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A practical introduction to epidemiology, biostatistics, and research methodology for the whole health care community This comprehensive text, which has been extensively revised with new material and additional topics, utilizes a practical slant to introduce health professionals and students to epidemiology, biostatistics, and research methodology. It draws examples from a wide range of topics, covering all of the main contemporary health research methods, including survival analysis, Cox regression, and systematic reviews and meta-analysis—the explanation of which go beyond introductory concepts. This second edition of Quantitative Methods for Health Research: A Practical Interactive Guide to Epidemiology and Statistics also helps develop critical skills that will prepare students to move on to more advanced and specialized methods. A clear distinction is made between knowledge and concepts that all students should ensure they understand, and those that can be pursued further by those who wish to do so. Self-assessment exercises throughout the text help students explore and reflect on their understanding. A program of practical exercises in SPSS (using a prepared data set) helps to consolidate the theory and develop skills and confidence in data handling, analysis, and interpretation. Highlights of the book include: * Combining epidemiology and bio-statistics to demonstrate the relevance and strength of statistical methods * Emphasis on the interpretation of statistics using examples from a variety of public health and health care situations to stress relevance and application * Use of concepts related to examples of published research to show the application of methods and balance between ideals and the realities of research in practice * Integration of practical data analysis exercises to develop skills and confidence * Supplementation by a student companion website which provides guidance on data handling in SPSS and study data sets as referred to in the text Quantitative Methods for Health Research, Second Edition is a practical learning resource for students, practitioners and researchers in public health, health care and related disciplines, providing both a course book and a useful introductory reference. 

Food systems are increasingly being understood as driving various health and ecological crises and their transformation is recognised as a key opportunity for planetary health. First-food systems represent an underexplored aspect of this transformation. Despite breastfeeding representing the optimal source of infant nutrition, use of commercial milk formula (CMF) is high and growing rapidly. In this review, we examine the impact of CMF use on planetary health, considering in particular its effects on climate change, water use and pollution and the consequences of these effects for human health. Milk is the main ingredient in the production of CMF, making the role of the dairy sector a key area of attention. We find that CMF use has twice the carbon footprint of breastfeeding, while 1 kg of CMF has a blue water footprint of 699 L; CMF has a significant and harmful environmental impact. Facilitation and protection of breastfeeding represents a key part of developing sustainable first-food systems and has huge potential benefits for maternal and child health.

ObjectivesThis study aims to estimate the prevalence of low back pain (LBP) in Europe and to quantify its associated mental and physical health burdens among adults in European urban areas.DesignThis research is a secondary analysis of data from a large multicountry population survey.SettingThe population survey on which this analysis is based was conducted in 32 European urban areas across 11 countries.ParticipantsThe dataset for this study was collected during the European Urban Health Indicators System 2 survey. There were a total of 19 441 adult respondents but data from 18 028, 50.2% female (9 050) and 49.8% male (8 978), were included in these analyses.Primary and secondary outcome measuresBeing a survey, data on the exposure (LBP) and outcomes were collected simultaneously. The primary outcomes for this study are psychological distress and poor physical health.ResultsThe overall European prevalence of LBP was 44.6% (43.9–45.3) widely ranging from 33.4% in Norway to 67.7% in Lithuania. After accounting for sex, age, socioeconomic status and formal education, adults in urban Europe suffering LBP had higher odds of psychological distress aOR 1.44 (1.32–1.58) and poor self-rated health aOR 3.54 (3.31–3.80). These associations varied widely between participating countries and cities.ConclusionPrevalence of LBP, and its associations with poor physical and mental health, varies across European urban areas.

Globally, 2.8 billion people rely on household solid fuels. Reducing the resulting adverse health, environmental, and development consequences will involve transitioning through a mix of clean fuels and improved solid fuel stoves (IS) of demonstrable effectiveness. To date, achieving uptake of IS has presented significant challenges. We performed a systematic review of factors that enable or limit large-scale uptake of IS in low- and middle-income countries. We conducted systematic searches through multidisciplinary databases, specialist websites, and consulting experts. The review drew on qualitative, quantitative, and case studies and used standardized methods for screening, data extraction, critical appraisal, and synthesis. We summarized our findings as \"factors\" relating to one of seven domains-fuel and technology characteristics; household and setting characteristics; knowledge and perceptions; finance, tax, and subsidy aspects; market development; regulation, legislation, and standards; programmatic and policy mechanisms-and also recorded issues that impacted equity. We identified 31 factors influencing uptake from 57 studies conducted in Asia, Africa, and Latin America. All domains matter. Although factors such as offering technologies that meet household needs and save fuel, user training and support, effective financing, and facilitative government action appear to be critical, none guarantee success: All factors can be influential, depending on context. The nature of available evidence did not permit further prioritization. Achieving adoption and sustained use of IS at a large scale requires that all factors, spanning household/community and program/societal levels, be assessed and supported by policy. We propose a planning tool that would aid this process and suggest further research to incorporate an evaluation of effectiveness.

