Journal of Preventive Medicine and Public Health

Original Articles

Excess Deaths During the COVID-19 Pandemic in Southern Iran: Estimating the Absolute Count and Relative Risk Using Ecological Data: Mohammadreza Zakeri, Alireza Mirahmadizadeh, Habibollah Azarbakhsh, Seyed Sina Dehghani, Maryam Janfada, Mohammad Javad Moradian, Leila Moftakhar, Mehdi Sharafi, Alireza Heiran; J Prev Med Public Health. 2024;57(2):120-127. Published online February 7, 2024; DOI: https://doi.org/10.3961/jpmph.23.198; Funded: Shiraz University of Medical Sciences

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Abstract Summary PDF Supplementary Material: Objectives
The coronavirus disease 2019 (COVID-19) pandemic led to increased mortality rates. To assess this impact, this ecological study aimed to estimate the excess death counts in southern Iran.
Methods
The study obtained weekly death counts by linking the National Death Registry and Medical Care Monitoring Center repositories. The P-score was initially estimated using a simple method that involved calculating the difference between the observed and expected death counts. The interrupted time series analysis was then used to calculate the mean relative risk (RR) of death during the first year of the pandemic.
Results
Our study found that there were 5571 excess deaths from all causes (P-score=33.29%) during the first year of the COVID-19 pandemic, with 48.03% of these deaths directly related to COVID-19. The pandemic was found to increase the risk of death from all causes (RR, 1.26; 95% confidence interval [CI], 1.19 to 1.33), as well as in specific age groups such as those aged 35-49 (RR, 1.21; 95% CI, 1.12 to 1.32), 50-64 (RR, 1.38; 95% CI, 1.28 to 1.49), and ≥65 (RR, 1.29; 95% CI, 1.12 to 1.32) years old. Furthermore, there was an increased risk of death from cardiovascular diseases (RR, 1.17; 95% CI, 1.11 to 1.22).
Conclusions
There was a 26% increase in the death count in southern Iran during the COVID-19 pandemic. More than half of these excess deaths were not directly related to COVID-19, but rather other causes, with cardiovascular diseases being a major contributor.; Summary

Key Message
During the first year of the COVID-19 pandemic in southern Iran, there was a notable increase in excess deaths, representing a 33.29% rise compared to expected figures. Approximately half of these excess deaths were directly attributed to COVID-19. Moreover, the pandemic heightened the risk of death across all causes by 26%, with specific age groups, notably those aged 50-64, experiencing heightened vulnerability. Notably, cardiovascular diseases emerged as a significant contributor to excess mortality during this period, while decreases were observed in deaths related to chronic respiratory diseases and cancers.

Knowledge, Attitudes, and Practices Regarding Dengue Prevention Among Health Volunteers in an Urban Area – Malang, Indonesia: Alidha Nur Rakhmani, Lilik Zuhriyah; J Prev Med Public Health. 2024;57(2):176-184. Published online February 21, 2024; DOI: https://doi.org/10.3961/jpmph.23.484; Funded: Faculty of Medicine of Universitas Brawijaya

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Abstract Summary PDF: Objectives
The dengue prevention program known as “One House One Mosquito Larva Inspector” involves health volunteers who play a crucial role in the surveillance of mosquito larvae and reporting their findings to local public health officials. This study aimed to identify factors related to the knowledge, attitudes, and practices (KAP) of dengue prevention behavior among these health volunteers.
Methods
A study was conducted in 5 sub-districts in Malang, an urban area in Indonesia. We employed a cross-sectional design and utilized a semi-structured questionnaire to assess the KAP of 400 health volunteers. Data were collected through face-to-face interviews.
Results
Multiple logistic regression analysis revealed that individuals with a more positive attitude (odds ratio [OR], 1.69; p<0.05) and those with family sizes greater than five persons (OR, 1.90; p<0.05) were more likely to engage in effective dengue prevention practices. Additionally, possesing good knowledge was significantly assocated with more positive attitude (OR, 2.24; p<0.001). Furthermore, 40% reduction in positive attitude was observed in those over 45 years (OR, 0.60; p<0.05). The best practices most frequently reported by the majority of respondents included always reporting their surveillance activities (75.8%) and cleaning the water container in the bathroom at least once a week (65.2%). However, only 52.2% of respondents regularly checked for mosquito larvae in their neighborhood.
Conclusions
Sustainable promotion and training for the “One House One Mosquito Larva Inspector” initiative are necessary, particularly among young health volunteers, to improve dengue prevention behaviors both within their own homes and in the surrounding environment.; Summary

Key Message
The study among health volunteers emphasizes that better knowledge and younger age < 45 were associated with a positive attitude. While a positive attitude and family size > 5 persons were associated with better dengue prevention practices. Therefore, there is a need for sustained promotion and training among health volunteers to enhance the knowledge and attitude that may shape good dengue prevention practices.

