Educating tomorrow's public health professionals to utilize the arts for health.

Momentum has been building over the last few years around capitalizing on the arts for improving health and wellbeing. But how are public health professionals to develop the skills needed to utilize the arts? In this article, Annie Harrison and Hannah Waterson discuss the evidence for the use of arts in health and describe 'Arts and Public Health' an optional module of the University of Manchester: Master of Public Health designed to equip students to meet the arts and health challenge.

Engaging older people to explore the age-friendliness of a rural community in Northern England: A photo-elicitation study.

An ageing society brings with it increased health costs due to the prevalence of long term conditions increasing with age. It is therefore vital to support good health in older people, both to improve their quality of life and to reduce the financial implications of an ageing society. Isolation and loneliness can put people at risk of dying early, and increasing opportunities for social interaction and engagement could mitigate some of the health effects of ageing. However, this requires society to create the conditions that enable older people to participate fully. The World Health Organization's Age-Friendly Cities programme has identified factors that make urban areas Age-Friendly, but research shows that older rural dwellers have unique unmet needs preventing full engagement in their communities. This article describes a pilot project which adapted photo-elicitation to explore the age-friendliness of a rural area in Calderdale, Northern England. It shows that photo-elicitation is a successful method for identifying what older people think is important in making their community age-friendly and it reveals differences between ageing in a city and in a rural setting. This rich data can be used to inform the development of policy in rural areas which is more closely aligned to the needs, preferences and interests of the growing population of older residents. The project also demonstrates the engagement potential of this methodology. Participants continued as co-researchers, learning new skills and taking responsibility for a variety of dissemination activities such as photographic exhibitions, a public report and presentations. This suggests that adapted photo-elicitation is a useful tool for engaging older people in research.

The impact of a volunteer-led community cancer awareness programme on knowledge of cancer risk factors and symptoms, screening, and barriers to seeking help.

OBJECTIVE: To analyse the impact of a community cancer awareness programme on knowledge of cancer risk factors and symptoms, screening, and barriers to seeking help. METHODS: Personalised information through peer-led champions was delivered to 5500 people in a range of settings and Cancer Awareness Measures questionnaires were completed by 119 participants at pre-arranged sessions (convenience sampling) before and after the intervention. Data were analysed using McNemar tests, Mann-Whitney U test and a Wilcoxon Signed Rank test. RESULTS: Data showed increase in knowledge after the intervention for cancer screening programmes (p < 0.05), recognition of warning signs for cancer (p < 0.05), and recognition of risk factors for cancer in seven of the eleven options (p < 0.001). Results suggest a decrease in perception of barriers to seeking help (p < 0.05). The intervention had a stronger impact on recognition of cancer symptoms for people who have been affected by cancer (p = 0.02). CONCLUSION: The Cancer Awareness Measures questionnaire proved an effective tool for evaluation and awareness improved after the intervention amongst those who completed it. PRACTICE IMPLICATIONS: Enhancing the perceived personal relevance of information to those with experience of cancer may improve information processing and retention. The study highlights cancer awareness gaps among the public for future intervention development.

What factors are associated with the prevalence of atopic symptoms amongst adolescents in Greater Manchester?

INTRODUCTION: Atopy commonly manifests itself as atopic diseases (ADs), namely asthma, eczema and hay fever. The prevalence of AD is rising worldwide, and it is widely accepted as a major public health issue, due to the significant burden of AD on health care systems. METHOD: Data were obtained from the youth survey of the European Urban Health Indicator System 2 project. The study participants were students aged 14-16 years from Greater Manchester. The main outcomes measured were the prevalence of atopic symptoms and the factors associated with the development of atopy. RESULTS: Of the sample studied, 70% reported having had an AD during their lifetime. The lifetime prevalence of ever having asthma, eczema or hay fever was 33.4%, 28.1% and 49.0%, respectively. Gender, family affluence, body mass index, diet, smoking and worrying were all significantly associated with atopic symptoms. Smoking was the only variable to be significantly associated with all three ADs. Season of birth and pollution were not shown to be associated with atopic symptoms. CONCLUSION: This study demonstrates that the prevalence of AD in Greater Manchester was high amongst adolescents. Several environmental, demographic and social factors were found to be significantly associated with the development of atopic symptoms. This study provides a baseline for future studies to further investigate the factors that are associated with AD and allow for the implementation of preventative public health policy.

