Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013.
Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent.
The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services.
There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective.
Children are uniquely susceptible to environmental health exposures that effect developmental delays and negatively impact long-term health outcomes. Despite extensive hours spent at early child care centers, child care providers (CCPs) lack the knowledge to identify and mitigate environmental hazards to the children.
From 2007 to 2010, we recruited child care centers in the District of Columbia and offered interactive environmental health training to the CCPs. Each center underwent a 90-min environmental health risk assessment (ERA) at baseline and also after the trainings. Dependent t-tests were used to assess the mean change on the ERA score and also the knowledge test administered pre- and post-trainings. Analysis of variance was used to examine the association between knowledge change for the CCPs and the ERA scores of their centers.
Of the 60 facilities, 68% reduced their environmental risk. The 585 CCPs who attended the training session showed significant improvement on all items on the test. However, test scores for the CCPs from centers that reduced their risk were not significantly different from the other CCPs.
The trainings increased knowledge on environmental health hazards among CCPs. Areas of significant risk reduction were under the direct control of the CCPs and corresponded to key items on the knowledge test.
Maternal obesity is emerging as a public health problem, recently highlighted together with maternal under-nutrition as a ‘double burden’, especially in African countries undergoing social and economic transition. This systematic review was conducted to investigate the current evidence on maternal obesity in Africa.
MEDLINE, EMBASE, Scopus, CINAHL and PsycINFO were searched (up to August 2014) and identified 29 studies. Prevalence, associations with socio-demographic factors, labour, child and maternal consequences of maternal obesity were assessed. Pooled risk ratios comparing obese and non-obese groups were calculated.
Prevalence of maternal obesity across Africa ranged from 6.5 to 50.7%, with older and multiparous mothers more likely to be obese. Obese mothers had increased risks of adverse labour, child and maternal outcomes. However, non-obese mothers were more likely to have low-birthweight babies. The differences in measurement and timing of assessment of maternal obesity were found across studies. No studies were identified either on the knowledge or attitudes of pregnant women towards maternal obesity; or on interventions for obese pregnant women.
These results show that Africa's levels of maternal obesity are already having significant adverse effects. Culturally adaptable/sensitive interventions should be developed while monitoring to avoid undesired side effects.
To examine the associations of cardiovascular disease risk factors (CVDRF) with wealth, defined by the asset index, in 25- to 74-year-old black Africans in Cape Town.
Assets, including consumer durable goods, and CVDRF were determined in a randomly selected cross-sectional sample. A principal component analysis of the pooled data, based on assets that defined wealth, was used to develop an asset index. Ordinal logistic regression analyses assessed the independent associations of CVDRF with wealth tertiles.
Among the 1099 participants, the least poor compared with the poorest tertile had significantly higher prevalence of diabetes (16.3 versus 9.6%), hypercholesterolaemia (33.9 versus 21.4%), obesity (45.4 versus 26.3%) and fat intake ≥30% of diet (44.2 versus 29.3%). Daily smoking was highest in the poorest (35.8%) versus the least poor (26.4%). Psychosocial stress (low sense of coherence or locus of control) was significantly higher in poorer participants. In the regression analyses, wealth was associated with male gender [odds ratio (OR): 1.89, 95% confidence interval (CI): 1.37–2.60], urbanization (OR: 1.02, 95% CI: 1.01–1.02), high fat intake, obesity and hypercholesterolaemia. Daily smoking, problematic alcohol use (OR: 0.70, 95% CI: 0.52–0.94) and psychosocial stress were inversely related to wealth.
Differential distribution of CVDRF by wealth mandates incorporating equity components when developing tailored interventions.
A growing body of evidence suggests that childhood overweight may have its roots in early life. This study aimed to explore patterns of weight in children from birth to 40 months, born between 1994 and 2006, in Halton, Northwest England.
Halton infants were compared with the UK-90 reference population at four time points (birth, 2 months, 8 months and 40 months) by converting heights and weights into age–sex adjusted SD scores. The mean and SD of Halton SD scores were calculated for each time point and sex. Cohort trends and gender differences in rates of children above the 85th and 95th centiles at each time point were tested for using Poisson regression modelling.
A total of 16 381 births were analysed. At birth, 8 months and 40 months, proportions of Halton children above the 85th and 95th centiles were consistently higher than reference data. Proportions above the 85th and 95th centiles at birth did not change significantly year on year, but for all other time points the proportions increased with subsequent cohorts.
This study may provide evidence that the development of overweight and obesity has its roots in very early life and has highlighted patterns of infant overweight and obesity not previously reported.
Verocytotoxin-producing Escherichia coli (VTEC) are bacteria that cause infectious gastroenteritis and in certain settings can cause widespread infection due to secondary transmission. We describe the findings of an investigation of a school-based outbreak of VTEC in Staffordshire, England.
Outbreak investigation at a school in February 2012 after two children were diagnosed with VTEC infection. Cases were defined as pupils and staff (or their household contacts) with gastrointestinal symptoms or asymptomatic screened persons, with laboratory confirmed VTEC O157 infection (phage type 32, verocytotoxin 2) occurring on or after 1 February 2012. Microbiological tests of food and faecal samples plus screening of asymptomatic contacts were undertaken. Epidemiological and clinical data were descriptively analysed.
Thirty-eight cases were detected. Nineteen were asymptomatic and identified via screening of 191 pupils. Infection was introduced into the school from an earlier household cluster, followed by extensive person-to-person transmission within the nursery/infant group with limited spread to the wider school population.
Control measures included several interventions, in particular, universal screening of pupils and staff. Screening during school outbreaks is not underpinned by guidance but proved to be a key control measure. Screening of asymptomatic contacts should be considered in similar outbreaks.
It has been shown that higher education associates with health outcomes, but the less is known about the specific mechanisms mediating this association. We examined whether higher education would associate with long-term health transitions from childhood to adulthood and whether health behaviors, self-esteem, social support and work-related health hazards could mediate or confound this association.
The participants were from a population-based sample of 3596 men and women from the Young Finns study aged 3–18 years at the beginning of the study in 1980, and who responded to repeated surveys of educational attainment and self-rated health in four study phases from 1997 to 2012. The associations were tested using multistate Markov models for the health-state transition intensities.
