Is living in a rural area good for your respiratory health? Results from a cross-sectional study in Scotland

A cross-sectional analysis of medical conditions and environmental factors associated with fractional exhaled nitric oxide (FeNO) in women and children from the ISA birth cohort, Costa Rica

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is a marker of airway inflammation. Elevated FeNO has been associated with environmental exposures, however, studies from tropical countries are limited. Using data from the Infants' Environmental Health Study (ISA) birth cohort, we evaluated medical conditions and environmental exposures' association with elevated FeNO.

METHODS

We performed a cross-sectional analysis of 277 women and 293 8-year old children who participated in the 8-year post-partum visit in 2019. We measured FeNO and collected information on medical conditions and environmental exposures including smoke from waste burning, work in banana plantations, and home pesticide use. We defined elevated FeNO as >25 ppb for women and >20 ppb for children. To evaluate factors associated with elevated FeNO, we used logistic regression models adjusted for obesity in women and unadjusted in children.

RESULTS

Overall elevated FeNO was common (20% of women, 13% of children). Rhinitis diagnosis was significantly associated with elevated FeNO in both women (odds ratio (OR): 3.67 95% Confidence Interval (CI): 1.81,7.35) and children (OR: 8.18 95%CI: 3.15, 21.22); wheeze was associated with elevated FeNO in women (OR: 4.50 95% CI: 2.25, 8.99). Environmental exposures were associated with elevated FeNO, but not significantly. Waste burning was associated with elevated FeNO in both women (OR: 1.58 95%CI 0.68, 4.15) and children (OR: 2.49 95%CI:0.82, 10.79). Para-occupational pesticide exposures were associated with elevated FeNO in women and children. For women, having a partner working in agriculture was associated with elevated FeNO (OR: 1.61 95%CI:0.77, 3.58) and for children, maternal work in agriculture was associated with elevated FeNO. (OR 2.08 95%CI 0.86, 4.67) CONCLUSION: Rhinitis and wheeze were associated with elevated FeNO in this rural, agricultural population. Smoke from waste burning as well as para-occupational pesticide exposure may contribute to elevated FeNO in rural communities.

Geographische Unterschiede zwischen städtischem und ländlichem Raum beim Risiko für atopische Dermatitis: Systematischer Review und Meta-Analyse

Die atopische Dermatitis ist die häufigste chronisch‐entzündliche Hauterkrankung im Kindesalter. Einige Studien kamen zu dem Ergebnis, das Risiko für diese Erkrankung sei im städtischen Raum höher als im ländlichen. Wir haben die verfügbaren Studien systematisch untersucht und eine Meta‐Analyse durchgeführt, um Unterschiede im Risiko für atopische Dermatitis zwischen städtischem und ländlichem Raum zu erkennen. Die Suche in den Datenbanken Embase und MEDLINE wurde am 19. April 2021 durchgeführt. Einschlusskriterium war das Stichwort “Beobachtungsstudie”. Wir haben außerdem Subgruppenanalysen bezüglich Patientenalter, Publikationsjahr und Land durchgeführt. Insgesamt wurden bei der Datenbanksuche 2115 Studien aufgefunden, von denen letztlich 43 Studien mit insgesamt 1 728 855 Patienten in die Meta‐Analyse eingeschlossen wurden. Ein Wohnsitz im städtischen Raum war mit einem erhöhten Risiko für atopische Dermatitis assoziiert; die Odds Ratio war 1,56 (95 %‐Konfidenzintervall 1,43–1,71). Dieses signifikant erhöhte Risiko war nur bei Kindern zu beobachten (Odds Ratio 1,55, 95 %‐Konfidenzintervall 1,39–1,73), nicht jedoch bei Erwachsenen. Hier betrug die Odds Ratio 1,29 (95 %‐Konfidenzintervall 0,99–1,67). Das Risiko für atopische Dermatitis ist in den letzten Jahrzehnten angestiegen, wobei das Risiko in Entwicklungsländern mit einer Odds Ratio von 1,95 höher liegt als in Industrieländern (Odds Ratio 1,35). Unsere Studie bestätigt die Assoziation zwischen atopischer Dermatitis und dem Wohnsitz im städtischen gegenüber dem ländlichen Raum.

Geographic differences in atopic dermatitis risk between urban and rural area: A systematic review and meta-analysis

Atopic dermatitis is the most common chronic inflammatory skin disease affecting children. Some studies have reported a higher risk of atopic dermatitis in urban areas than in rural areas. We systematically reviewed and carried out a meta-analysis to investigate the differences in the development of atopic dermatitis between urban and rural areas. The search was performed on April 19, 2021, using Embase and MEDLINE databases. Eligible for inclusion were observational studies. Subgroup analyses were performed for age, publication year, and country. We identified 2,115 studies, and 43 studies with 1,728,855 subjects were finally included. Urban residency was associated with an increased risk of atopic dermatitis, with an odds ratio of 1.56 (95% confidence interval, 1.43-1.71). A significantly increased risk was observed only in children, with an odds ratio of 1.55 (95% confidence interval, 1.39-1.73), but not in adults, with an odds ratio of 1.29 (95% confidence interval, 0.99-1.67). The risk has increased in recent decades, with a higher risk in developing countries (odds ratio, 1.95) compared to developed countries (odds ratio, 1.35). Our study provides evidence of an association between atopic dermatitis and urban compared to rural living.