Factors associated with the prevalence of adolescent binge drinking in the urban areas of Greater Manchester.

Background: Binge drinking in adolescents is a serious problem that has been recognised for over a generation. On average 61% of students in the European region had consumed alcohol in the last 30 days and 43% had participated in binge drinking in the same period. This article investigates the prevalence of adolescent binge drinking and the factors associated with this prevalence in urban areas of Greater Manchester. Methods: Data were obtained from the youth survey of the European Urban Health Indicator System 2 project. Study participants were school students aged 14-16 from the urban areas of Greater Manchester. The main outcome measures were adolescent binge drinking prevalence in Greater Manchester and the socio-demographic factors influencing it. Results: Greater Manchester had an adolescent binge drinking prevalence of 49.8%. Individual factors associated with increased prevalence of binge drinking were: age, substance use, school performance and early initiation of drinking (all significant at χ2, P < 0.05). Peer factors associated with increased prevalence of binge drinking were spending evenings with friends, keeping in touch with friends, having a good relationship with peers and self-reported bullying behaviours (all significant at χ2, P < 0.05). Family support lowered the prevalence of adolescent binge drinking. Conduct problems, family affluence and perceived local crime increased the prevalence of adolescent binge drinking. Conclusions: Binge drinking is highly prevalent in Greater Manchester adolescents. Various individual, peer-related, family-related and community-related factors were associated with this problem. Any attempt to tackle the prevalence of adolescent binge drinking must take into account all of these factors.

The link between perceived characteristics of neighbourhood green spaces and adults' physical activity in UK cities: analysis of the EURO-URHIS 2 Study.

Background: Urban dwellers represent half the world's population and are increasing worldwide. Their health and behaviours are affected by the built environment and green areas may play a major role in promoting physical activity, thus decreasing the burden of chronic diseases, overweight and inactivity. However, the availability of green areas may not guarantee healthy levels of physical activity among the urban dwellers. It is therefore necessary to study how the perceived characteristics of green areas affect physical activity. Methods: Data from the EURO-URHIS 2 survey of residents of 13 cities across the UK were analyzed and a multivariable model was created in order to assess the association between their perceptions of the green areas in their neighbourhood and their engagement in physical activity. Results were adjusted for age, gender and other potential confounders. Results: Those who felt unable to engage in active recreational activities in their local green spaces were significantly less likely to carry out moderate physical exercise for at least 60 min per week (adjusted OR: 0.50; 95% 0.37-0.68). Availability of green areas within walking distance did not affect engagement in physical activity. Other characteristics such as accessibility and safety may play an important role. Conclusion: This study showed that the presence of green space may not itself encourage the necessary preventative health behaviours to tackle physical inactivity in urban populations. Development of more appropriate green spaces may be required. Further research is needed to shed light on the types green spaces that are most effective.

The relationship between physical activity and self-rated health status in European adolescents: Results of the EURO-URHIS 2 survey.

Background: Engaging in regular physical activity has a beneficial impact on both physical health and on subjective health indicators. The aims of this study were (i) to assess the association between physical activity levels and self-reported health status in European adolescents and (ii) to identify any differences in the distribution of adolescents reporting good health between active and inactive subjects across urban areas. The study sample comprised 13 783 15-year olds from 21 urban areas across Europe who participated in the European Urban Health Indicators System Part 2 youth survey in 2010/11. Data collected on physical activity levels, self-rated health status and covariates including gender, BMI, socioeconomic status and sedentary behaviour were analyzed in a multivariable logistic regression model. High levels of physical activity (OR: 1.607, 95% CI: 1.245-2.074, P < 0.001) were associated with self-rated 'good health' across the cohort as a whole. All cities except Iasi showed a positive association between high levels of physical activity and good health. This was significant in four cases: Amsterdam, Cardiff, Greater Manchester and Merseyside ( P = 0.035, 0.016, 0.010 and 0.049, respectively). Only 13.3% of the cohort met the current WHO physical activity level recommendations. High levels of physical activity are positively associated with self-rated 'good health' status in European adolescents. Alarming levels of physical inactivity make it a priority to encourage greater engagement in physical activity. Promotion of physical activity should be specifically tailored to each urban area.

A systematic review of the relationship of physical activity and health status in adolescents.