Patterns of Health-related Quality of Life in Men Who Inject Drugs: A Survey in Southeast Iran: Marzieh Nojomi, Maysam Rezapour, Neda Soleimanvandi Azar, Mehdi Darabi, Mehran Asadi-Aliabadi; J Prev Med Public Health. 2024;57(2):148-156. Published online February 23, 2024; DOI: https://doi.org/10.3961/jpmph.23.379; Funded: Iran University of Medical Sciences

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Abstract Summary PDF: Objectives
Understanding patterns of quality of life in people who inject drugs (PWID) can help healthcare providers plan and manage their health problems in a more focused manner. Therefore, the current study aimed to identify patterns of health-related quality of life in PWID in southeast Iran.
Methods
This cross-sectional study was conducted in southeast Iran on men who had injected drugs at least once during the last year. We used convenience sampling in 2 drop-in centers and venue-based sampling at 85 venues. Demographic characteristics, high-risk behaviors, and health-related quality of life were evaluated using the 5-level EQ-5D version (EQ-5D-5L) questionnaire. Latent profile analysis was used to identify patterns of quality of life.
Results
This study enrolled 398 PWID, who had a mean age of 34.1±11.4 years. About 47.9% reported a prison history in the last 10 years, 59.2% had injected drugs in the last month, and 31.6% had a history of sharing syringes. About 46.3% reported having 2 or more sexual partners in the last 6 months, and 14.7% had a history of sex with men. Out of the 5 EQ-5D-5L profiles, the fifth profile had the most people (36.6%). Most variations in quality of life were related to pain and discomfort.
Conclusions
We showed that the pain and discomfort dimension of EQ-5D-5L had more variation in PWID. This finding will be useful for allocating appropriate interventions and resources to promote health-related quality of life in this population.; Summary

Key Message
People who Inject drugs, as an at-risk population in physical and mental disorders, need support to reduce harm. This study found that the health-related quality of life of these people is affected more by the pain and discomfort dimension. This can be caused by their social exclusion and marginalization. Hence, regular planning is necessary to organize the health status of these people. Due to the hard-to-reach nature of this population, special arrangements such as utilizing peer groups may be effective to provide them with services.

Mortality Burden Due to Short-term Exposure to Fine Particulate Matter in Korea: Jongmin Oh, Youn-Hee Lim, Changwoo Han, Dong-Wook Lee, Jisun Myung, Yun-Chul Hong, Soontae Kim, Hyun-Joo Bae; J Prev Med Public Health. 2024;57(2):185-196. Published online March 29, 2024; DOI: https://doi.org/10.3961/jpmph.23.514; Funded: Korea Environment Industry & Technology Institute, Ministry of Environment

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Abstract Summary PDF Supplementary Material: Objectives
Excess mortality associated with long-term exposure to fine particulate matter (PM_2.5) has been documented. However, research on the disease burden following short-term exposure is scarce. We investigated the cause-specific mortality burden of short-term exposure to PM_2.5 by considering the potential non-linear concentration–response relationship in Korea.
Methods
Daily cause-specific mortality rates and PM_2.5 exposure levels from 2010 to 2019 were collected for 8 Korean cities and 9 provinces. A generalized additive mixed model was employed to estimate the non-linear relationship between PM_2.5 exposure and cause-specific mortality levels. We assumed no detrimental health effects of PM_2.5 concentrations below 15 μg/m³. Overall deaths attributable to short-term PM_2.5 exposure were estimated by summing the daily numbers of excess deaths associated with ambient PM_2.5 exposure.
Results
Of the 2 749 704 recorded deaths, 2 453 686 (89.2%) were non-accidental, 591 267 (21.5%) were cardiovascular, and 141 066 (5.1%) were respiratory in nature. A non-linear relationship was observed between all-cause mortality and exposure to PM_2.5 at lag0, whereas linear associations were evident for cause-specific mortalities. Overall, 10 814 all-cause, 7855 non-accidental, 1642 cardiovascular, and 708 respiratory deaths were attributed to short-term exposure to PM_2.5. The estimated number of all-cause excess deaths due to short-term PM_2.5 exposure in 2019 was 1039 (95% confidence interval, 604 to 1472).
Conclusions
Our findings indicate an association between short-term PM_2.5 exposure and various mortality rates (all-cause, non-accidental, cardiovascular, and respiratory) in Korea over the period from 2010 to 2019. Consequently, action plans should be developed to reduce deaths attributable to short-term exposure to PM_2.5.; Summary