Our results suggested that a 1-year difference in education was related to a 16% higher transition probability from mediocre to good self-rated health over the 5-year follow-up. Depressive symptoms and job strain seemed to partly mediate or confound the association, but self-esteem and social support did not.
These results suggest that educational attainment is associated with good self-rated health transitions from childhood to adulthood, and multiple processes rather than a single underlying mechanism are likely to drive the educational differences in self-rated health.
This study determined annual prevalence and incidence trends of asthma among children in Taiwan from 2002 to 2008. Risk factors and traditional Chinese medicine (TCM) use were examined.
A random sample was selected for a population-based study with a selection probability of 0.5 from all 3–18 years insurants. The annual prevalence and incidence of asthma were estimated according to age, sex, insurance premium and degree of urbanization.
The prevalence of asthma increased from 12.99% in 2002 to 16.86% in 2008. The increase was greatest in 2008, among boys, 11–15 years, ≥medium insurance premium, and high- and medium-density urban area. TCM use in asthma-prevalent children decreased from 1.16% in 2002 to 0.59% in 2008. The incidence fluctuated, ranging from 1.01% in 2002 to 1.49% in 2005. The highest was in 2005, among boys, 3–5 years, ≥medium insurance premium and high-density urban area. TCM use in asthma-incident children decreased from 3.59% in 2002 to 1.69% in 2008.
This study demonstrated a substantial increase in annual prevalence of asthma among children in Taiwan from 2002 to 2008. The incidence fluctuated. The TCM use showed a decreasing linear trend and was higher in incident than in prevalent cases.
Anaemia is a public health problem that can lead to a variety of detrimental effects on physical and neurodevelopment in young children. The present study explored the epidemiology of anaemia among infants in Romania, identified risk factors and created a model for predicting it.
Data from 1532 infants aged 6–24 months were selected from a larger nationally representative cross-sectional survey. Demographic predictor variables and haemoglobin concentration were extant variables in the data set. Multiple logistic regression was used to determine the best predictors of anaemia.
Overall, 46% of 6–24 month olds in the sample had anaemia (Hb < 11.0 g/dl). A variety of risk factors were associated with significantly greater odds of anaemia, but a five-factor model best predicted it (67.9% accuracy). These predictors included being male, living in a rural area, being third born or later, being a Hungarian and living in the South, South-West or West region of Romania.
While data indicate a modest decrease in anaemia from earlier Romanian studies, it remains a significant problem. Models like this one have the potential to improve identification and treatment of anaemia in young children.
This meta-analysis addressed the association between substance use disorder (SUD) and suicide outcomes based on current evidence.
We searched PubMed, Web of Science and Scopus until May 2015. We also searched the reference lists of included studies and Psycinfo website. We included observational (cohort, case–control, cross-sectional) studies addressing the association between SUD and suicide. Our outcomes of interest were suicide ideation, suicide attempt and suicide death. For each outcome, we calculated the odds ratio (OR) or risk ratio (RR) with 95% confidence intervals (CI) based on the random-effects model.
We identified a total of 12 413 references and included 43 studies with 870 967 participants. There was a significant association between SUD and suicidal ideation: OR 2.04 (95% CI: 1.59, 2.50; I2 = 88.8%, 16 studies); suicide attempt OR 2.49 (95% CI: 2.00, 2.98; I2 = 94.3%, 24 studies) and suicide death OR 1.49 (95% CI: 0.97, 2.00; I2 = 82.7%, 7 studies).
Based on current evidence, there is a strong association between SUD and suicide outcomes. However, evidence based on long-term prospective cohort studies is limited and needs further investigation. Moreover, further evidence is required to assess and compare the association between suicide outcomes and different types of illicit drugs, dose–response relationship and the way they are used.
Lifestyle risk behaviours show an inverse social gradient, clustering in vulnerable groups. We designed and piloted an intervention to address barriers to lifestyle behaviour change among hospital patients.
We designed our intervention using effective components of behaviour change interventions informed by psychological theory. Delivered by a health psychologist based at the Royal Free London NHS Foundation Trust, the 4-week intervention included detailed baseline assessment, personalized goal setting, psychological skills development, motivation support and referral to community services. Primary outcomes were feasibility and patient acceptability. We also evaluated changes to health and well-being.
From 1 July 2013 to 31 September 2014, 686 patients were referred, 338 (49.3%) attended a first appointment and 172 (25.1%) completed follow-up. Furthermore, 72.1% of attenders were female with the median age 55 years and poor self-reported baseline health. After 4 weeks, self-efficacy, health and well-being scores significantly improved: 63% of lifestyle goals and 89% of health management goals were fully achieved; 58% of referrals to community lifestyle behaviour change services and 79% of referrals to other services (e.g. Citizen's Advice Bureau) were accepted; 99% were satisfied/very satisfied with the service.
Our hospital-based intervention was feasible, acceptable and showed preliminary health and well-being gains.
Although people who inject drugs (IDU) often contend with various health-related harms, timely access to health care among this population remains low. We sought to identify specific individual, social and structural factors constraining healthcare access among IDU in Bangkok, Thailand.
Data were derived from a community-recruited sample of IDU participating in the Mitsampan Community Research Project between July and October 2011. We assessed the prevalence and correlates of healthcare avoidance due to one's drug use using multivariate logistic regression.
Among 437 participants, 112 (25.6%) reported avoiding health care because they were IDU. In multivariate analyses, factors independently associated with avoiding health care included having ever been drug tested by police [adjusted odds ratio (AOR) = 1.80], experienced verbal abuse (AOR = 3.15), been discouraged from engaging in usual family activities (AOR = 3.27), been refused medical care (AOR = 10.90), experienced any barriers to health care (AOR = 4.87) and received healthcare information and support at a drop-in centre (AOR = 1.92) (all P < 0.05).
These findings highlight the need to address the broader policy environment, which perpetuates the criminalization and stigmatization of IDU, and to expand peer-based interventions to facilitate access to health care for IDU in this setting.
Recent policy initiatives in the UK have underlined the importance of public health education for healthcare professionals. We aimed to describe teaching inputs to medical undergraduate curricula, to identify perceived challenges in the delivery of public health teaching and make recommendations that may overcome them.
We undertook a cross-sectional survey; questionnaires were sent electronically to 32 teaching leads in academic departments of public health in UK medical schools and followed up by telephone interviews.