WHO estimates exposure to air pollution from cooking with solid fuels is associated with over 4 million premature deaths worldwide every year including half a million children under the age of 5 years from pneumonia. We hypothesised that replacing open fires with cleaner burning biomass-fuelled cookstoves would reduce pneumonia incidence in young children. We did a community-level open cluster randomised controlled trial to compare the effects of a cleaner burning biomass-fuelled cookstove intervention to continuation of open fire cooking on pneumonia in children living in two rural districts, Chikhwawa and Karonga, of Malawi. Clusters were randomly allocated to intervention and control groups using a computer-generated randomisation schedule with stratification by site, distance from health centre, and size of cluster. Within clusters, households with a child under the age of 4·5 years were eligible. Intervention households received two biomass-fuelled cookstoves and a solar panel. The primary outcome was WHO Integrated Management of Childhood Illness (IMCI)-defined pneumonia episodes in children under 5 years of age. Efficacy and safety analyses were by intention to treat. The trial is registered with ISRCTN, number ISRCTN59448623. We enrolled 10 750 children from 8626 households across 150 clusters between Dec 9, 2013, and Feb 28, 2016. 10 543 children from 8470 households contributed 15 991 child-years of follow-up data to the intention-to-treat analysis. The IMCI pneumonia incidence rate in the intervention group was 15·76 (95% CI 14·89–16·63) per 100 child-years and in the control group 15·58 (95% CI 14·72–16·45) per 100 child-years, with an intervention versus control incidence rate ratio (IRR) of 1·01 (95% CI 0·91–1·13; p=0·80). Cooking-related serious adverse events (burns) were seen in 19 children; nine in the intervention and ten (one death) in the control group (IRR 0·91 [95% CI 0·37–2·23]; p=0·83). We found no evidence that an intervention comprising cleaner burning biomass-fuelled cookstoves reduced the risk of pneumonia in young children in rural Malawi. Effective strategies to reduce the adverse health effects of household air pollution are needed. Medical Research Council, UK Department for International Development, and Wellcome Trust.

Globally, approximately 3 billion primarily cook using inefficient and poorly vented combustion devices, leading to unsafe levels of household air pollution (HAP) in and around the home. Such exposures contribute to nearly 4 million deaths annually (WHO 2018a, 2018b ). Characterizing the effectiveness of interventions for reducing HAP concentration and exposure is critical for informing policy and programmatic decision-making on which cooking solutions yield the greatest health benefits. This review synthesizes evidence of in-field measurements from four cleaner cooking technologies and three clean fuels, using field studies aimed at reducing HAP concentration and personal exposure to health damaging pollutants (particulate matter (PM 2.5 ) and carbon monoxide (CO)). Fifty studies from Africa, Asia, South and Latin America, provided 168 estimates synthesized through meta-analysis. For PM 2.5 kitchen concentrations, burning biomass more cleanly through improved combustion stoves (ICS) with ( n = 29; 63% reduction) or without ( n = 12; 52%) venting (through flue or chimney) and through forced-draft combustion ( n = 9; 50%) was less effective than cooking with clean fuels including ethanol ( n = 4; 83%), liquefied petroleum gas (LPG) ( n = 11; 83%) and electricity ( n = 6; 86%). Only studies of clean fuels consistently achieved post-intervention kitchen PM 2.5 levels at or below the health-based WHO interim target level 1 (WHO-IT1) of 35 μ g m −3 . None of the advanced combustion stoves (gasifiers) achieved WHO-IT1, although no evidence was available for pellet fuelled stoves. For personal exposure to PM 2.5, none of the ICS ( n = 11) were close to WHO-IT1 whereas 75% ( n = 6 of 8) of LPG interventions were at or below WHO-IT1. Similar patterns were observed for CO, although most post-intervention levels achieved the WHO 24 h guideline level. While clean cooking fuel interventions (LPG, electric) significantly reduce kitchen concentrations and personal exposure to PM 2.5 in household settings, stove stacking and background levels of ambient air pollution, have likely prevented most clean fuel interventions from approaching WHO-IT1. In order to maximize health gains, a wholistic approach jointly targeting ambient and HAP should be followed in lower-and-middle income countries.

