Knowledge, Beliefs, and Behaviors Related to Secondhand Smoke and Smoking in the Home: A Qualitative Study With Men in Malaysia.

INTRODUCTION: Despite the health risks associated with secondhand smoke (SHS) exposure, smoking in the home is common in Malaysia, and almost exclusively a male behavior. AIMS AND METHODS: This study explored male smokers' knowledge, beliefs, and behaviors related to SHS exposure and smoking in the home, to guide future intervention development. Twenty-four men who smoked and lived in Klang Valley, Kuantan, or Kuala Terengganu took part in semi-structured interviews which explored knowledge and beliefs regarding SHS in the home, and associated home-smoking behaviors. Data were managed and analyzed using the framework approach. RESULTS: There was limited knowledge regarding the health risks associated with SHS: the smell of SHS in the home was a more prominent concern in most cases. Many had no rules in place restricting home smoking, and some suggested that smoking in specific rooms and/or near windows meant SHS was not "shared" with other household members. A few fathers had created but not maintained a smoke-free home prior to and/or after their children were born. Desire to smoke in the home conflicted with men's sense of responsibility as the head of the household to protect others and set a good example for their children. CONCLUSIONS: Men's home-smoking behaviors are shaped by a lack of understanding of the health risks associated with SHS exposure. Gaining a broader understanding of the factors that shape men's decisions to create a smoke-free home is important to facilitate the development of culturally appropriate interventions that address their responsibility to protect other household members from SHS exposure. IMPLICATIONS: Our findings highlight the need for public information campaigns in Malaysia to educate men who smoke regarding the health harms associated with SHS in the home and the ways in which SHS travels and lingers in household air. This is important given men's concerns about SHS often focus on the smell of cigarette smoke in the home. Our findings suggest a number of potential avenues for future intervention development, including household and community-level initiatives that could build on men's sense of responsibility as the head of the household and/or their general desire to protect their families.

Heavy metal quantification of classroom dust in school environment and its impacts on children health from Rawang (Malaysia).

This study aimed to determine bioavailable heavy metal concentrations (As, Cd, Co, Cu, Cr, Ni, Pb, Zn) and their potential sources in classroom dust collected from children's hand palms in Rawang (Malaysia). This study also aimed to determine the association between bioavailable heavy metal concentration in classroom dust and children's respiratory symptoms. Health risk assessment (HRA) was applied to evaluate health risks (non-carcinogenic and carcinogenic) due to heavy metals in classroom dust. The mean of bioavailable heavy metal concentrations in classroom dust found on children's hand palms was shown in the following order: Zn (1.25E + 01 µg/g) > Cu (9.59E-01 µg/g) > Ni (5.34E-01 µg/g) > Cr (4.72E-02 µg/g) > Co (2.34E-02 µg/g) > As (1.77E-02 µg/g) > Cd (9.60E-03 µg/g) > Pb (5.00E-03 µg/g). Hierarchical cluster analysis has clustered 17 sampling locations into three clusters, whereby cluster 1 (S3, S4, S6, S15) located in residential areas and near to roads exposed to vehicle emissions, cluster 2 (S10, S12, S9, S7) located near Rawang town and cluster 3 (S13, S16, S1, S2, S8, S14, S11, S17, S5) located near industrial, residential and plantation areas. Emissions from vehicles, plantations and industrial activities were found as the main sources of heavy metals in classroom dust in Rawang. There is no association found between bioavailable heavy metal concentrations and respiratory symptoms, except for Cu (OR = 0.03). Health risks (non-carcinogenic and carcinogenic risks) indicated that there are no potential non-carcinogenic and carcinogenic risks of heavy metals in classroom dust toward children health.

A systematic review of micro correlates of maternal mortality.

In the year 2000, the World Health Organization launched the Millennium Development Goals (MDGs) which were to be achieved in 2015. Though most of the goals were not achieved, a follow-up post 2015 development agenda, the Sustainable Development Goals (SDGs) was launched in 2015, which are to be achieved by 2030. Maternal mortality reduction is a focal goal in both the MDGs and SDGs. Achieving the maternal mortality target in the SDGs requires multiple approaches, particularly in developing countries with high maternal mortality. Low-income developing countries rely to a great extent on macro determinants such as public health expenditure, which are spent mostly on curative health and health facilities, to improve population health. To complement the macro determinants, this study employs the systematic review technique to reveal significant micro correlates of maternal mortality. The study searched MEDLINE, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, and Global Index Medicus of the World Health Organization. Our search was time framed from the 1st January, 2000 to the 30th September, 2016. In the overall search result, 6758 articles were identified, out of which 33 were found to be eligible for the review. The outcome of the systematic search for relevant literature revealed a concentration of literature on the micro factors and maternal mortality in developing countries. This shows that maternal mortality and micro factors are a major issue in developing countries. The studies reviewed support the significant relationship between the micro factors and maternal mortality. This study therefore suggests that more effort should be channelled to improving the micro factors in developing countries to pave the way for the timely achievement of the SDGs' maternal mortality ratio (MMR) target.