Air pollution and health outcomes: Evidence from Black Saturday Bushfires in Australia

This paper presents new evidence of the causal effect of air pollution on Australian health outcomes, using the Black Saturday bushfires (BSB) in 2009 as a natural experiment. This event was one of the largest bushfires in Australian history and emitted approximately four million tonnes of CO₂ into the atmosphere. We use data from the Household Income and Labour Dynamic Australia (HILDA) panel and compare the health status of individuals who were living in affected and unaffected regions before and after the event. Using a triple differences procedure, we further examine whether a difference in vulnerability to bushfire smoke exists comparing people living in urban or regional areas. We find that ambient air pollution had significant negative effects on health and that the magnitudes were actually larger for individuals residing in urban areas.

Predisposing factors to acquisition of acute respiratory tract infections in the community: a systematic review and meta-analysis

Background

Preventing respiratory tract infections (RTIs) could have profound effects on quality of life, primary care workload, antibiotic prescribing and stewardship. We aimed to identify factors that increase and decrease RTI acquisition within Organisation for Economic Cooperation and Development (OECD) member countries.

Methods

Systematic search of Medline, Embase, Cochrane and ISI Web of Knowledge for studies conducted up to July 2020 reporting predisposing factors for community RTI acquisition. Pooled odds ratios were calculated using a random-effects model.

Results

23 studies investigated risk factors associated with community-acquired pneumonia (n = 15); any RTI (n = 4); influenza like illness (n = 2); and lower RTI (n = 2). Demographic, lifestyle and social factors were: underweight BMI (pooled odds ratio (OR_p 2.14, 95% CI 1.58 to 2.70, p = 0.97); male sex (OR_p 1.30, 95% CI 1.27 to 1.33, p = 0.66); contact with pets (OR_p 1.35, 95% CI 1.16 to 1.54, p = 0.72); contact with children (OR_p 1.35, 95% CI 1.15 to 1.56, p = 0.05); and ex-smoking status (OR_p 1.57, 95% CI 1.26 to 1.88, p = 0.76). Health-related factors were: chronic liver condition (OR_p 1.30, 95% CI 1.09 to 1.50, p = 0.34); chronic renal condition (OR_p 1.47, 95% CI 1.09 to 1.85, p = 0.14); and any hospitalisation in previous five years (OR_p 1.64, 95% CI 1.46 to 1.82, p = 0.66).

Conclusions

We identified several modifiable risk factors associated with increased likelihood of acquiring RTIs in the community, including low BMI, contact with children and pets. Modification of risk factors and increased awareness of vulnerable groups could reduce morbidity, mortality and antibiotic use associated with RTIs.

PROSPERO registration

CRD42019134176.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06954-3.

Association Between Rural Residence and In-Hospital and 30-Day Mortality Among Veterans Hospitalized with COPD Exacerbations

Background

We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations.

Methods

We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics.

Results

Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (P=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (P<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, P=0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, P=0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, P<0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, P<0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality.

Conclusion

Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.

Does distance to hospital affect emergency department presentations and hospital length of stay among COPD patients?

BACKGROUND

The primary goal of COPD management is to optimize a patient's functional status and quality of life. By encouraging effective patient self-management within primary health care, unplanned and potentially avoidable COPD admissions to the emergency department can be avoided.

AIM

The aim of this study is to examine whether distance to hospital influences the rate of ED presentation, hospital admission and hospital length of stay for COPD patients.

METHODS

The 2016 to 2018 resulted in a total of 5253 patient presentations with a primary medical diagnosis code of J44 (COPD). These were at the main hospitals of three Queensland Hospital and Health Services: Toowoomba, Ipswich and Gold Coast. To examine the variations in patient characteristics based on distance a one-way ANOVA (Analysis of Variance) test was conducted. The Kruskal-Wallis (KW) test indicated that there were group differences.

RESULTS

This study identified significant variation in COPD-related hospital length of stay and distance to hospital among COPD patients within three hospitals in South East Queensland, Australia. These results confirm that distance plays an important role in determining duration of hospital stay (in number of days) among COPD patients, with clear evidence of the distance 'decay phenomenon'. It appears from the findings of the current study that distance to the hospital is not associated with the greater likelihood of ED presentation but may influence length of stay.

CONCLUSIONS

Several distance-specific studies have concluded that lower utilisation of hospital care is associated with distance to hospital. This article is protected by copyright. All rights reserved.