Exposure to indoor air pollution from solid fuel use (IAP) has been linked to approximately 1.5 million annual deaths (World Health Organization (http://www.who.int/indoorair/publications/fuelforlife/en/index.html)) due to acute lower respiratory infections in children <5 years of age and chronic obstructive lung disease and lung cancer in adults. Emerging evidence suggests that IAP increases the risk of other conditions, including adverse pregnancy outcomes. To establish the relation of IAP with birth weight and stillbirth, systematic reviews with meta-analyses were conducted. Studies reporting outcomes of mean birth weight, percentage of low birth weight (LBW; <2,500 g), and/or stillbirth and assessing IAP were identified. Five LBW studies (of 982) and 3 stillbirth studies (of 171) met inclusion criteria for the reviews. Fixed-effect meta-analyses (I2 = 0%) found that IAP was associated with increased risk of percentage LBW (odds ratio = 1.38, 95% confidence interval: 1.25, 1.52) and stillbirth (odds ratio = 1.51, 95% confidence interval: 1.23, 1.85) and reduced mean birth weight (−95.6 g, 95% confidence interval: −68.5, −124.7). Evidence from secondhand smoke, ambient air pollution, and animal studies—and suggested plausible mechanisms—substantiate these associations. Because a majority of pregnant women in developing countries, where rates of LBW and stillbirth are high, are heavily exposed to IAP, increased relative risk translates into substantial population attributable risks of 21% (LBW) and 26% (stillbirth).

In sub-Saharan Africa, approximately 85% of the population uses polluting cooking fuels (e.g. wood, charcoal). Incomplete combustion of these fuels generates household air pollution (HAP), containing fine particulate matter (PM 2.5 ) and carbon monoxide (CO). Due to large spatial variability, increased quantification of HAP levels is needed to improve exposure assessment in sub-Saharan Africa. The CLEAN-Air(Africa) study included 24-h monitoring of PM 2.5 and CO kitchen concentrations (n pm2.5  = 248/n CO  = 207) and female primary cook exposures (n pm2.5  = 245/n CO  = 222) in peri-urban households in Obuasi (Ghana), Mbalmayo (Cameroon) and Eldoret (Kenya). HAP measurements were combined with survey data on cooking patterns, socioeconomic characteristics and ambient exposure proxies (e.g. walking time to nearest road) in separate PM 2.5 and CO mixed-effect log-linear regression models. Model coefficients were applied to a larger study population (n = 937) with only survey data to quantitatively scale up PM 2.5 and CO exposures. The final models moderately explained variation in mean 24-h PM 2.5 (R 2  = 0.40) and CO (R 2  = 0.26) kitchen concentration measurements, and PM 2.5 (R 2  = 0.27) and CO (R 2  = 0.14) female cook exposures. Primary/secondary cooking fuel type was the only significant predictor in all four models. Other significant predictors of PM 2.5 and CO kitchen concentrations were cooking location and household size; household financial security and rental status were only predictive of PM 2.5 concentrations. Cooking location, household financial security and proxies of ambient air pollution exposure were significant predictors of PM 2.5 cook exposures. Including objective cooking time measurements (from temperature sensors) from (n = 143) households substantially improved (by 52%) the explained variability of the CO kitchen concentration model, but not the PM 2.5 model. Socioeconomic characteristics and markers of ambient air pollution exposure were strongly associated with mean PM 2.5 measurements, while cooking environment variables were more predictive of mean CO levels.

While transitioning from polluting cooking fuels (e.g. wood, charcoal) to cleaner fuels, like liquefied petroleum gas (LPG), can lead to time savings, the amount of time saved is uncertain due to minimal stove use monitoring (SUM) data. Approximately three months (mean:82 days (SD:41)) of SUM data from Geocene temperature sensors was collected from 186 households in Mbalmayo, Cameroon; Obuasi, Ghana and Eldoret, Kenya. Households exclusively using LPG (mean:1 h 22 min/day) cooked for two hours/day less than those stacking LPG and polluting fuels (3 h 19 min/day), and almost three hours/day less than those exclusively using polluting fuels (4 h 10 min/day). Financially insecure households exclusively using polluting fuels cooked for ~ 45 min longer (4 h 29 min) than financially secure households (3 h 45 min). During a 24-hour household air pollution (HAP) monitoring period, average cooking time was 38 min longer (3 h 48 min vs. 3 h 10 min) and households cooked nearly once more per day (3.63 events) than during the remaining SUM period (2.72 events). Longer cooking times among financially insecure polluting fuel users suggests that LPG access may disproportionately benefit poorer households via greater time savings. Households may cook for longer-than-normal when monitored for HAP.