Reducing work-related musculoskeletal symptoms through implementation of Kiken Yochi training intervention approach.

BACKGROUND: Work tasks in pineapple plantations in Malaysia are characterised by non-ergonomic work postures, repetitive tasks, awkward posture and manual handling of work tools that contribute to the reporting of musculoskeletal symptoms (MSS). There have been very limited studies performed among pineapple plantation workers focusing on ergonomic intervention programs to specifically reduce MSS. OBJECTIVE: The aim of this study was to assess the effects of work improvement module using a Kiken Yochi participatory approach intervention in reducing MSS among male migrant pineapple farm plantation workers in Pontian, Johor. METHODOLOGY: In this interventional study, a total of 68 male migrant workers from two plantation farms were invited to become a participant in this study. In total, 45 participants that consisted of 27 workers for the intervention group and 18 workers for the control group were recruited. The background of workers and MSS were assessed using questionnaires. Ergonomic and postural risks were evaluated and the work tasks with the highest risk were used as a basis for the development of the Kiken Yochi training module. MSS education and training intervention that provided information on proper lifting techniques and education on body mechanics and ergonomics to reduce MSS were implemented to both groups of workers. Kiken Yochi Training was given to the intervention group only. MSS were reassessed after 2 months of the follow-up period. Data was entered into statistical software and were analysed according to objectives. RESULTS: In terms of the postural risk assessment, almost two-third of the participants (68.5%) had working postures categorized as high risk for MSS. Ergonomic risk assessment identified cultivation, manual weeding and harvesting of pineapples as the work tasks contributing the highest health risks to workers. The most commonly reported MSS between both groups of workers were at the knees, lower back and shoulder area. Upon completion of the delivery of intervention module to both groups of workers, the MSS prevalence reported (after 2 months) were significantly lower for the ankles and feet area within the intervention group. CONCLUSION: This study suggested that development and implementation of programs using effective participatory approach training methods are able to prevent selected musculoskeletal problems for this occupation. To enhance the effects of such trainings, modifications of work tools in this occupation are desirable.

Vaping Topography and Reasons of Use among Adults in Klang Valley, Malaysia

Background: Consistency and accuracy of results in assessing health risks due to vaping or e-cigarette use are difficult to achieve without established consumption data. The present report covers baseline data on vaping topography and reasons for use among local users in Klang Valley, Malaysia. Methods: An 80-item survey regarding socio-demographic characteristics, smoking topography and reasons for e-cigarette use was employed to assess e-cigarette users recruited from several public universities and private organisations. The survey questionnaire was self-administered. Data were analysed using statistical software. Results: Eighty-six current e-cigarette users participated with more than half (51.2%) of them aged ≥ 25 years old. Significant proportions of the sample were single (51.2%), had a tertiary education level (63.5%) and a household income of less than USD1000 per month (65.2%). Median duration of e-cigarette use was less than a year; users drew approximately 50 puffs per day and refilled twice a day. The majority (74%) used e-liquids containing nicotine with a concentration of 6 µg/mL. Daily users spent USD18-23 per month. Reasons for using the e-cigarette included enjoyment of the products (85.9%), perception of lower toxicity than tobacco (87%), and the fact that it was a cheaper smoking alternative (61%). Conclusion: The data on e-cigarette smoking topography obtained in this study are novel. The reasons of usage were mainly users' enjoyment of e-cigarettes, preparation for quitting smoking, perception of low toxicity and a healthier smoking substitute and cheapness in the long run. The results establish basic knowledge for the local vaping topography and reference material for future e-cigarette-related research.

Electronic cigarettes: a systematic review of available studies on health risk assessment.