Background: Reduced physical activity is a known risk factor for many illnesses. Research in adolescent populations found increased physical activity levels improves objective health outcomes, but there is conflicting evidence regarding the relationship between physical activity levels and self-reported health status. To synthesise current evidence on the association between physical activity and self-reported health status in adolescents. Secondary objectives are to assess whether the relationship is dose dependant, and the appropriateness of WHO recommendations on adolescents' physical activity. The main databases were searched using keywords for the main outcome of interest (health status, health behaviour and self-perception) and exposure of interest (motor activity, physical activity and exercise), supplemented with manual searches, secondary citation and reference searches. Quality appraisal was carried out using the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Eleven studies entered this review. Nine studies reported a significant relationship between increased levels of physical activity and improved self-reported health status, however two did not. Two studies followed up participants and found that the relationship persisted over time. Two papers described a dose-response relationship. Improvements in self-perceived health can be observed even below the current recommended levels of physical activity. The review supports initiatives to encourage adolescents to engage in physical activity as it improves self-reported health status. Sub-optimal levels of physical activity can also be beneficial. Further research should use standardised measurement scales and objectively measured physical activity levels. The roles of gender, income and culture should be further investigated.

Can health indicators help policy-makers? Experience from European system of urban health indicators (EURO-URHIS).

Background: This paper proposes that Population Impact Measures (PIMs), the Population Impact Number of Eliminating a Risk Factor over a time period (PIN-ER-t) and the number of events prevented in your population (NEPP), can assist in policy making as they include relevant information which describes the impact or benefits to the population of risk factors and interventions. In this study, we explore the utilization of the indicators from European System of Urban Health Indicators System to produce the two PIMs. We identified from the indicators list the health determinants, health status and health interventions which can be linked, and searched Medline for evidence of association. We then investigated whether the type of frequency measure available for the indicator match with the measure used in PIMs, and explored data availability for the City of Manchester (UK) as an urban area. Of the 39 indicators relevant to socio-economic factors, health determinants and health status, it was possible to calculate the population impact of a risk factor, i.e. the PIN-ER-t, for only six associations, and the population impact of health interventions, i.e. NEPP, for only one out of the three listed indicators, as the relevant health conditions were not included. The results of this study suggest that if an indicator system is intended to play a part in the policy making process, then the method of presentation to policy-makers should be decided before setting up the system, as it is likely that some indicators which would be essential might not be available.

Utilizing community and voluntary sector partnerships to survey and compare the health outcomes of hard-to- reach groups to the wider community-the EURO- URHIS 2 Hard-to-Reach Project.

Background: This article describes the Hard-to-Reach (HtR) Project that was developed to capture health and lifestyle data from groups who are HtR by postal surveys within the larger EURO-URHIS 2 project. By collaborating with partner organizations, data were collected using standard survey tools, allowing for comparison with the wider population. Following a scoping exercise to determine which groups were HtR in Greater Manchester, black and minority ethnic (BME) groups and students were selected. BME groups were surveyed through partnership with Community and Voluntary Sector Organizations (CVSOs). Language barriers were addressed through the recruitment of volunteer interpreters. Students were surveyed by accessing university premises. Fifteen survey visits took place at nine CVSOs and five visits to University facilities. In total, 144 eligible surveys were collected. There were significant differences for both HtR groups, compared with Greater Manchester and the EURO-URHIS 2 mean. Both HtR groups had worse outcomes than both Greater Manchester and EURO-URHIS 2 for psychological problems. In addition, students had worse outcomes for passive smoking, binge drinking, use of cannabis, lack of access to green spaces, less sense of belonging and social cohesion and damp or mildewed homes, and better outcomes for self-perceived health and overweight and obesity. BME had in addition worse outcomes than both Greater Manchester and EURO-URHIS 2 for long-standing restrictive illness. Despite the limitations of this study, the development of this methodology allowed for the collection of comparable data, showing up statistically significant differences between the HtR populations and the wider population which merits further investigation.

Differences in adults' health and health behaviour between 16 European urban areas and the associations with socio-economic status and physical and social environment.