Korean summary
본 연구는 2010~2019년 한국의 초미세먼지 단기 노출로 인한 사망 부담을 추정하였으며 2010~2019년간, 초미세먼지 단기노출로 인한 전체원인 사망은 10,814명, 비사고 사망은 7,855명, 심혈관 사망은 1,642명, 호흡기 사망은 708명으로 추정하였다. 본 연구 결과는 대기오염 관리, 규제, 정책 수립에 있어 도움을 줄 것으로 예상한다.

Key Message
- We estimated mortality burden attributable to short-term exposure to PM 2.5 in Korea from 2010 to 2019 - Over the 10-years study period, the estimated excess deaths due to short-term exposure to PM 2.5 totaled 10,814 for all-causes, 7,855 for non-accidental, 1,642 for cardiovascular disease, and 708 for respiratory disease. - Our findings can assist in air pollution management, regulation, and policy-making.

Prevalence and Determinants of Catastrophic Healthcare Expenditures in Iran From 2013 to 2019: Abdoreza mousavi, Farhad lotfi, Samira Alipour, Aliakbar Fazaeli, Mohsen Bayati; J Prev Med Public Health. 2024;57(1):65-72. Published online November 25, 2023; DOI: https://doi.org/10.3961/jpmph.23.291; Funded: Shiraz University of Medical Sciences

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1 Crossref

Abstract Summary PDF

Objectives
Protecting people against financial hardship caused by illness stands as a fundamental obligation within healthcare systems and constitutes a pivotal component in achieving universal health coverage. The objective of this study was to analyze the prevalence and determinants of catastrophic health expenditures (CHE) in Iran, over the period of 2013 to 2019.
Methods
Data were obtained from 7 annual national surveys conducted between 2013 and 2019 on the income and expenditures of Iranian households. The prevalence of CHE was determined using a threshold of 40% of household capacity to pay for healthcare. A binary logistic regression model was used to identify the determinants influencing CHE.
Results
The prevalence of CHE increased from 3.60% in 2013 to 3.95% in 2019. In all the years analyzed, the extent of CHE occurrence among rural populations exceeded that of urban populations. Living in an urban area, having a higher wealth index, possessing health insurance coverage, and having employed family members, an employed household head, and a literate household head are all associated with a reduced likelihood of CHE (p<0.05). Conversely, the use of dental, outpatient, and inpatient care, and the presence of elderly members in the household, are associated with an increased probability of facing CHE (p<0.05).
Conclusions
Throughout the study period, CHE consistently exceeded the 1% threshold designated in the national development plan. Continuous monitoring of CHE and its determinants at both household and health system levels is essential for the implementation of effective strategies aimed at enhancing financial protection.

Summary

Key Message
• The aim of this study was to analyze the prevalence and determinants of catastrophic health expenditures (CHE) in Iran. • Catastrophic health expenditures (CHE) are used for monitoring financial protection within health systems. • The World Health Organization defines CHE as out-of-pocket payments for healthcare that exceed 40% of a household’s capacity to pay. • In Iran, the prevalence of CHE increased from 3.60% in 2013 to 3.95% in 2019. • Continuous monitoring of CHE and its determinants is essential for implementing effective strategies aimed at enhancing financial protection.

Citations

Citations to this article as recorded by

An analysis of financial protection and financing incidence of out-of-pocket health expenditures in Kazakhstan from 2018 to 2021
Askhat Shaltynov, Yulia Semenova, Madina Abenova, Assel Baibussinova, Ulzhan Jamedinova, Ayan Myssayev
Scientific Reports.2024;[Epub] CrossRef

Behavioral Predictors Associated With COVID-19 Vaccination and Infection Among Men Who Have Sex With Men in Korea: Minsoo Jung; J Prev Med Public Health. 2024;57(1):28-36. Published online November 27, 2023; DOI: https://doi.org/10.3961/jpmph.23.381; Funded: National Research Foundation of Korea