OBJECTIVE: This paper primarily aimed to review articles which specifically quantified the risk of electronic cigarette's (e-cigarette) usage via the health risk assessment (HRA) approach. METHODS: Systematic literature searches were conducted using PubMed search engine databases. Search terms such as "electronic cigarette", "e-cigarette", "electronic nicotine delivery systems", "electronic cigarette liquid", "electronic cigarette vapors", and "health risk assessment" were used to identify the relevant articles to be included in this review. To enable comparison, hazard quotient (HQ) and lifetime cancer risk (LCR) for the chemicals measured in the selected articles were calculated for three of the articles using the formula: [1] HQ=average daily dose (ADD)/reference dose (RfD) or exposure air concentration (EC)/reference concentration (RfC); [2] LCR=lifetime average daily dose (LADD) × cancer slope factor (CSF) or exposure air concentration (EC) × inhalation unit risk (IUR). RESULTS: Four articles pertaining to HRA of e-cigarettes were critically reviewed, three of the papers focused on specific chemicals namely nicotine, propylene glycol (PG), glycerol and 1,2-propanediol, while one article evaluated the health risks posed by heavy metals contained in e-cigarettes. The calculated HQs for the chemicals in this review had large variations. HQs of the six chemicals, i.e. nicotine, PG, glycerol, cadmium, ethylene glycol, nickel, aluminum and titanium, were found to have the potential to contribute to non-carcinogenic health risks. None of the LCR calculated had risks exceeding the acceptable limit. CONCLUSION: There are limited HRA studies and the ones that were available provided inconsistent scientific evidences on the health risk characterization arising from the usage of e-cigarettes. As such, there is a need to perform more studies on HRA of e-cigarettes by using uniformed and comprehensive steps and similar reference threshold levels of exposures.

Pesticide management approach towards protecting the safety and health of farmers in Southeast Asia.

BACKGROUND: It is estimated that pesticide production and use have increased continuously in the countries of Southeast Asia in recent years. Within the context of protecting the safety and health of workers in the agricultural sector, there is an existing gap in the implementation of the pesticide management framework because safety and health effects arising from occupational exposures continue to be reported. OBJECTIVE: This study aims to provide narrative similarities, differences and weaknesses of the existing pesticide management system in Southeast Asian countries (Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam) within the context of occupational safety and health. METHODS: This is preliminary traditional review study. Pesticide regulation and management at the country level were identified using web-based search engines such as Scopus, ScienceDirect, PubMed and Google. Book, reports, legislation document and other documents retrieved were also gathered from international organizations and specific websites of governmental agency in Southeast Asian countries. The scope of this review is only limited to literature written in English. In total, 44 review articles, reports and documents were gathered for this study. The approach of pesticide management in protecting safety and health in the agricultural setting were benchmarked according to the elements introduced by the United States Environmental Protection Agency, namely, (1) the protection of workers and (2) the practice of safety. RESULTS: All countries have assigned a local authority and government organization to manage and control pesticide use in the agricultural sector. The countries with the highest usage of pesticide are Thailand, Philippines and Malaysia. Most Southeast Asian countries have emphasized safety practice in the management of pesticide usage, but there were less emphasis on the element of protection of workers within the framework in Indonesia, Myanmar, Thailand and Vietnam. CONCLUSION: The governing bodies in the countries of Southeast Asia have placed significant effort to develop framework related to pesticide management at the country level. The implementation of pesticide management based on the existing framework is evident in most of the countries but needs to be improved. It is suggested that emphasis be given to the implementation of diagnosis, health surveillance and reporting system as well as following or adopting standard guidelines for the protection of workers in terms of safety and health in the agricultural sector.

A review of heavy metals in indoor dust and its human health-risk implications.

Indoor dust acts as a media for heavy metal deposition. Past studies have shown that heavy metal concentration in indoor dust is affected by local human activities and atmospheric transport can have harmful effects on human health. Additionally, children are more sensitive to heavy metals due to their hand-to-mouth behaviour and rapid body development. However, limited information on health risks were found in past dust studies as these studies aimed to identify heavy metal concentrations and sources of indoor dust. The objective of this review is to discuss heavy metal concentration and sources influencing its concentration in indoor dust. Accordingly, high lead (Pb) concentration (639.10 µg/g) has been reported in heavy traffic areas. In addition, this review paper aims to estimate the health risk to children from heavy metals in indoor dust via multiple exposure pathways using the health-risk assessment (HRA). Urban areas and industrial sites have revealed high heavy metal concentration in comparison to rural areas. Hazard index (HI) values found in arsenic (As), chromium (Cr) and Pb were 21.30, 1.10 and 2.40, respectively, indicate that non-carcinogenic elements are found in children. Furthermore, most of the past studies have found that carcinogenic risks for As, cadmium (Cd), Cr and Pb were below the acceptable total lifetime cancer risk (TLCR) range (1×10-6-1×10-4). The results of health risk assessment in this review show that carcinogenic risk exists among children. Hence, this proves that future studies need to focus on children's carcinogenic risk in indoor dust studies in order to find out the sources of heavy metals in indoor dust. This review highlights the importance of having the HRA application using bioavailable heavy metal concentration as it provides more accurate health-risk estimation. Moreover, this review is also useful as a reference for policy decision making in protecting children's health.

Implementation of smoke-free legislation in Malaysia: are adolescents protected from respiratory health effects?