Effects of biomass burning on pulmonary functions in tribal women in northeastern India

Wood smoke causes adverse effects on pulmonary function (PF) in women in developing countries. This study compared PF among rural tribal women in northeastern India among 266 wood users and 82 liquefied petroleum gas (LPG) users, all healthy nonsmoking women from April to July, 2014. PF measurements included FVC, FEV₁, FEV₁/FVC, PEF, and FEF_25-75%. Information on participants' health status, demographic, and socioeconomic characteristics were collected by questionnaire. Multiple linear regressions were performed to compare PF between the two groups, adjusting for potential confounders. Wood users had significantly lower pulmonary values than LPG users: FVC (2.65 vs. 2.85 L, p < .001), FEV₁ (1.46 vs. 1.92 L, p < .001), PEF (1.89 vs. 2.56 L/s, p < .001), and FEF_25-75% (1.12 vs. 1.68 L/s, p < .001) except for FEV₁/FVC (76.5 vs. 75.5 percent, p = .27). Wood use was associated with 7 percent lower FVC, 24 percent lower FEV₁, 1.3 percent lower FEV₁/FVC, 26 percent lower PEF, and 33 percent lower FEEF_25-75% compared to LPG use. Wood use was associated with a 0.27-L decrease in FEV₁, adjusted for covariates. Women cooking with wood had lower PF and more respiratory symptoms and gastritis than those using LPG. Thus, reducing indoor air pollution from biomass burning is needed to protect tribal women's health.

Uncontrolled burning of solid waste by households in Mexico is a significant contributor to climate change in the country

Uncontrolled burning of municipal solid waste (MSW) is an important source of air pollution and is wide spread in many developing countries, but only limited data quantify the extent of domestic open burning of household waste. Here, we present some of the first field data to be reported on the uncontrolled domestic burning of waste. A representative community of Mexico (Huejutla de Reyes Municipality) was investigated and household surveys, interviews with waste operators and a waste characterisation analysis were completed to assess the extent of, and factors controlling, the open burning of waste. Waste collection provision to rural communities was very limited and, consequently 92% of households in rural areas reported that they disposed of waste by uncontrolled burning in backyards or unofficial dumps. Overall, 24% of the total MSW generated in the Municipality was disposed by uncontrolled burning. Urban and periurban areas received twice-weekly collections and the rate of uncontrolled burning was considerably smaller compared to rural households, corresponding to approximately 2% of total waste generation. Carbon equivalency calculations showed that burning waste in backyards represented approximately 6% of the total and 8.5% of fuel related CO₂Eq emissions by the municipality. Moreover, the equivalent carbon dioxide (CO₂Eq) from black carbon (BC) emitted by uncontrolled burning in backyards was over fifteen times larger compared to methane (CH₄) potentially released from equivalent amounts of combustible biodegradable waste disposal at the official dumpsite. An assessment of local respiratory health data showed the incidence of disease was higher in rural than in urban areas, when the opposite trend is typically observed in the international literature; given the high rate of burning activity found in rural areas we suggest that open burning of waste could be a major reason for the apparent poorer respiratory health status of the rural population and requires further investigation. The results emphasise the importance of including BC from uncontrolled burning of waste in international emission inventories of greenhouse gases and in the assessment of the health status of local communities in developing countries where this practice is prevalent.

Occupational Exposure to Vapor-Gas, Dust, and Fumes in a Cohort of Rural Adults in Iowa Compared with a Cohort of Urban Adults

Problem/Condition

Many rural residents work in the field of agriculture; however, employment in nonagricultural jobs also is common. Because previous studies in rural communities often have focused on agricultural workers, much less is known about the occupational exposures in other types of jobs in rural settings. Characterizing airborne occupational exposures that can contribute to respiratory diseases is important so that differences between rural and urban working populations can be assessed.

Reporting Period

1994–2011.

Description of System

This investigation used data from the baseline questionnaire completed by adult rural residents participating in the Keokuk County Rural Health Study (KCRHS). The distribution of jobs and occupational exposures to vapor-gas, dust, and fumes (VGDF) among all participants was analyzed and stratified by farming status (current, former, and never) then compared with a cohort of urban workers from the Multi-Ethnic Study of Atherosclerosis (MESA). Occupational exposure in the last job was assessed with a job-exposure matrix (JEM) developed for chronic obstructive pulmonary disease (COPD). The COPD JEM assesses VGDF exposure at levels of none or low, medium, and high.

Results

The 1,699 KCRHS (rural) participants were more likely to have medium or high occupational VGDF exposure (43.2%) at their last job than their urban MESA counterparts (15.0% of 3,667 participants). One fifth (20.8%) of the rural participants currently farmed, 43.1% were former farmers, and approximately one third (36.1%) had never farmed. These three farming groups differed in VGDF exposure at the last job, with the prevalence of medium or high exposure at 80.2% for current farmers, 38.7% for former farmers, and 27.4% for never farmers, and all three percentages were higher than the 15.0% medium or high level of VGDF exposure for urban workers.

Interpretation

Rural workers, including those who had never farmed, were more likely to experience occupational VGDF exposure than urban workers.

Public Health Action

The occupational exposures of rural adults assessed using the COPD JEM will be used to investigate their potential association with obstructive respiratory health problems (e.g., airflow limitation and chronic bronchitis). This assessment might highlight occupations in need of preventive interventions.