We obtained a 75% response rate; 13 public health teaching leads were interviewed. We found much variability between schools in teaching methods, curricular content and resources used. Concerns regarding the long-term sustainability of teaching focus on: staffing levels and availability, funding and the prioritization of research over teaching. We give examples of integration of public health with clinical teaching, innovative projects in public health and ways of enabling students to witness public health in action.
There is a need to increase the supply of well-trained and motivated teachers and combine the best traditional teaching methods with more innovative approaches. Suggestions are made as to how undergraduate public health teaching can be strengthened.
The value of e-learning in medical education is widely recognized but there is little evidence of its value in teaching medical students about public health. Such evidence is needed because medical students' engagement with public health has been low. We present three recent case studies from UK medical schools to illustrate diverse ways in which online approaches can increase medical students' engagement with learning public health.
A comparative case study approach was used applying quantitative and qualitative data to examine engagement in terms of uptake/use amongst eligible students, acceptability and perceived effectiveness using an analytic framework based on Seven Principles of Effective Teaching.
Across the three case studies, most (67–85%) eligible students accessed online materials, and rated them more favourably than live lectures. Students particularly valued opportunities to use e-learning flexibly in terms of time and place. Online technologies offered new ways to consolidate learning of key public health concepts. Although students found contributing to online discussions challenging, it provided opportunities for students to explore concepts in depth and enabled students that were uncomfortable speaking in face-to-face discussions to participate.
E-learning can be applied in diverse ways that increase medical student engagement with public health teaching.
Despite National guidance recommending their use, there is uncertainty regarding the best way to deliver weight management services across the UK and worldwide.
To ascertain access, provision and interventions used in lifestyle Tier 2 and specialist Tier 3 weight management services in Scotland, a survey was distributed to all mainland health boards covering pathways for referral, eligibility criteria, intervention format and definitions of attendance completion and adherence.
Nine Health boards provided information on their weight management services. The provision of services was low. Only four health boards offered services for those with a BMI 25–30 kg/m2. Lifestyle Tier 2 services were mainly weekly or fortnightly group sessions for 8–12 weeks delivered by dietitians or community workers. Specialist Tier 3 services were largely similar to lifestyle Tier 2 services. The provision of specialist interventions including pharmacotherapy, cognitive behavioural therapy sessions and low-calorie prescribed diets was low.
This national survey has illustrated large disparities in the provision of weight management across Scotland, a likely consequence of uncertainty regarding best practice. There is a clear requirement for the evaluation of existing services to identify those that lead to the largest improvements in health outcomes and are cost-effective.
Allotments in the UK are popular and waiting lists long. There is, however, little evidence on the health benefits of allotment gardening. The aims of this study were to determine the impacts of a session of allotment gardening on self-esteem and mood and to compare the mental well-being of allotment gardeners with non-gardeners.
Self-esteem, mood and general health were measured in 136 allotment gardeners pre- and post- an allotment session, and 133 non-gardener controls. Allotment gardeners also detailed the time spent on their allotment in the current session and previous 7 days, and their length of tenure.
Paired t-tests revealed a significant improvement in self-esteem (P < 0.05) and mood (P < 0.001) as a result of one allotment session. Linear regression revealed that neither the time spent on the allotment in the current session, the previous 7 days or the length of tenure affected the impacts on self-esteem and mood (P > 0.05). One-way ANCOVA revealed that allotment gardeners had a significantly better self-esteem, total mood disturbance and general health (P < 0.001), experiencing less depression and fatigue and more vigour (P < 0.0083).
Allotment gardening can play a key role in promoting mental well-being and could be used as a preventive health measure.
Demand for healthcare services among older population is expected to rise, especially among those living with disabilities. This study aims to estimate the prevalence rate and identify the factors associated with healthcare service use among Chinese elderly with disabilities.
This study employed a nationally representative survey and defined healthcare service utilization as use of curative care, auxiliary aids or rehabilitation services for elderly with disabilities (aged ≥60 years) in China. Population-weighted numbers, proportions and prevalence rates were calculated. Multivariate logistic regression was used to calculate the adjusted odd ratios and 95% confidence interval (CI).
A weighted total of 45 005 026 Chinese elderly with disabilities were reported. The weighted prevalence rate of healthcare service use was 36.6% (95% CI: 35.6–37.5). Significantly less use of healthcare services was observed among those who were older, males, less educated, singles, rural dwellers, non-eastern residents, with lower annual family income, without medical insurance coverage, without a disability certificate, with a single disability and with less severe disabilities.
Low use of healthcare services indicates an unmet need among Chinese elderly with disabilities especially for the old–old. More effort should be warranted to enhance healthcare service use among the elderly with disabilities.
Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of ‘prudent healthcare’ championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted.
A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest.
A sum of £86.9 million was spent on respiratory care in 2012–13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment.
This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored.
Non-attendance at TB contact screening clinics has been highlighted as a common phenomenon across a number of sites during recruitment to the PREDICT TB Study. This has obvious implications for the safety of patients, their communities and for NHS resources. The objective of this study was to explore why adults who have been in contact with TB do, and do not, attend their screening appointment, thereby allowing identification of interventions to reduce non-attendance.
A multi-method approach was taken using 15 questionnaires with adults who attended for screening, 15 telephone questionnaires with adults who did not attend and in-depth interviews with 8 TB nurses. Interviews were coded to trace emerging descriptive themes, then refined through an iterative process of interpretation and recoding.
Findings from the questionnaires and interviews were categorized into three principle themes following analysis: awareness, hospital factors and leadership. These themes deconstruct the complex phenomena of patients' lack of attendance at this TB contact screening service.
Recommendations related to issues of leadership, outreach services, flexibility of clinic timing and awareness amongst both the local community and GPs were made.
Opioid dependence treatment, comprising opioid substitution treatment (OST) and psychosocial intervention, is accepted to improve outcomes in opioid addiction for both the individual and public health. OST medication such as methadone or buprenorphine may be misused or diverted. This results in failure to recover from addiction, increased crime and the spread of blood-borne viruses. Worldwide, attempts to address misuse and diversion have been proposed and implemented with varying impact.
