Reimagining Rural: Shifting Paradigms About Health and Well-Being in the Rural United States.

Rural health disparities have attracted increased national attention, compelling an expanded focus on rural health research. In this article, we deconstruct the definitions and narratives of "rural" communities and suggest that a paradigm shift is needed that centers the complexity and strength of rural places. We discuss the relevance of health equity frameworks, implementation science, and community-engaged approaches to promote rural well-being. Focusing on rural in its own right will lead to intervention innovations and reinvention with implications beyond rural areas. We conclude with suggestions for research and practice to inspire renewed interest in partnering with rural communities to promote health equity.

The passage of tobacco control law 174 in Lebanon: reflections on the problem, policies and politics.

Progress in tobacco control policy making has occurred worldwide through advocacy campaigns involving multiple players- civil society groups, activists, academics, media and policymakers. The Framework Convention on Tobacco Control (FCTC)-the first ever global health treaty-outlines evidence-based tobacco control policies. Lebanon ratified the FCTC in 2005, but until 2011, tobacco control policies remained rudimentary and not evidence-based. Beginning in 2009, a concerted advocacy campaign was undertaken by a variety of stakeholders with the aim of accelerating the process of adopting a strong tobacco control policy. The campaign was successful, and Law 174 passed the Lebanese Parliament in August 2011. In this article, we analyse the policy making process that led to the adoption of Law 174 using Kingdon's model. The analysis relies on primary and secondary data sources including historical records of key governmental decisions, documentation of the activities of the concerted advocacy campaign and in-depth interviews with key stakeholders. We describe the opening of a window of opportunity as a result of the alignment of the problem, policy and politics streams. Furthermore, findings revealed that despite the challenge of persistent tobacco industry interference and established power relations between the industry, its allies and policymakers; policy entrepreneurs succeeded in supporting the alignment of the streams, and influencing the passage of the law. Kingdon's multiple stream approach was useful in explaining how tobacco control became an emerging policy issue at the front of the policy agenda in Lebanon.

Parental smoking and exposure to environmental tobacco smoke are associated with waterpipe smoking among youth: results from a national survey in Lebanon.

OBJECTIVES: Waterpipe tobacco smoking (WTS) is a growing public health concern worldwide yet little is known about the epidemiology of use among young people. The objectives of this study were to examine the prevalence, patterns and correlates of WTS among students across Lebanon. STUDY DESIGN: The study design was a cross sectional survey. METHODS: 126-item tobacco questionnaire was conducted among 1128 sixth and seventh grade students across Lebanon. Current patterns of use were descriptively analysed, and logistic regression models examined correlates of WTS. RESULTS: Ever WTS prevalence was 44.3%, current WTS prevalence was triple that of cigarettes (22.1% vs 7.4%), and 40.0% of current users were at least weekly or daily smokers. Initiation and patterns of use, as well as addiction and cessation attitudes have been reported. Significant correlates of current WTS included older age, reduced religiosity, peer and parent tobacco use, recent waterpipe advertisement exposure, increased pluralistic ignorance and current cigarette use. Significant correlates of ever WTS were similar to current WTS, but included second hand waterpipe tobacco smoke exposure at home and did not include recent waterpipe advertisement exposure. Neither gender nor socio-economic status were significant correlates of current or ever WTS. CONCLUSIONS: Waterpipe is the most common form of tobacco smoking, and is used regularly, among sixth and seventh grade Lebanese students. It should be considered a public health priority with increased tobacco surveillance and legislation. Widespread educational and policy interventions might help denormalize the social acceptability of WTS. Meanwhile, more research is needed to understand the changing paradigm of WTS epidemiology and the health outcomes among young smokers.

The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally.