Point prevalence and epidemiological characteristics of chronic cough in the general adult population: The Korean National Health and Nutrition Examination Survey 2010-2012

Cough is frequently self-limiting, but may persist longer in certain individuals. Most of previous studies on the epidemiology of chronic cough have only measured period prevalence, and thus have afforded limited information on the burden and natural course. We aimed to investigate the epidemiology of chronic cough by using a point prevalence measure in a large-scale general population.We analyzed cross-sectional data collected from 18,071 adults who participated in the Korean National Health and Nutrition Examination Survey 2010-2012. Presence and duration of current cough was ascertained by structured questionnaires, and cough was classified into acute (<3 weeks), subacute (3-8 weeks), or chronic cough (≥8 weeks). Demographic and clinical parameters were examined in relation to chronic cough.The point prevalences of acute, subacute, and chronic cough were 2.5 ± 0.2%, 0.8 ± 0.1% and 2.6 ± 0.2%, respectively. The proportion of current cough showed a steep decrease after 1 week of duration. However, 2 peaks in the prevalence of current cough were revealed; cough durations of less than 1 week and longer than 1 year were most common (31.1% and 27.7% of current cough, respectively). Subacute and chronic cough were more prevalent in the elderly (≥65 years); the positive associations with older age were independent of other confounders, including current smoking and comorbidities.This is the first report on the epidemiology of cough using a point prevalence measure in a nationally representative population sample. Our findings indicate a high burden of chronic cough among adults with current cough in the community. The dual-peak of cough duration suggested that the pathophysiology of acute and chronic cough may differ. The preponderance of elderly people in the prevalence of chronic cough warrants further investigation. In addition, more sophistication and validation of tools to define chronic cough will help our understanding of the epidemiology.

Environment and Health: Not Only Cancer

The Hippocratic tradition emphasized environmental causes of diseases and the need for harmony between the individual and the natural environment as the right philosophy to maintain a good health status. Public awareness and scientific attention concerning environmental pollution is usually focused on the consequent increased risk of developing cancer. Air pollution has been recognized by the World Health Organization (WHO) to cause cardiovascular and respiratroy diseases, as well as lung cancer, after acute/chronic exposure to fine particulates (PM2.5 and PM10) even at concentrations which are 50% lower than those accepted as legal limits in many developed countries. An increase of 10 µg/m³ of PM2.5 produces a +4%-6% of overall mortality, a +10% of cardiovascular disease prevalence (arithmyas, acute myocardial infarctions, and heart failure) and a +22% of lung cancer prevalence. In addition to these chronic effects, acute hospitalizations are also affected, especially among susceptible populations such as children and diabetic patients. Water and soil contamination also have an additional detrimental effect on people's health. Other issues concerning environment contamination and human health include male/female fertility, metabolic and thyroid conditions, but also professional exposures resulting in occupational diseases. Moreover, in the perspective of "gender medicine", different acute or chronic effects of environmental pollution should be specifically assessed both in men and in women. This special issue on "Environmental Diseases" is aimed at providing a global overview about different threats to human health possibily originating from environmental contamination.

Defining Chronic Cough: A Systematic Review of the Epidemiological Literature

Purpose

Recent evidence suggests a global burden of chronic cough in general populations. However, the definitions vary greatly among epidemiological studies, and none have been validated for clinical relevance. We aimed to examine previous epidemiological definitions in detail and explore the operational characteristics.

Methods

A systematic review was conducted for epidemiological surveys that reported the prevalence of chronic cough in general adult populations during the years 1980 to 2013. A literature search was performed on Pubmed and Embase without language restriction. Epidemiological definitions for chronic cough were classified according to their components, such as cutoff duration. Meta-analyses were performed for the male-to-female ratio of chronic cough prevalence to explore operational characteristics of epidemiological definitions.

Results

A total of 70 studies were included in the systematic review. The most common epidemiological definition was identified as 'cough ≥3 months' duration without specification of phlegm (n=50); however, it conflicted with the cutoff duration in current clinical guidelines (cough ≥8 weeks). Meta-analyses were performed for the male-to-female ratio of chronic cough among 28 studies that reported sex-specific prevalence using the most common definition. The pooled male-to-female odds ratio was 1.26 (95% confidence interval 0.92-1.73) with significant heterogeneity (I²=96%, P<0.001), which was in contrast to clinical observations of female predominance from specialist clinics. Subgroup analyses did not reverse the ratio or reduce the heterogeneity.

Conclusions

This study identified major issues in defining chronic cough in future epidemiological studies. The conflict between epidemiological and clinical diagnostic criteria needs to be resolved. The unexpected difference in the gender predominance between the community and clinics warrants further studies. Clinical validation of the existing definition is required.

Impact of Climate Change on Air Quality and Public Health in Urban Areas

This review discusses how climate undergo changes and the effect of climate change on air quality as well as public health. It also covers the inter relationship between climate and air quality. The air quality discussed here are in relation to the 5 criteria pollutants; ozone (O3), carbon dioxide (CO2), nitrogen dioxide (NO2), sulfur dioxide (SO2), and particulate matter (PM). Urban air pollution is the main concern due to higher anthropogenic activities in urban areas. The implications on health are also discussed. Mitigating measures are presented with the final conclusion.

Evaluating the effect of an asthma self-management intervention for rural families

OBJECTIVE

To present outcomes of an asthma self-management educational intervention delivered to children (grades 2-5) at school and to parents in a home visit.

