7 years and 1.35 (95% CI 1.11–1.64) for children aged 13–14 years [4]. Nepalese children are exposed to high levels of indoor air pollution from the burning of biomass fuels [5]. This study aimed to estimate their prevalence of asthma, and to investigate the association of air pollution and risk of wheeze and rhinitis symptoms using personal exposure estimates of air pollution

Factors associated with breastfeeding cessation in nursing mothers in a peer support programme in Eastern Lancashire

<p>Abstract</p> <p>Background</p> <p>The UK has one of the lowest breastfeeding rates worldwide and in recent years the Government has made breastfeeding promotion one of its priorities. The UNICEF UK Baby Friendly Initiative is likely to increase breastfeeding initiation but not duration. Other strategies which involve provision of support for breastfeeding mothers in the early weeks after birth are therefore required to encourage UK mothers to breastfeed for the recommended duration. This paper examines the effects of maternal socio-demographic factors, maternal obstetric factors, and in-hospital infant feeding practices on breastfeeding cessation in a peer support setting.</p> <p>Methods</p> <p>Data on mothers from Blackburn with Darwen (BwD) and Hyndburn in Eastern Lancashire who gave birth at the Royal Blackburn Hospital and initiated breastfeeding while in hospital were linked to the Index of Multiple Deprivation (IMD). The data were analysed to describe infant feeding methods up to 6 months and the association between breastfeeding cessation, and maternal factors and in-hospital infant feeding practices.</p> <p>Results</p> <p>The mean breastfeeding duration was 21.6 weeks (95% CI 20.86 to 22.37 weeks) and the median duration was 27 weeks (95% CI 25.6 to 28.30 weeks). White mothers were 69% more likely to stop breastfeeding compared with non-White mothers (HR: 0.59; 95% CI, 0.52 to 0.67 [White mothers were the reference group]). Breastfeeding cessation was also independently associated with parity and infant feeding practices in hospital. There were no significant associations between breastfeeding cessation and marital status, mode of delivery, timing of breastfeeding initiation and socio-economic deprivation.</p> <p>Conclusion</p> <p>In this study ethnicity, parity and in-hospital infant feeding practices remained independent predictors of breastfeeding cessation in this peer support setting. However other recognised predictors such as marital status, mode of delivery, timing of breastfeeding initiation and socio-economic deprivation were not found to be associated with breastfeeding cessation.</p

Speed limits, air quality and health

Improving air quality by lowering vehicle emissions is important for public health. Limiting vehicle speeds on the UK strategic road network can reduce individual vehicle exhaust emissions, however, there are implications for driver behaviour and traffic congestion patterns. This briefing note examines the current evidence for speed limit reduction to benefit air quality and health and provides recommendations for future priority research. Recommended citation: Lacey, S., Zhong, J., Ghaffarpasand, O. and Bartington, S.E. (2023). ‘Speed limits, air quality and health’, TRANSITION Clean Air Network, Birmingham, U

Machine learning techniques to improve the field performance of low-cost air quality sensors

Low-cost air quality sensors offer significant potential for enhancing urban air quality networks by providing higher-spatiotemporal-resolution data needed, for example, for evaluation of air quality interventions. However, these sensors present methodological and deployment challenges which have historically limited operational ability. These include variability in performance characteristics and sensitivity to environmental conditions. In this work, we investigate field “baselining” and interference correction using random forest regression methods for low-cost sensing of NO2, PM10 (particulate matter) and PM2.5. Model performance is explored using data obtained over a 7-month period by real-world field sensor deployment alongside reference method instrumentation. Workflows and processes developed are shown to be effective in normalising variable sensor baseline offsets and reducing uncertainty in sensor response arising from environmental interferences. We demonstrate improvements of between 37 % and 94 % in the mean absolute error term of fully corrected sensor datasets; this is equivalent to performance within ±2.6 ppb of the reference method for NO2, ±4.4 µg m−3 for PM10 and ±2.7 µg m−3 for PM2.5. Expanded-uncertainty estimates for PM10 and PM2.5 correction models are shown to meet performance criteria recommended by European air quality legislation, whilst that of the NO2 correction model was found to be narrowly (∼5 %) outside of its acceptance envelope. Expanded-uncertainty estimates for corrected sensor datasets not used in model training were 29 %, 21 % and 27 % for NO2, PM10 and PM2.5 respectively