A structured, expert-led process recommended the most impact. As an initial step, a broad range of strategies were defined, and a systematic review of published literature identified 37 highly relevant sources of evidence. Experts reviewed this evidence and ranked the list of strategies for effectiveness and ease of implementation, based on their clinical experience.
Three groups of strategies to address misuse or diversion are defined, depending on impact (effectiveness and ease of implementation). Preferred strategies include the promotion of access to treatment and the use of product formulations less likely to be misused. However, additional data and innovative approaches to address this complex problem are needed.
To analyse the scientific evidence that exists for the advertising claims made for two products containing Lactobacillus casei and Bifidobacterium lactis and to conduct a comparison between the published literature and what is presented in the corporate website.
Systematic review, using Medline through Pubmed and Embase. We included human clinical trials that exclusively measured the effect of Lactobacillus casei or Bifidobacterium lactis on a healthy population, and where the objective was related to the health claims made for certain products in advertising. We assessed the levels of evidence and the strength of the recommendation according to the classification criteria established by the Oxford Centre for Evidence Based Medicine (CEBM). We also assessed the outcomes of the studies published on the website that did not appear in the search.
Of the 440 articles identified, 16 met the inclusion criteria. Only four (25%) of these presented a level of evidence of 1b and a recommendation grade of A, all corresponding to studies on product containing Bifidobacterium lactis, and only 12 of the 16 studies were published on the corporate website (47).
There is insufficient scientific evidence to support the health claims made for these products, especially in the case of product containing Lactobacillus casei.
In this Perspectives paper, I outline the limitations of the concept of ‘intentionality’ in public reproductive health understandings of pregnancy. ‘Intentionality’, ‘plannedness’, ‘wantedness’ and ‘timing’ place individual cognitions, psychology and/or behaviors at the center of public health conceptualizations of pregnancies, thereby leaving the underlying social and structural dynamics under-examined. I propose a model that places ‘supportability’ at the center of thinking about pregnancies and that allows for an analysis of the intersection of individual cognitions, emotions and behavior with micro-level interactive spaces and macro-level issues.
Electronic medical records (EMR) can be a cost-effective source for hypertension surveillance. However, diagnosis of hypertension in EMR is commonly under-coded and warrants the needs to review blood pressure and antihypertensive drugs for hypertension case identification.
We included all the patients actively registered in The Health Improvement Network (THIN) database, UK, on 31 December 2011. Three case definitions using diagnosis code, antihypertensive drug prescriptions and abnormal blood pressure, respectively, were used to identify hypertension patients. We compared the prevalence and treatment rate of hypertension in THIN with results from Health Survey for England (HSE) in 2011.
Compared with prevalence reported by HSE (29.7%), the use of diagnosis code alone (14.0%) underestimated hypertension prevalence. The use of any of the definitions (38.4%) or combination of antihypertensive drug prescriptions and abnormal blood pressure (38.4%) had higher prevalence than HSE. The use of diagnosis code or two abnormal blood pressure records with a 2-year period (31.1%) had similar prevalence and treatment rate of hypertension with HSE.
Different definitions should be used for different study purposes. The definition of ‘diagnosis code or two abnormal blood pressure records with a 2-year period’ could be used for hypertension surveillance in THIN.
There are growing calls within public health for researchers and practitioners working to improve and protect the public's health to become more involved in politics and advocacy. Such a move takes practitioners and researchers beyond the traditional, evidence-based public health paradigm, raising potential dilemmas and risks for those who undertake such work. Drawing on the example of the People's Health Movement, this short paper argues that advocacy and social movements are an essential component of public health's efforts to achieve great health equity. It outlines how the Scottish branch of the People's Health Movement sought to overcome potential tensions between public health evidence and advocacy by developing a regional manifesto for health via transparent and democratic processes which combine empirical and experiential evidence. We suggest that this is an illustrative example of how potential tensions between public health research and advocacy can be overcome, through bottom–up movements of solidarity and action.
It is unclear why rates of homelessness claims in England have risen since 2010. We used variations in rates across local authorities to test the impact of economic downturns and budget cuts.
Using cross-area fixed effects models of data from 323 UK local authorities between 2004 and 2012, we evaluated associations of changes in statutory homelessness rates with economic activity (Gross Value Added per capita), unemployment, and local and central government expenditure.
Each 10% fall in economic activity was associated with an increase of 0.45 homelessness claims per 1000 households (95% CI: 0.10–0.80). Increasing rates of homelessness were also strongly linked with government reductions in welfare spending. Disaggregating types of welfare expenditure, we found that strongest associations with reduced homelessness claims were spending on social care, housing services, discretionary housing payments and income support for older persons.
Recession and austerity measures are associated with significant increases in rates of homelessness assistance. These findings likely understate the full burden of homelessness as they only capture those who seek aid. Future research is needed to investigate what is happening to vulnerable groups who may not obtain assistance, including those with mental health problems and rough sleepers.
The manifesto Start Well, Live Better by the UK Faculty of Public Health (Start Well, Live Better—A Manifesto for the Public's Health. London: UK Faculty of Public Health, 2014) sets out 12 compelling priorities for the protection of people's health. The focus of this document is preventative, calling for a comprehensive strategy to target a wide-ranging set of challenges to public health; however, it fails to mention child maltreatment and its negative impact on long-term health outcomes. In this article, we explore the long-term negative consequences of child maltreatment and how these can be conceptually aligned with four different characteristics of long-term health conditions. We suggest that situating child maltreatment within a long-term conditions framework could have significant advantages and implications for practice, policy and research, by strengthening a commitment across disciplines to apply evidence-based principles linked with policy and evaluation and recognizing the chronic effects of maltreatment to concentrate public, professional and government awareness of the extent and impact of the issue. We argue that a public health approach is the most effective way of focusing preventative efforts on the long-term sequelae of child maltreatment and to foster cooperation in promoting children's rights to grow and develop in a safe and caring environment free from violence and abuse.
Prior research identified associations between residential moves during adolescence and depression, but studies used small or nonrepresentative samples. The aim of this study was to examine the associations between residential moves and major depressive episode (MDE) in a large, nationally representative sample of adolescents in the USA.
This study analyzed data on 139 606 adolescents (12–17 years old) from the National Survey on Drug Use and Health, an annual cross-sectional survey from 2005 to 2012. We analyzed data on MDE prevalence within the past 12 months and residential moves within the past 5 years, using multivariable logistic regression models to control for observable covariates.