Background: With a growing proportion of the European population living in urban areas (UAs), exploring health in urban areas becomes increasingly important. The objective of this study is to assess the magnitude of differences in health and health behaviour between adults living in urban areas (UAs) across Europe. We also explored whether and to what extent such differences can be explained by socio-economic status (SES) and physical or social environment. Data were obtained from a cross-sectional questionnaire survey, performed between as part of the European Urban Health Indicator System Part 2 (EURO-URHIS 2) project. Using multi-level logistic regression analysis, UA differences in psychological distress, self-assessed health, overweight and obesity, daily smoking, binge drinking and physical exercise were assessed. Median Odds Ratios (MORs) were calculated to estimate the extent to which the observed variance is attributable to UA, individual-level SES (measured by perceived financial strains, education level and employment status) and/or characteristics of physical and social environment. The dataset included 14 022 respondents in 16 UAs within 9 countries. After correction for age and gender, all MORs, except that for daily smoking, indicated statistically significant UA health differences. SES indicators (partly) explained UA differences in psychological distress, decreasing the MOR from 1.43 [95% credible interval (Cr.I.) 1.27-1.67, baseline model], to 1.25 (95% Cr.I. 1.14-1.40, SES model): a reduction of 42%. Accounting for the quality of green areas reduced the MOR for psychological distress by an additional 40%, to 1.15 (95% Cr.I. 1.05-1.28). Our study showed large differences in health and health behaviour between European UAs. Reducing socio-economic disadvantage and improving the quality of the neighbourhood's green spaces may reduce UA differences in psychological distress.

Development of an Urban Health Impact Assessment methodology: indicating the health equity impacts of urban policies.

Background: An overarching recommendation of the global Commission on Social Determinants of Health was to measure and understand health inequalities and assess the impact of action. In a rapidly urbanising world, now is the time for Urban HIA. This article describes the development of robust and easy-to-use HIA tools to identify and address health inequalities from new urban policies. Rapid reviews and consultation with experts identified existing HIA screening tools and methodologies which were then analyzed against predefined selection criteria. A draft Urban HIA Screening Tool (UrHIST) and Urban HIA methodology (UrHIA) were synthesised. The draft tools were tested and refined using a modified Delphi approach that included input from urban and public health experts, practitioners and policy makers. The outputs were two easy-to-use stand-alone urban HIA tools. The reviews and consultations identified an underpinning conceptual framework. The screening tool is used to determine whether a full HIA is required, or for a brief assessment. Urban health indicators are a readily available and efficient means of identifying variations in the health of populations potentially affected by policies. Indicators are, however, currently underutilised in HIA practice. This may limit the identification of health inequalities by HIA and production of recommendations. The new tools utilise health indicator data more fully. UrHIA also incorporates a hierarchy of evidence for use during impact analysis. The new urban HIA tools have the potential to enhance the rigour of HIAs and improve the identification and amelioration of health inequalities generated by urban policies.

Developing a European urban health indicator system: results of EURO-URHIS 1.

Introduction: More than half of the world's population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUA's, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

Are pharmacists reducing COPD'S impact through smoking cessation and assessing inhaled steroid use?

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) COPD 2004 guidelines recommend: ∗ COPD patients who smoke should be encouraged to stop at every opportunity; ∗ Inhaled corticosteroid should be used only among patients with moderate to severe COPD; ∗ Pharmacists should identify smokers and provide smoking cessation advice. The community pharmacy contract requires pharmacists to review patients' medications, creating an opportunity for reviewing the prescribing of inhaled corticosteroids in COPD. The survey explored the degree to which community pharmacists in North West England identify and provide advice to smokers and assess prescribed inhaled corticosteroids among COPD patients. METHODS: A self-completion questionnaire was sent to 2080 community pharmacists from the 2005 pharmacist census database. RESULTS: Of the 1051 (50.5%) respondants, 37.1% mentioned COPD as a risk from smoking most or every time and 54.5% sometimes or rarely, and 19.6% routinely asked about smoking status when dispensing COPD medication. Pharmacists with more than 20 years experience were more likely to have read the Guideline compared to pharmacists with 10 years or less (OR: 1.54; 95% CI: 1.13 to 2.10). Pharmacists who had read the NICE Guideline (46.8%) were around twice as likely to mention COPD as a risk of smoking, ask about COPD if inhaled corticosteroids were dispensed and ask about smoking routinely if COPD medication was dispensed. (p<0.005). CONCLUSION: The NICE guidelines on COPD encourage community pharmacists to carry out smoking cessation and educational interventions, but further support is needed.