BACKGROUND: This study aimed to examine the relationship between respiratory health of Malaysian adolescents with secondhand smoke (SHS) exposure and smoke-free legislation (SFL) implementation. MATERIALS AND METHODS: A total of 898 students from 21 schools across comprehensive- and partial-SFL states were recruited. SHS exposures and respiratory symptoms were assessed via questionnaire. Prenatal and postnatal SHS exposure information was obtained from parental-completed questionnaire. RESULTS: The prevalence of respiratory symptoms was: 11.9% ever wheeze, 5.6% current wheeze, 22.3% exercise-induced wheeze, 12.4% nocturnal cough, and 13.1% self-reported asthma. SHS exposure was most frequently reported in restaurants. Hierarchical logistic regression indicates living in a comprehensive-SFL state was not associated with a lower risk of reporting asthma symptoms. SHS exposure in public transport was linked to increased risk for wheeze (Adjusted Odds Ratio (AOR) 16.6; 95%confidence interval (CI), 2.69-101.7) and current wheezing (AOR 24.6; 95%CI, 3.53-171.8). CONCLUSIONS: Adolescents continue to be exposed to SHS in a range of public venues in both comprehensive- and partial-SFL states. Respiratory symptoms are common among those reporting SHS exposure on public transportation. Non-compliance with SFL appears to be frequent in many venues across Malaysia and enforcement should be given priority in order to reduce exposure.

Second-hand smoke in public spaces: how effective has partial smoke-free legislation been in Malaysia?

BACKGROUND: This study was performed to gather data on second-hand smoke (SHS) concentrations in a range of public venues following the implementation of partial Smoke-Free Legislation in Malaysia in 2004. MATERIALS AND METHODS: PM2.5 was measured as a marker of SHS levels in a total of 61 restaurants, entertainment centres, internet cafes and pubs in Kuala Lumpur, Malaysia. RESULTS: Under the current smoke-free laws smoking was prohibited in 42 of the 61 premises. Active smoking was observed in nearly one-third (n=12) of these. For premises where smoking was prohibited and no active smoking observed, the mean (standard deviation) indoor PM2.5 concentration was 33.4 (23.8) µg/m3 compared to 187.1 (135.1) µg/m3 in premises where smoking was observed The highest mean PM2.5 was observed in pubs [361.5 (199.3) µg/m3]. CONCLUSIONS: This study provides evidence of high levels of SHS across a range of hospitality venues, including about one-third of those where smoking is prohibited, despite 8 years of smoke-free legislation. Compliance with the legislation appeared to be particularly poor in entertainment centres and internet cafes. Workers and non-smoking patrons continue to be exposed to high concentrations of SHS within the hospitality industry in Malaysia and there is an urgent need for increased enforcement of existing legislation and consideration of more comprehensive laws to protect health.

A survey of schoolchildren's exposure to secondhand smoke in Malaysia.

BACKGROUND: There is a lack of data describing the exposure of Malaysian schoolchildren to Secondhand Smoke (SHS). The aim of this study is to identify factors influencing schoolchildren's exposures to SHS in Malaysia. METHOD: This cross-sectional study was carried out to measure salivary cotinine concentrations among 1064 schoolchildren (10-11 years) attending 24 schools in Malaysia following recent partial smoke-free restrictions. Parents completed questionnaires and schoolchildren provided saliva samples for cotinine assay. RESULTS: The geometric mean (GM) salivary cotinine concentrations for 947 non-smoking schoolchildren stratified by household residents' smoking behaviour were: for children living with non-smoking parents 0.32 ng/ml (95% CI 0.28-0.37) (n = 446); for children living with a smoker father 0.65 ng/ml (95% CI 0.57-0.72) (n = 432); for children living with two smoking parents 1.12 ng/ml (95% CI 0.29-4.40) (n = 3); for children who live with an extended family member who smokes 0.62 ng/ml (95% CI 0.42-0.89) (n = 33) and for children living with two smokers (father and extended family member) 0.71 ng/ml (95% CI 0.40-0.97) (n = 44). Parental-reported SHS exposures showed poor agreement with children's self-reported SHS exposures. Multiple linear regression demonstrated that cotinine levels were positively associated with living with one or more smokers, urban residence, occupation of father (Armed forces), parental-reported exposure to SHS and education of the father (Diploma/Technical certificate). CONCLUSIONS: This is the first study to characterise exposures to SHS using salivary cotinine concentrations among schoolchildren in Malaysia and also the first study documenting SHS exposure using salivary cotinine as a biomarker in a South-East Asian population of schoolchildren. Compared to other populations of similarly aged schoolchildren, Malaysian children have higher salivary cotinine concentrations. The partial nature of smoke-free restrictions in Malaysia is likely to contribute to these findings. Enforcement of existing legislation to reduce exposure in public place settings and interventions to reduce exposure at home, especially to implement effective home smoking restriction practices are required.