Adolescents who moved at least once in the past 5 years had 35% higher odds of MDE than those who did not (odds ratio, 1.35; 95% confidence interval, 1.28–1.43), with odds of MDE increasing as the number of moves increased. Associations were particularly strong among younger and higher income adolescents.
Findings suggest that adolescents who move often may be a vulnerable group in need of mental health screening and services. Next steps in research include longitudinal studies with data on preexisting mental health issues and childhood adverse events.
We used an expanded conceptualization of ethnic density at the neighborhood level, tailored to Hispanic majority communities in the USA, and a robust measure of children's acculturation at the individual level, to predict Hispanic children's respiratory health.
We conducted a cross-sectional survey of 1904 children in 2012 in El Paso, TX, USA. One thousand one hundred and seven Hispanic children nested within 72 census tracts were analyzed. Multilevel logistic regression models with cross-level interactions were used to predict bronchitis, asthma and wheezing during sleep.
A neighborhood-level ethnic density factor was a non-significant risk factor while individual-level acculturation was a significant risk factor for the three outcomes. Pest troubles and not having been breastfed as an infant intensified the positive association between ethnic density and bronchitis. Increases in ethnic density intensified the odds of wheezing in sleep if the child was not low birth weight or was not economically deprived.
Results suggest that increasing individual-level acculturation is detrimental for US Hispanic children's respiratory health in this Hispanic majority setting, while high ethnic density neighborhoods are mildly risky and pose more significant threats when other individual-level factors are present.
To assess the prevalence, awareness, treatment and control of hypertension among adults in Ireland and to describe the determinants of awareness, treatment and control in order to inform public health policy.
A cross-sectional study of a nationally representative sample of community living adults aged 50 years and older using data collected from 2009 to 2011 for the first wave of the Irish Longitudinal Study on Ageing (TILDA) (n = 5857). Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg and/or currently taking antihypertensive medications.
The prevalence of hypertension was 63.7% [95% confidence interval (CI) 62.3–65.1%]. Among those with hypertension, 54.5% (95% CI 52.6–56.2%) were aware of their hypertensive status and 58.9% (95% CI 57.1–60.4%) were on antihypertensive medication. Among those on treatment, 51.6% (95% CI 49.3–53.9%) had their BP controlled to below 140/90 mmHg. Respondents facing financial barriers to primary care and medication were less likely to be on antihypertensive treatment compared with those without financial barriers.
A high prevalence of hypertension was identified in this cohort, with low levels of awareness, treatment and control. Population and primary care interventions are required to reduce prevalence and to improve awareness, detection and management of hypertension.
This study looked at the degree of weight gain between the first (Reception) and last year (Year 6) of primary school and how weight status in Reception predicts becoming overweight/obese by Year 6.
A longitudinal sample of 1863 children was created using two time points (2006/7, 2012/13) from the National Child Measurement Programme (NCMP) in South Gloucestershire. T-test and logistic regression were used to test the difference between the BMI z-scores and BMI percentiles, and predict the probability of being overweight (BMI ≥ 85th) or obese (≥95th) at Year 6 based on BMI percentile in Reception.
Of those children who were obese at Reception age, 68% were obese at Year 6. Compared with children with a BMI in the 2nd to 49th percentile range, children between the 75th and 84th percentiles of BMI at Reception age were 10 times more likely (odds ratio (OR) = 10.18, P < 0.01), and those with a BMI between the 85th and 94th percentiles were 13 times more likely (OR = 13.38, P < 0.01), to become obese by Year 6. Boys were more likely than girls to revert to a healthy weight.
This is the first study to link data from the NCMP. It provides estimates of prevalence and offers new evidence on obesity emergence and gender differences.
Brazil and Canada are on opposite poles of the spectrum for life expectancy in America. We identified factors underlying Brazil's lower life expectancy relative to Canada, with emphasis on the role of injury compared with other major causes.
We computed life expectancy at birth in Brazil and Canada in 2010 and identified the ages and causes of death responsible for the gap between both countries. The main outcome measure was the contribution of homicide and traffic accidents to the gap, compared with other causes of death.
Relative to Canada, life expectancy was lower in Brazil by 8.2 years (men) and 5.2 years (women). Injury lowered life expectancy of men in Brazil by 2.2 years, or more than a quarter of the gap, mainly due to homicide and traffic accidents between ages 20 and 64 years. Homicide and traffic accidents contributed more than all circulatory diseases combined. In women, circulatory disease was the most important cause of lower life expectancy.
In 2010, homicides and traffic accidents were the principal cause for short life expectancy of men in Brazil. Improving life expectancy in Brazil requires addressing the root causes of inequalities that drive illicit drug trade, violence and accidents.
To report the level and correlates of oral cancer literacy in a deprived area of the UK.
This study is part of the East London Oral Health Inequality Study, which included a representative sample of adults 16–65 (n = 2343) years old living in Waltham Forest, Redbridge and Barking and Dagenham in 2009–10. This cross-sectional study adopted a multi-stage, stratified, random sampling approach. Data were collected through home visits by trained examiners and interviewers. Hierarchical logistic regression modelling was adopted.
Only 26.7% participants were aware that a small lesion in the mouth can develop into oral cancer, and 39.5% were aware that early treatment could prevent a lesion from developing into oral cancer. Adjusted odds ratios confirmed the social gradient in awareness that a small lesion in the mouth can develop into oral cancer, even after adjusting for age, gender and ethnicity. Inequalities in awareness that a small lesion in the mouth can develop into oral cancer were significantly attenuated after forcing education level into the equation. Interestingly, adjusting for education cancelled the difference previously observed between manual/routine and professional/managerial occupations.
Oral cancer literacy is poor among adults in Outer North East London, and we have identified particularly vulnerable sub-populations.
Few studies have focused on relating physical activity (PA) and sedentary behaviour (SB) to identify homogeneous groups. This study aimed to identify patterns of PA and SB in France general population and their correlates.
A sample of 3294 (mean age 44 ± 17 years) from the general population in France was included. PA and SB were assessed by the World Health Organization Global Physical Activity Questionnaire. Cluster analysis was used to identify PA and SB patterns, with polytomous logistic regression to identify their correlates.