METHODS

The intervention effectiveness was tested in a 12-month longitudinal study with randomization by elementary schools into treatment and attention-control groups with 183 children who had a diagnosis of asthma. Data were collected at four time points. Change over time was examined with linear mixed models.

RESULTS

Quality of life (QOL), hospitalizations, and emergency department visits improved significantly for all the children. African American and Mexican American children had worse asthma-related QOL than did White children. Asthma management behaviors, asthma self-efficacy, and coping likewise improved with girls improving significantly more than the boys. Significant improvements in inhaler skill and asthma severity were seen in the treatment group children when compared to the control group. Treatment group parents showed significant improvements in home asthma management and self-efficacy.

CONCLUSIONS

The improvement in inhaler skill is an important finding for practitioners as this is a behavior that can be addressed in the clinical setting. The reduction in the treatment group's asthma severity scores may reflect the improvement in medication delivery as their inhaler skill improved. The differential improvement between boys and girls points to the need for testing other formats in asthma education that can address different learning styles. The individualized parent asthma education enabled the intervener to incorporate neighborhood and home environmental information thereby allowing for tailoring of parental instruction.

Urban vs. rural factors that affect adult asthma

In this review, our aim was to examine the influence of geographic variations on asthma prevalence and morbidity among adults, which is important for improving our understanding, identifying the burden, and for developing and implementing interventions aimed at reducing asthma morbidity. Asthma is a complex inflammatory disease of multifactorial origin, and is influenced by both environmental and genetic factors. The disparities in asthma prevalence and morbidity among the world's geographic locations are more likely to be associated with environmental exposures than genetic differences. In writing this article, we found that the indoor factors most consistently associated with asthma and asthma-related symptoms in adults included fuel combustion, mold growth, and environmental tobacco smoke in both urban and rural areas. Asthma and asthma-related symptoms occurred more frequently in urban than in rural areas, and that difference correlated with environmental risk exposures, SES, and healthcare access. Environmental risk factors to which urban adults were more frequently exposed than rural adults were dust mites,high levels of vehicle emissions, and a westernized lifestyle.Exposure to indoor biological contaminants in the urban environment is common.The main risk factors for developing asthma in urban areas are atopy and allergy to house dust mites, followed by allergens from animal dander. House dust mite exposure may potentially explain differences in diagnosis of asthma prevalence and morbidity among adults in urban vs. rural areas. In addition, the prevalence of asthma morbidity increases with urbanization. High levels of vehicle emissions,Western lifestyles and degree of urbanization itself, may affect outdoor and thereby indoor air quality. In urban areas, biomass fuels have been widely replaced by cleaner energy sources at home, such as gas and electricity, but in most developing countries, coal is still a major source of fuel for cooking and heating, particularly in winter. Moreover, exposure to ETS is common at home or at work in urban areas.There is evidence that asthma prevalence and morbidity is less common in rural than in urban areas. The possible reasons are that rural residents are exposed early in life to stables and to farm milk production, and such exposures are protective against developing asthma morbidity. Even so, asthma morbidity is disproportionately high among poor inner-city residents and in rural populations. A higher proportion of adult residents of nonmetropolitan areas were characterized as follows:aged 55 years or older, no previous college admission, low household income, no health insurance coverage, and could not see a doctor due to healthcare service availability, etc. In rural areas, biomass fuels meet more than 70% of the rural energy needs. Progress in adopting modern energy sources in rural areas has been slow. The most direct health impact comes from household energy use among the poor, who depend almost entirely on burning biomass fuels in simple cooking devices that are placed in inadequately ventilated spaces. Prospective studies are needed to assess the long-term effects of biomass smoke on lung health among adults in rural areas.Geographic differences in asthma susceptibility exist around the world. The reason for the differences in asthma prevalence in rural and urban areas may be due to the fact that populations have different lifestyles and cultures, as well as different environmental exposures and different genetic backgrounds. Identifying geographic disparities in asthma hospitalizations is critical to implementing prevention strategies,reducing morbidity, and improving healthcare financing for clinical asthma treatment. Although evidence shows that differences in the prevalence of asthma do exist between urban and rural dwellers in many parts of the world, including in developed countries, data are inadequate to evaluate the extent to which different pollutant exposures contribute to asthma morbidity and severity of asthma between urban and rural areas.

Is the health of people living in rural areas different from those in cities? Evidence from routine data linked with the Scottish Health Survey

BACKGROUND

To examine the association between rurality and health in Scotland, after adjusting for differences in individual and practice characteristics.

METHODS

DESIGN

Mortality and hospital record data linked to two cross sectional health surveys.

SETTING

Respondents in the community-based 1995 and 1998 Scottish Health Survey who consented to record-linkage follow-up.

MAIN OUTCOME MEASURES

Hypertension, all-cause premature mortality, total hospital stays and admissions due to coronary heart disease (CHD).

RESULTS

Older age and lower social class were strongly associated with an increased risk of each of the four health outcomes measured. After adjustment for individual and practice characteristics, no consistent pattern of better or poorer health in people living in rural areas was found, compared to primary cities. However, individuals living in remote small towns had a lower risk of a hospital admission for CHD and those in very remote rural had lower mortality, both compared with those living in primary cities.