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Abstract Summary PDF: Objectives
This study investigated the impact of socioeconomic factors and sexual orientation-related attributes on the rates of coronavirus disease 2019 (COVID-19) vaccination and infection among men who have sex with men (MSM).
Methods
A web-based survey, supported by the National Research Foundation of Korea, was conducted among paying members of the leading online portal for the lesbian, gay, bisexual, transgender, or queer and questioning (LGBTQ+) community in Korea. The study participants were MSM living in Korea (n=942). COVID-19 vaccination and infection were considered dependent variables, while sexual orientation-related characteristics and adherence to non-pharmacological intervention (NPI) practices served as primary independent variables. To ensure analytical precision, nested logistic regression analyses were employed. These were further refined by dividing respondents into 4 categories based on sexual orientation and disclosure (or “coming-out”) status.
Results
Among MSM, no definitive association was found between COVID-19 vaccination status and factors such as socioeconomic or sexual orientation-related attributes (with the latter including human immunodeficiency virus [HIV] status, sexual orientation, and disclosure experience). However, key determinants influencing COVID-19 infection were identified. Notably, people living with HIV (PLWH) exhibited a statistically significant predisposition towards COVID-19 infection. Furthermore, greater adherence to NPI practices among MSM corresponded to a lower likelihood of COVID-19 infection.
Conclusions
This study underscores the high susceptibility to COVID-19 among PLWH within the LGBTQ+ community relative to their healthy MSM counterparts. Consequently, it is crucial to advocate for tailored preventive strategies, including robust NPIs, to protect these at-risk groups. Such measures are essential in reducing the disparities that may emerge in a post–COVID-19 environment.; Summary

Korean summary
한국에서 남성 동성애자의 코로나-19 예방접종과 그들의 사회경제적 지위 또는 성적 지향과 관련된 요인 사이에는 명확한 연관성이 없었지만, HIV에 감염된 남성 동성애자는 코로나-19의 감염 위험이 유의미하게 높았다. 또한, 남성 동성애자의 비약물적 중재 실천율이 높을수록 그들의 코로나-19 감염 가능성은 감소하는 경향이 있었다. 이 연구는 LGBTQ+ 커뮤니티 내의 HIV 양성 동성애자와 같은 취약한 집단을 보호하고 포스트 코로나-19 환경에서 성 소수자 간의 건강 격차를 줄이기 위한 강력한 맞춤형 예방 전략의 필요성을 강조한다.

Key Message
While there were no clear associations between COVID-19 vaccination and socioeconomic or sexual orientation-related factors among men who have sex with men (MSM) in Korea, individuals living with HIV (PLWH) had a significantly higher risk of COVID-19 infection. Additionally, greater adherence to non-pharmacological intervention (NPI) practices was linked to a reduced likelihood of COVID-19 infection among MSM. This study emphasizes the need for tailored preventive strategies, including robust NPIs, to protect at-risk groups like PLWH within the LGBTQ+ community and reduce health disparities in a post-COVID-19 environment.

Mental Health Among Healthcare Workers During the COVID-19 Pandemic in Vietnam: Nhan Phuc Thanh Nguyen, Ha Phan Ai Nguyen, Cao Khoa Dang, Minh Tri Phan, Huynh Ho Ngoc Quynh, Van Tuan Le, Chinh Van Dang, Tinh Huu Ho, Van Trong Phan, Thang Van Dinh, Thang Phan, Thi Anh Thu Dang; J Prev Med Public Health. 2024;57(1):37-46. Published online December 11, 2023; DOI: https://doi.org/10.3961/jpmph.23.327; Funded: World Health Organization

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Abstract Summary PDF: Objectives
The objective of this study was to characterize mental health issues among Vietnamese healthcare workers (HCWs) and to identify related factors.
Methods
A cross-sectional study was conducted with 990 HCWs in 2021. Their mental health status was measured using the Depression, Anxiety, and Stress Scale.
Results
In total, 49.9%, 52.3%, and 29.8% of respondents were found to have depression, anxiety, and stress, respectively. The multivariable linear regression model revealed that factors associated with increased anxiety scores included depression scores (β, 0.45; 95% confidence interval [CI], 0.39 to 0.51) and stress scores (β, 0.46; 95% CI, 0.41 to 0.52). Factors associated with increased depression scores included being frontline HCWs (β, 0.57; 95% CI, 0.10 to 1.10), stress scores (β, 0.50; 95% CI, 0.45 to 0.56), and anxiety scores (β, 0.41; 95% CI, 0.36 to 0.47), while working experience was associated with reduced depression scores (β, -0.08; 95% CI, -0.16 to -0.01). Factors associated with increased stress scores included working experience (β, 0.08; 95% CI, 0.00 to 0.16), personal protective equipment interference with daily activities (β, 0.55; 95% CI, 0.07 to 1.00), depression scores (β, 0.54; 95% CI, 0.48 to 0.59), and anxiety scores (β, 0.45; 95% CI, 0.39 to 0.50), while age was associated with reduced stress scores (β, -0.12; 95% CI, -0.20 to -0.05).
Conclusions
Specific interventions are necessary to enhance and promote the mental health of HCWs so they can successfully cope with the circumstances of the pandemic.; Summary