Five clusters were identified: (i) ‘low total PA, active-transportation and low SB’ (41%), (ii) ‘low total PA and moderate SB’ (22%), (iii) ‘low total PA, leisure-time PA and high SB’ (15%), (iv) ‘high total PA, moderate occupational PA and moderate SB’ (17%) and (v) ‘high total PA, vigorous occupational PA and low SB’ (5%). Occupational PA substantially contributed to total PA which depended on socioeconomic status (SES): low total PA and high SB in higher SES and high total PA and low SB in lower SES.
Based on PA and SB, French adults were clustered into groups with socioeconomic differences emphasizing that adapted interventions may be more beneficial for health.
We report development of a group-based lifestyle intervention, Let's Prevent, using the UK Medical Research Council (MRC) framework, and delivered by structured education to prevent type 2 diabetes mellitus (T2DM) in people with impaired glucose regulation (IGR) in a UK multi-ethnic population.
Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) is the first national T2DM programme that meets National Institute for Health and Care Excellence criteria and formed the basis for Let's Prevent. An iterative cycle of initial development, piloting, collecting and collating qualitative and quantitative data, and reflection and modification, was used to inform and refine lifestyle intervention until it was fit for evaluation in a definitive randomized controlled trial (RCT). The programme encouraged IGR self-management using simple, non-technical language and visual aids.
Qualitative and quantitative data suggested that intervention resulted in beneficial short-term behaviour change such as healthier eating patterns, improved health beliefs and greater participant motivation and empowerment. We also demonstrated that recruitment strategy and data collection methods were feasible for RCT implementation.
Let's Prevent was developed following successful application of MRC framework criteria and the subsequent RCT will determine whether it is feasible, reliable and transferable from research into a real-world NHS primary healthcare setting.
Health assessments are used to prioritize community-level health concerns, but the role of individuals' health concerns and experiences is unknown. We sought to understand to what extent community health assessments reflect health concerns of the community-at-large versus a representation of the participants sampled.
We conducted a health assessment survey in 30 rural African American churches (n = 412). Multivariable logistic regression produced odds ratios examining associations between personal health concern (this health concern is important to me), personal health experience (I have been diagnosed with this health issue) and community health priorities (this health concern is important to the community) for 20 health issues.
Respondents reported significant associations for 19/20 health conditions between personal health concern and the ranking of that concern as a community priority (all P < 0.05). Inconsistent associations were seen between personal health experience of a specific health condition and the ranking of that condition as a community priority.
Personal health concerns reported by individuals in a study sample may impact prioritization of community health initiatives. Further research should examine how personal health concerns are formed.
We report an outbreak of Clostridium perfringens in a care home in North East England.
A retrospective cohort study was used to investigate this outbreak. Faecal samples were obtained from symptomatic residents. Environmental Health Officers carried out a food hygiene inspection and formal statements were taken.
Fifteen residents reported illness and the epidemic curve was suggestive of a point source outbreak. Results suggest that illness was associated with consumption of mince & vegetable pie and/or gravy. There were a number of issues with food served, in particular the mince products had been cooked, cooled, reheated and served again over a period of several days. Faecal sampling revealed the presence of C.perfringens enterotoxin gene and four samples were indistinguishable by fluorescent amplified fragment length polymorphism, indicating a likely common source. The operator of the home was charged with three offences under the General Food Regulations 2004 and the Food Hygiene (England) Regulations 2006 and was convicted on all counts.
An outbreak of C.perfringens occurred in a care home. The likely cause was consumption of mince & vegetable pie and/or gravy. Epidemiological evidence can be used to help prosecute businesses with food safety offences in such circumstances.
Tobacco companies use a host of strategies to undermine public health efforts directed to reduce and eliminate smoking. The success, failure and trends in domestic litigation used by tobacco companies to undermine tobacco control are not well understood, with commentators often assuming disputes are trade related or international in nature. We analyse domestic legal disputes involving tobacco companies and public health actors in high-income countries across the last decade to ascertain the types of action and the success or failure of cases, develop effective responses.
WorldLii, a publicly available online law repository, was used to identify domestic court cases involving tobacco companies from 2004 to 2014, while outcome data from LexisNexis and Westlaw databases were used to identify appeals and trace case history.
We identified six domestic cases in the UK, Australia and Canada, noting that the tobacco industry won only one of six cases; a win later usurped by legislative reform and a further court case. Nevertheless, we found cases involve significant resource costs for governments, often progressing across multiple jurisdictional levels.
We suggest that, in light of our results, while litigation takes up significant time and incurs legal costs for health ministries, policymakers must robustly fend off suggestions that litigation wastes taxpayers' money, pointing to the good prospects of winning such legal battles.
This research examined the influence of sit-to-stand desks on classroom sitting time in primary school children.
Pilot controlled trials with similar intervention strategies were conducted in primary schools in Melbourne, Australia, and Bradford, UK. Sit-to-stand desks replaced all standard desks in the Australian intervention classroom. Six sit-to-stand desks replaced a bank of standard desks in the UK intervention classroom. Children were exposed to the sit-to-stand desks for 9–10 weeks. Control classrooms retained their normal seated desks. Classroom sitting time was measured at baseline and follow-up using the activPAL3 inclinometer.
Thirty UK and 44 Australian children provided valid activPAL data at baseline and follow-up. The proportion of time spent sitting in class decreased significantly at follow-up in both intervention groups (UK: –9.8 ± 16.5% [–52.4 ± 66.6 min/day]; Australian: –9.4 ± 10% [–43.7 ± 29.9 min/day]). No significant changes in classroom sitting time were observed in the UK control group, while a significant reduction was observed in the Australian control group (–5.9 ± 11.7% [–28.2 ± 28.3 min/day]).
Irrespective of implementation, incorporating sit-to-stand desks into classrooms appears to be an effective way of reducing classroom sitting in this diverse sample of children. Longer term efficacy trials are needed to determine effects on children's health and learning.
The NHS Health Check Programme was introduced in 2009 to improve primary prevention of coronary heart disease, stroke, diabetes and chronic kidney disease; however, there has been debate regarding the impact. We present a retrospective evaluation of Leicester City Clinical Commissioning Group.
Data are reported on diagnosis of type 2 diabetes, hypertension, chronic kidney disease, high risk of type 2 diabetes and high risk of cardiovascular disease. Data on management following the Health Check are also reported.