CONCLUSION

This study has shown how linked data can be used to explore the possible influence of area of residence on health. We were unable to find a consistent pattern that people living in rural areas have materially different health to that of those living in primary cities. Instead, we found stronger relationships between compositional determinants (age, gender and socio-economic status) and health than contextual factors (including rurality).

Environmental factors in early childhood are associated with multiple sclerosis: a case-control study

BACKGROUND

Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) with increasing incidence mainly in high-income countries. One explanation of this phenomenon may be a higher prevalence of allergic and autoimmune diseases in industrialized countries as a consequence of otherwise beneficial advances in sanitation (hygiene hypothesis). We investigated environmental factors in early childhood associated with MS.

METHODS

A case-control study was performed of 245 MS patients and 296 population-based controls in Berlin. The study participants completed a standardized questionnaire on environmental factors in childhood and youth, including aspects of personal and community hygiene. Multivariable logistic regression analysis was performed to investigate factors in childhood and youth associated with the occurrence of MS.

RESULTS

Mean age was 46 years (range, 20-80) in the MS group and 42 years (range 18-80) in the control group, of which 73.9% in the MS and 61.5% in the control group were female. The multivariable analysis showed that having at least two older siblings (OR 0.54; p = 0.05, for individuals with two older siblings compared to individuals without older siblings), attending a day-care center (OR 0.5; p = 0.004) and growing up in an urban center with more than 100, 000 inhabitants (OR 0.43; p = 0.009) were factors independently associated with a lower chance for MS.

CONCLUSIONS

The hygiene hypothesis may play a role in the occurrence of MS and could explain disease distribution and increasing incidence.

A review of equity issues in quantitative studies on health inequalities: the case of asthma in adults

BACKGROUND

The term 'inequities' refers to avoidable differences rooted in injustice. This review examined whether or not, and how, quantitative studies identifying inequalities in risk factors and health service utilization for asthma explicitly addressed underlying inequities. Asthma was chosen because recent decades have seen strong increases in asthma prevalence in many international settings, and inequalities in risk factors and related outcomes.

METHODS

A review was conducted of studies that identified social inequalities in asthma-related outcomes or health service use in adult populations. Data were extracted on use of equity terms (objective evidence), and discussion of equity issues without using the exact terms (subjective evidence).

RESULTS

Of the 219 unique articles retrieved, 21 were eligible for inclusion. None used the terms equity/inequity. While all but one article traced at least partial pathways to inequity, only 52% proposed any intervention and 55% of these interventions focused exclusively on the more proximal, clinical level.

CONCLUSIONS

Without more in-depth and systematic examination of inequities underlying asthma prevalence, quantitative studies may fail to provide the evidence required to inform equity-oriented interventions to address underlying circumstances restricting opportunities for health.

Ascertaining the size of the symptom iceberg in a UK-wide community-based survey

BACKGROUND

The symptom iceberg describes the phenomenon that most symptoms are managed in the community without people seeking professional health care. The size of the iceberg for many symptoms is unknown, as is their association with personal characteristics, including history of a chronic disease.

AIM

To ascertain the size of the symptom iceberg in the UK.

DESIGN OF STUDY

A UK-wide community-based postal survey.

SETTING

Urban and rural communities across the UK.

METHOD

A postal survey was sent to an age- and sex-stratified random sample of 2474 adults, aged 18-60 years, drawn from 20 practices around the UK. Questions were aimed at investigating adults' experiences of 25 different symptoms in the previous 2 weeks.

RESULTS

The number of symptoms experienced by one individual in the previous 2 weeks ranged from 0 to 22 (mean 3.66). Of the symptoms examined, the three most common were: feeling tired/run down; headaches; and joint pain. Univariate analysis found symptom prevalence to be significantly associated with a wide range of participant characteristics. However, after adjustment, many of these associations no longer remained significant for a number of the symptoms. Presence of a chronic condition, age, and employment status were the three factors most commonly associated with the 2-week prevalence of symptoms. Reported symptom characteristics (severity, duration, interference, and time off work) varied little by sex or age.

CONCLUSION

Symptoms in the UK community are common. Symptom prevalence was associated with a number of participant characteristics, although the extent of this association was less than has been reported in previous research. This study provides an important current baseline prevalence of 25 symptoms in the community for those who do, and do not, have a chronic condition.

Urban-rural health differences: primary care data and self reported data render different results

AIM

Assessing the usefulness of GP electronic medical records for assessing the health of rural populations by comparing these data with data from health interview surveys.

DATA

Data from electronic medical records routinely recorded in general practices in 2000-2002. Data on self-reported health problems were obtained through questionnaires in a subset of the same patient population.

RESULTS

According to GP-records, acute somatic and chronic diseases were more frequently presented in rural areas. At the same time self reported health problems point to a better health in rural areas.

CONCLUSION

GP electronic medical records may be used to monitor the health of rural populations. These data can be obtained relatively quickly and easily and against acceptable cost. However, they do not give the same outcomes as health interview surveys. Reasons for this discrepancy may be; differences in the accessibility of specialist services and help seeking behaviour between urban and rural populations.