OBJECTIVE: The objective of this narrative review is to highlight the determinants of the epidemic rise in waterpipe tobacco smoking (WTS) among youth globally. The Ecological Model of Health Promotion (EMHP) was the guiding framework for the review. DATA SOURCES: The following electronic databases were searched: Cochrane library, MEDLINE, EMBASE, PsycINFO, Web of Science and CINAHL Plus with Full Text. Search terms included waterpipe and its many variant terms. STUDY SELECTION: Articles were included if they were published between 1990 and 2014, were in English, were available in full text and included the age group 10-29 years. DATA EXTRACTION: Articles which analysed determinants of WTS at any of the levels of the EMHP were retained regardless of methodological rigour: 131 articles are included. Articles were coded in a standard template that abstracted methods as well as results. DATA SYNTHESIS: The review found that methodologies used to assess determinants of WTS among youth were often conventional and lacked rigor: 3/4 of the studies were cross-sectional surveys and most enrolled non-representative samples. Within the framework, the review identified determinants of WTS at the intrapersonal, interpersonal, organisational, community and policy levels. CONCLUSIONS: The review suggests potential interventions to control WTS among youth, with emphasis on creative utilisation of social media, and tobacco control policies that include the specificities of WTS. The review further suggests the need for rigorous qualitative work to better contextualise determinants, and prospective observational and experimental studies that track and manipulate them to assess their viability as intervention targets.

Waterpipe tobacco and cigarette smoking among university students in Jordan.

SETTING: While waterpipe and cigarette smoking have been well studied in Syria and Lebanon, data from Jordan are limited. OBJECTIVES: To characterize the relative prevalence of waterpipe tobacco and cigarette smoking among university students in Jordan, and to compare the demographic and environmental factors associated with each form of tobacco use. DESIGN: We surveyed 1845 students randomly recruited from four universities in Jordan. We used multivariable logistic regression controlling for clustering of individuals within universities to determine associations between demographic and environmental covariates and waterpipe tobacco and cigarette use. RESULTS: Waterpipe tobacco smoking rates were 30% in the past 30 days and 56% ever, while cigarette smoking rates were 29% in the past 30 days and 57% ever. Past 30-day waterpipe tobacco smoking rates were 59% for males and 13% for females. Females had substantially lower odds than males of being current waterpipe (OR 0.12, 95%CI 0.10-0.15) or cigarette (OR 0.08, 95%CI 0.05-0.14) smokers. Current cigarette smoking was more significantly associated with markers of high socio-economic status (SES) than waterpipe tobacco smoking. CONCLUSION: Waterpipe tobacco smoking is as common as cigarette smoking among Jordanian university students. While cigarette smoking is consistently associated with high SES, waterpipe tobacco smoking is more evenly distributed across various populations.

Domestic violence against women during pregnancy: the case of Palestinian refugees attending an antenatal clinic in Lebanon.

OBJECTIVES: To determine the factors associated with domestic violence against pregnant Palestinian refugee women residing in Lebanon and currently using the United Nation Relief and Work Agency's (UNRWA) primary healthcare services. METHODS: This was a cross-sectional study conducted at a polyclinic of primary healthcare of the UNRWA in South Lebanon during the years 2005-2006. The sample was 351 pregnant women who were 15-42 years of age and not accompanied by their husbands or relatives. All women were invited by the midwife to participate in the study during their visit to the clinic for their first checkup or during a follow-up visit. The Abuse Assessment Screen instrument was used to screen for past and recent history of physical and emotional abuse among the participants. RESULTS: Domestic violence was significantly associated with education, gestational age, fear of husband or someone else in the house, and unintended pregnancy. The odds of abuse for women with an elementary or lower education were 6.86 (95% CI 1.2-38.1) and for women with an intermediate or secondary education 6.84 (95% CI 1.4-33.3) compared with women with a university education. The odds of abuse during pregnancy for women whose husbands did not desire their pregnancy were 3.80 (95% CI 1.5-9.7) compared with other women. CONCLUSIONS: Domestic violence against women in Lebanon was associated with educational level, gestational age, fear of husband or someone else in the house, and unintended pregnancy.

Risk perceptions and participation in colorectal cancer screening.

Compared individuals at high versus average risk for colorectal cancer (CRC) with respect to factors they cited as affecting their risk of developing CRC. We also examined the relationship of these risk-factor perceptions to perceived susceptibility and participation in a CRC screening test. All individuals in the high-risk group were informed that, as a sibling of someone with CRC, they were more likely to get this cancer themselves. We found minimal differences among siblings with respect to perceived susceptibility. Further, although high-risk siblings were more likely to participate in screening, only 20.2% cited heredity as a risk-increasing factor, and, among these siblings, there was no relationship between screening participation and the citation of any specific risk factors, including heredity. These findings demonstrate the need for more research examining how high-risk individuals process risk-relevant information and the effect of this information on health behavior.