Over a 5-year period, 53 799 health checks were performed, 16 388 (30%) people were diagnosed with at least one condition when diagnosis of being at high risk of cardiovascular disease was defined as ≥20%. This figure increased to 43% when diagnosis of high cardiovascular risk ≥10% was included. Of the 3063 (5.7%) individuals diagnosed with type 2 diabetes, 54% were prescribed metformin and 26% were referred for structured education. Of the 5797 (10.8%) individuals diagnosed at high risk of cardiovascular disease (≥20%), 64% were prescribed statins.
A high proportion of new cases of people at risk of cardiovascular disease were identified by the NHS Health Check Programme. Data suggest that this has translated into appropriate preventative measures.
NHS Health Checks are a national cardiovascular risk assessment and management programme in England and Wales. We examined the experiences of patients attending and healthcare professionals (HCPs) conducting NHS Health Checks.
Interviews were conducted with a purposive sample of 28 patients and 16 HCPs recruited from eight general practices across a range of socio-economic localities. Interviews were audio recorded, transcribed, anonymized and analysed thematically.
Patients were motivated to attend an NHS Health Check because of health beliefs, the perceived value of the programme, a family history of cardiovascular and other diseases and expectations of receiving a general health assessment. Some patients reported benefits including reassurance and reinforcement of healthy lifestyles. Others experienced confusion and frustration about how results and advice were communicated, some having a poor understanding of the implications of their results. HCPs raised concerns about the skill set of some staff to competently communicate risk and lifestyle information.
To improve the satisfaction of patients attending and improve facilitation of lifestyle change, HCPs conducting the NHS Health Checks require sufficient training to equip them with appropriate skills and knowledge to deliver the service effectively.
To evaluate the effect of NHS Health Checks on cardiovascular risk factor detection and inequalities.
Matched cohort study in the Clinical Practice Research Datalink, including participants who received a health check in England between 1 April 2010 and 31 March 2013, together with matched control participants, with linked deprivation scores.
There were 91 618 eligible participants who received a health check, of whom 75 123 (82%) were matched with 182 245 controls. After the health check, 90% of men and 92% of women had complete data for blood pressure, total cholesterol, smoking and body mass index; a net 51% increase (P < 0.001) over controls. After the check, gender and deprivation inequalities in recording of all risk factors were lower than for controls. Net increase in risk factor detection was greater for hypercholesterolaemia (men +33%; women +32%) than for obesity (men +8%; women +4%) and hypertension in men only (+5%) (all P < 0.001). Detection of smoking was 5% lower in health check participants than controls (P < 0.001). Over 4 years, statins were prescribed to 11% of health -check participants and 7.6% controls (hazard ratio 1.58, 95% confidence interval 1.53–1.63, P < 0.001).
NHS Health Checks are associated with increased detection of hypercholesterolaemia, and to a lesser extent obesity and hypertension, but smokers may be under-represented.
Socio-demographic factors characterizing disadvantage may influence uptake of preventative health interventions such as the NHS Health Check and research trials informing their content.
A cross-sectional study examining socio-demographic characteristics of participants and non-participants to the NHS Health Check and a nested trial of very brief physical activity interventions within this context. Age, gender, Index of Multiple Deprivation (IMD) and ethnicity were extracted from patient records of four General Practices (GP) in England.
In multivariate analyses controlling for GP surgery, the odds of participation in the Health Check were higher for older patients (OR 1.05, 95% CI 1.04–1.07) and lower from areas of greater deprivation (IMD Quintiles 4 versus 1, OR 0.37, 95% CI 0.18–0.76, 5 versus 1 OR 0.42, 95% CI 0.20–0.88). Older patients were more likely to participate in the physical activity trial (OR 1.04, 95% CI 1.02–1.06).
Younger patients and those living in areas of greater deprivation may be at risk of non-participation in the NHS Health Check, while younger age also predicted non-participation in a nested research trial. The role that GP-surgery-specific factors play in influencing participation across different socio-demographic groups requires further exploration.
To identify the barriers and facilitators to uptake of the HPV vaccine in an ethnically diverse group of young women in the south west of England.
Three school-based vaccination sessions were observed. Twenty-three young women aged 12 to 13 years, and six key informants, were interviewed between October 2012 and July 2013. Data were analysed using thematic analysis and the Framework method for data management.
The priority given to preventing cervical cancer in this age group influenced whether young women received the HPV vaccine. Access could be affected by differing levels of commitment by school staff, school nurses, parents and young women to ensure parental consent forms were returned. Beliefs and values, particularly relevant to minority ethnic groups, in relation to adolescent sexual activity may affect uptake. Literacy and language difficulties undermine informed consent and may prevent vaccination.
The school-based HPV vaccination programme successfully reaches the majority of young women. However, responsibility for key aspects remain unresolved which can affect delivery and prevent uptake for some groups. A multi-faceted approach, targeting appropriate levels of the socio-ecological model, is required to address procedures for consent and cultural and literacy barriers faced by minority ethnic groups, increase uptake and reduce inequalities.
Immunization advice services can support health professionals by providing rapid access to accurate and reliable current information and advice. The Vaccine Advice for Clinicians Service (VACCSline) is a service for health professionals working within the Thames Valley Area of the UK.
We reviewed all 4299 enquiries received by VACCSline over 3 years. Queries were summarized by vaccine type and topic of enquiry. Associations with profession and workplace of the enquirer were tested using Fisher's exact tests.
Incomplete immunization status and non-UK schedules were the most common topics of enquiry. Practice nurses were the main service users followed by doctors. Enquiries varied by professional role. Alterations to the immunization programme led to temporary changes to enquiry content and some more persistent adjustments in the balance of enquiries were identified, such as an increase in enquiries relating to vaccination in pregnancy.
The content of enquiries to VACCSline is broad, confirming the need for immunizers to have a wide knowledge base and access to specialist advice to assist with complex scenarios. Systematic data capture provided intelligence to guide training and materials to support immunizers. A wider networked application of this approach could improve support for immunizers.
The burden of disease relating to undiagnosed HIV infection is significant in the UK. BHIVA (British HIV Association) recommends population screening in high prevalence areas, expanding outside traditional antenatal/GUM settings.