Quality of life in Jordanian children with asthma

The purpose of this study was to describe how Jordanian children with asthma experience their quality of life (QoL). Two hundred children with asthma (34% girls and 66% boys) participated in the study. The Paediatric Asthma Quality of Life Questionnaire was used to measure how children with asthma disease impaired their daily life during the previous week on three domains: 'activity limitations', 'symptoms' and 'emotional function'. The main finding of this study was that children with asthma scored their QoL towards the negative end of the scale, but they scored more limitations in the domain of activities than in emotions and symptoms. Children reported that the most restricted activity was their ability to run. Younger children, being a girl and living in the rural areas, were associated with lower QoL. The children in the present study might not comply with their health regimen, and this might gave a darker view of the daily life of children with asthma. Further studies of Jordanian children and their QoL were suggested to identify and support the factors which influence QoL of children with asthma and other chronic diseases in Jordan.

Urban residence is associated with bronchial hyperresponsiveness in Italian general population samples

BACKGROUND

The role of different risk factors for bronchial hyperresponsiveness (BHR), such as gender, atopy, IgE, and environmental factors (smoking, occupational exposure, infections), has been described. Indoor and outdoor pollution play an important role too, but few studies have analyzed the association with BHR. The aim of this study was to assess the effect of urban residence on BHR.

METHODS

We studied two general population samples enrolled in two cross-sectional epidemiological studies performed in Northern Italy (Po Delta, rural area) and Central Italy (Pisa, urban area). We analyzed 2,760 subjects (age range, 8 to 74 years). We performed analysis of variance and logistic regression analysis using ln slope of the dose-response curve of the methacholine challenge test as dependent variable, and sex, age, smoking habits, respiratory symptoms, skin-prick test results, IgE value, residence, and airway caliber as independent variables.

RESULTS

The mean value of ln slope of the dose-response curve adjusted for initial airways caliber (by baseline FEV(1) percentage of predicted value) was significantly higher in female subjects, in smokers, in subjects with respiratory symptoms, in younger and older ages, in subjects with high values of IgE, and in subjects with positive skin-prick test results. After controlling for the independent effects of all these variables, living in urban area was an independent risk factor for having BHR (odds ratio, 1.41; 95% confidence interval, 1.13 to 1.76).

CONCLUSION

Living in urban area is a risk factor for increased bronchial responsiveness.

Childhood asthma in a rural environment: implications for clinical nurse specialist practice

PURPOSE

The purpose of this study was to identify factors that impact asthma morbidity in rural school-aged children.

DESIGN

Exploratory analysis of baseline data collected in a longitudinal intervention study was performed.

SETTING

Four rural school districts that served small towns and unincorporated areas participated in this study.

SAMPLE

Participants were children in grades 2 to 5 who had current asthma and who spoke English or Spanish. There were 183 children (108 boys, 75 girls) with an average age of 8.78 years and who were Hispanic (46%), white (31%), or African American (22%).

METHODS

Associations between asthma risk factors (gender, ethnicity/race, socioeconomic status, asthma severity), asthma resources (access to care, health insurance), family asthma management, and asthma morbidity (absenteeism, emergency department visits, hospitalizations) were analyzed.

FINDINGS

Children with more severe asthma had higher absenteeism and more hospitalizations, and their parents performed more asthma management behaviors. Families who had difficulty accessing care had more hospitalizations and emergency department visits and were more likely to be poor. More boys, more Hispanic and African American children, and more children from poorer families were hospitalized for asthma than were middle-class and non-Hispanic white children.

CONCLUSIONS

Asthma is a chronic condition that is fairly easy for some families to manage, whereas other families are having higher asthma morbidity that needs to be addressed through targeted interventions.

Mortality from heart, respiratory, and kidney disease in coal mining areas of Appalachia

PURPOSE

The purpose of this study was to test whether population mortality rates from heart, respiratory and kidney disease were higher as a function of levels of Appalachian coal mining after control for other disease risk factors.

METHODS

The study investigated county-level, age-adjusted mortality rates for the years 2000-2004 for heart, respiratory and kidney disease in relation to tons of coal mined. Four groups of counties were compared: Appalachian counties with more than 4 million tons of coal mined from 2000 to 2004; Appalachian counties with mining at less than 4 million tons, non-Appalachian counties with coal mining, and other non-coal mining counties across the nation. Forms of chronic illness were contrasted with acute illness. Poisson regression models were analyzed separately for male and female mortality rates. Covariates included percent male population, college and high school education rates, poverty rates, race/ethnicity rates, primary care physician supply, rural-urban status, smoking rates and a Southern regional variable.

RESULTS

For both males and females, mortality rates in Appalachian counties with the highest level of coal mining were significantly higher relative to non-mining areas for chronic heart, respiratory and kidney disease, but were not higher for acute forms of illness. Higher rates of acute heart and respiratory mortality were found for non-Appalachian coal mining counties.

CONCLUSIONS

Higher chronic heart, respiratory and kidney disease mortality in coal mining areas may partially reflect environmental exposure to particulate matter or toxic agents present in coal and released in its mining and processing. Differences between Appalachian and non-Appalachian areas may reflect different mining practices, population demographics, or mortality coding variability.

Environmental factors and allergic disorders

Despite numerous studies on possible associations between environmental exposure and allergic disorders, any conclusions made remain a matter of controversy. We conducted a review of evidence in relation to environmental and nutritional determinants and wheeze, asthma, atopic dermatitis, and allergic rhinitis. Identified were 263 articles for analysis after consideration of 1093 papers that were published since 2000 and selected by electronic search of the PubMed database using keywords relevant to epidemiological studies. Most were cross-sectional and case-control studies. Several prospective cohort studies revealed inconsistent associations between various environmental factors and the risk of any allergic disorder. Therefore, the evidence was inadequate to infer the presence or absence of a causal relationship between various environmental exposures and allergic diseases. However, evidence is suggestive of positive associations of allergies with heredity. Because almost all the studies were performed in Western countries, the application of these findings to people in other countries, including Japan, may not be appropriate. Further epidemiological information gained from population-based prospective cohort studies, in particular among Japanese together with other Asians, is needed to assess causal relationships between various environmental factors and allergic diseases.

Children's health in the rural environment

The rural environment is not as wholesome as some might think. In fact, smoking, drinking, illicit drug use, and obesity are more prevalent in rural than in urban youngsters. Childhood mortality is higher in rural areas, with drowning, motor vehicle accidents, firearm injuries, and farm machinery accidents as the leading causes. Air and water quality are monitored less and actually may be worse in the country than in urban areas. This article describes children's health problems associated with the rural environment and provides a list of resources for addressing these problems.

Epidemiology of chronic obstructive pulmonary disease: health effects of air pollution

COPD is one of the leading causes of morbidity and mortality in the industrialized and the developing countries. According to the prediction of the World Health Organization, COPD will become the third leading cause of mortality and the fifth cause of disability in 2020 worldwide. In epidemiology, distinct phenotypic entities converge on the term COPD, so that prevalence and mortality data may be inclusive of chronic bronchitis, emphysema and asthma; moreover, the assessment of prevalence rates may change considerably according to the diagnostic tools used. Thus, a considerable problem is to estimate the real prevalence of COPD in the general population. COPD is determined by the action of a number of various risk factors, among which, the most important is cigarette smoking. However, during the last few decades, evidence from epidemiological studies finding consistent associations between air pollution and various outcomes (respiratory symptoms, reduced lung function, chronic bronchitis and mortality), has suggested that outdoor air pollution is a contributing cause of morbidity and mortality. In conclusion, epidemiological studies suggest that air pollution plays a remarkable role in the exacerbation and in the pathogenesis of chronic respiratory diseases. Thus, respiratory physicians, as well as public health professionals, should advocate for a cleaner environment.

Desigualdades sociais na prevalência de doenças crônicas no Brasil, PNAD-2003

Os inquéritos de saúde de base populacional constituem o principal instrumento utilizado para conhecer a prevalência de doenças crônicas, de restrições de atividades e de uso de serviços de saúde. Com base nos dados da PNAD-2003, foram estimadas as prevalências das 12 doenças crônicas pesquisadas, segundo sexo, idade, cor, escolaridade, macrorregião de residência e situação urbana ou rural do domicílio. Foram analisados a presença de limitações e o uso de serviços de saúde segundo a presença de doença crônica. Utilizando regressão de Poisson, foram estimadas as razões de prevalências ajustadas por idade, sexo, macrorregião de residência e tipo de respondente. A prevalência de pelo menos uma doença crônica aumentou com a idade, foi maior entre mulheres, indígenas, pessoas com menor escolaridade, cidadãos detentores de plano de saúde, migrantes de outros estados, residentes em áreas urbanas e moradores da região Sul. A presença de doença crônica provocou aumento de limitação de atividades e da demanda por serviços de saúde. As condições mais prevalentes foram: doença de coluna, hipertensão, artrite e depressão. Foi detectada significativa desigualdade social no padrão das doenças crônicas, segundo gênero, cor/raça, nível de escolaridade, região de residência e situação do domicílio.

Patient's perception of exacerbations of COPD--the PERCEIVE study

The evaluation of therapies requires the development of patient-reported outcomes (PROs) that help clinicians to understanding the symptoms, perceptions and feelings of patients with exacerbations of chronic obstructive pulmonary disease (COPD). With the aim of obtaining information on the perceptions of patients with COPD, their exacerbations and expectations of treatment, a random telephone contact survey in six countries was performed. From 83,592 households screened, 1100 subjects with symptoms compatible with COPD were identified. The most frequent symptom was shortness of breath (78%). The most frequent complaint was that due to their COPD: "they could not complete the activities they like to do" (54%); 17% (187) of individuals were afraid that their COPD would cripple, or eventually kill them. Exacerbations generated a mean of 5.1 medical visits/year (SD=4.6) with the mean duration of exacerbation symptoms being 10.5 days. Increased coughing was the exacerbation symptom having the strongest impact on well-being (42%). Fifty-five percent of patients declared that quicker symptom relief was the most desired requirement for treatment. New data are provided on the impact of COPD and its exacerbations on the daily life of patients. These data will help to develop PROs designed to evaluate the effectiveness of different therapies for exacerbated COPD.