RUClear 2011–12 piloted expanding HIV testing outside traditional settings using home-sampling kits (dry-blood-spot testing) ordered online. Greater Manchester residents (≥age 16) could request testing via an established, online chlamydia testing service (www.ruclear.co.uk). Participant attitudes towards this new service were assessed. Qualitative methods (thematic analysis) were used to analyse free-text data submitted by participants via hard copy questionnaires issued in all testing kits.
79.9% (2447/3062) participants completed questionnaires, of which 30.9% (756/2447) provided free-text data. Participants overwhelmingly supported the service, valuing particularly accessibility and convenience, allowing individuals to order tests any time of day and self-sample comfortably at home; avoiding the invasive nature of venipuncture and avoiding the need for face-to-face interaction with health services. The pilot was also clinically and cost-effective.
Testing via home-sampling kits ordered online (dry-blood-spot testing) was felt to be an acceptable and convenient method for accessing a HIV test. Many individuals undertook HIV testing where they would otherwise not have been tested at all. Expansion of similar services may increase the uptake of HIV testing.
Delay in presentation contributes to poorer survival of older women with breast cancer. Research has shown the effectiveness of the promoting early presentation (PEP) intervention when delivered by radiographers in the NHS Breast Screening Programme. This paper investigates the effectiveness of the intervention when delivered by practice nurses in general practice.
The Breast Cancer Awareness Measure was used to compare participants' awareness of breast cancer before, 1 month after and 12 months after the delivery of the PEP intervention. Five hundred and fifty-six women aged over 70 years took part, 308 of whom returned all three surveys.
The intervention was associated with increased awareness of non-lump breast symptoms and reported breast check frequency. There was a marked increase in breast cancer awareness which persisted for 12 months. Less than 5% of women were classified as ‘breast cancer aware’ before the intervention, rising to over 25% 1 month afterwards. This percentage dropped slightly after 1 year to just below 20%.
Delivery of the PEP intervention in general practice was very effective at raising the awareness of breast cancer among older women. Primary care settings are well placed to enhance the reach of this kind of intervention to at-risk women.
Referrals to ophthalmology are predominantly made from general practitioners (GPs) and optometrists. These two groups of referrers receive differing types and levels of training and are equipped with different instrumentation. The purpose of this study was to determine whether the quality of referrals to the hospital eye service (HES) differs between GPs and optometrists in Walsall.
Referrals into the HES were identified from Q1 2014 retrospectively until 1000 notes had been reached. Each record was scrutinized using a standard template. Data were analysed and summary statistics produced including positive predictive values and interobserver agreement.
We achieved our target of auditing 1000 records. The false-positive rate (patients being discharged from HES with a ‘normal vision’ diagnosis) was 7.7% of referrals from GPs and 6.2% of referrals from optometrists. Concordance between referred condition and diagnosed condition at HES between optometrists and ophthalmologists was 76.1%, and between GPs and ophthalmologists was 67.2%.
In view of findings from this study, it is important for commissioners in the new reconfigured National Health Service to ensure that enhanced ophthalmic services are commissioned only on the basis of hard evidence sourced from local data rather than opinion or on data from another geographical area.
Body mass index (BMI) tends to be higher among shorter adults, especially women. The dependence of BMI–height correlation on age and calendar time may inform us about temporal determinants of BMI.
Series of cross-sectional surveys: Health Survey for England, 1992–2011. We study the Benn Index, which is the coefficient in a regression of log(weight) on log(height). This is adjusted for age, gender and calendar time, allowing for non-linear terms and interactions.
By height quartile, mean BMI decreased with increasing height, more so in women than in men (P < 0.001). The decrease in mean BMI in the tallest compared with the shortest height quartile was 0.77 in men (95% CI 0.69, 0.86) and 1.98 in women (95% CI 1.89, 2.08). Regression analysis of log(weight) on log(height) revealed that the inverse association between BMI and height was more pronounced in older adults and stronger in women than in men, with little change over calendar time.
Unlike early childhood, where taller children tend to have higher BMI, adults, especially women and older people, show an inverse BMI–height association. BMI is a heterogeneous measure of weight-for-height; height may be an important and complex determinant of BMI trajectory over the life course.
The limited research on police sexual misconduct (PSM), a common form of police misconduct, suggests that no evidence-based strategies for prevention are available for use by police departments. To identify new avenues for prevention, we critically evaluated ‘front-end’ police recruiting, screening, hiring and training procedures.
Internal Affairs records were linked with administrative reports and police academy graduation data for officers accused of sexual assault or misconduct between 1994 and 2014. Logistic and proportional hazards regression methods were used to identify predictors of discharge for sustained allegations of PSM and time to discharge, respectively.
Officer's graduating class size was positively associated with odds of discharge for PSM. For every one-officer increase in class size, the rate of discharge for PSM increased by 9% [hazard ratio (HR) = 1.09, P < 0.01]. For particularly large classes (>35 graduates), discharge rates were at least four times greater than smaller classes (HR = 4.43, P < 0.05).
Large class sizes and more annual graduates increase rates of PSM. Officer recruitment strategies or training quality may be compromised during periods of intensive hiring. Trainee to instructor ratios or maximum class sizes may be instituted by academies to ensure that all police trainees receive the required supervision, one-on-one training, feedback and attention necessary to maximize public safety.
It is early Saturday morning: a day for heroes. Bogged down with various costumes, capes and action figures, young Nikoli bounds downstairs to catch reruns of Teen Titans. He puts his newly acquired reading skills to work, studying comic books and recreating the adventures therein. Nikoli imagines himself as the hero in his comics, defeating villains and saving victims, imitating the poses and catchphrases in the mirror. Although children like Nikoli will never gain super strength or the ability to fly, the superheroes they emulate in play are examples of people they can aspire to be. They don't even have to be fictional heroes—if we widen the scope of children's superheroes to include those that address real-life issues, or even real-life heroes who have made breakthroughs in fields such as public health, the impact could be tremendous. Imagine a world where Superman is mentioned in the same breath as Ignaz Semmelweis, the man who revolutionized sanitation in health care by demonstrating that hand washing prevents the spread of infection. Children who idolize the champions of health care could someday grow up to be heroes themselves, fighting epidemics and saving lives through education, treatment and research. Their wildest fantasies could become a reality.