Key Message
A cross-sectional study of 990 Vietnamese healthcare workers in Vietnam, 2021 revealed significant mental health issues: 49.9 % suffered from depression, 52.3 % from anxiety, and 29.8 % from stress. The study found a correlation between these conditions, with frontline workers being particularly vulnerable to depression. These findings highlight the critical need for targeted mental health interventions for healthcare workers, particularly those new to the field and working on the front lines, in order to better manage pandemic-related stressors.

Relationship Between Pesticide Exposure Factors and Health Symptoms Among Chili Farmers in Northeast Thailand: Ratchadaporn Pengpan, Kulthida Y. Kopolrat, Sribud Srichaijaroonpong, Nutta Taneepanichskul, Patiwat Yasaka, Ratanee Kammoolkon; J Prev Med Public Health. 2024;57(1):73-82. Published online December 20, 2023; DOI: https://doi.org/10.3961/jpmph.23.353; Funded: Kasetsart University

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Abstract Summary PDF: Objectives
The unsafe use of pesticides in agriculture represents a major hazard to human health. This study was conducted to investigate the association between pesticide exposure and health symptoms among chili farmers in northeast Thailand.
Methods
This cross-sectional analytic study included 141 chili farmers in Sakon Nakhon Province, in northeast Thailand. Data regarding health symptoms were gathered using a self-report questionnaire. A medical technician tested blood cholinesterase activity using an erythrocyte method, and an occupational medicine specialist at Ramathibodi Hospital in Bangkok, Thailand reviewed the results. Associations between personal characteristics, pesticide exposure factors, and health symptoms were analyzed using multiple logistic regression.
Results
Of the 141 chili farmers studied, 66.7% experienced pesticide poisoning, as indicated by below-normal cholinesterase levels. Fatigue was the most frequently reported symptom associated with pesticide exposure, affecting 37.6% of participants. This was followed by nausea and vomiting (31.9%), dizziness (14.9%), and dry throat (14.9%). Multivariate logistic regression analysis revealed that several factors were significantly associated with adverse symptoms: amount of work experience, volume of pesticides used, use of chemical pesticides, use of leaking containers during spraying, direct pesticide exposure while working, contact with pesticide-soaked clothing, consumption of food and drinks in the fields, and blood cholinesterase level indicating risk.
Conclusions
This study suggests potential health risks for chili farmers stemming from exposure to and contamination by pesticides used in agricultural practices. To mitigate these risks, it is essential to supply personal protective equipment and to implement educational programs aimed at improving protective behaviors among farmers.; Summary

Key Message
This study aimed to demonstrate the impact of pesticide exposure on health symptoms. In a cross-sectional study, the effects of pesticide exposure on acetylcholinesterase erythrocyte activity in blood during agricultural practices were examined as potential health risks for chili farmers. It is crucial to provide personal protective equipment and to implement educational initiatives targeted at encouraging farmers to adopt more protective behaviors to reduce these risks.

The Trajectory of Depressive Symptoms Across Years of Community Care Utilization Among Older Adults: A 14-Year Follow-up Study Using the ‘Korean Welfare Panel Survey’: Il-Ho Kim, Cheong-Seok Kim, Min-Hyeok Jeong; J Prev Med Public Health. 2023;56(6):495-503. Published online October 6, 2023; DOI: https://doi.org/10.3961/jpmph.23.022; Funded: Ministry of Education, National Research Foundation of Korea

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Abstract Summary PDF: Objectives
While older adults using community care services are known to be vulnerable for depression, community care utilization (CCU) may help to improve the mental health of these elderly. To date, however, it is much less clear how CCU affects depressive symptoms in the elderly population. This study focuses on the trajectory of depressive symptoms across years of CCU among older adults in Korea.
Methods
Using the 2006-2019 Korean Welfare Panel Survey, this study is focused on elderly born in 1940 or earlier and selected 3281 persons for baseline interviews in 2006. This consisted of 35 800 person-year observations during a period of 14 years. Panel data analysis were employed to construct years of CCU.
Results
After controlling for covariates, linear term of years using community care was negatively associated with depressive symptoms, but a quadratic term was positively significant. The trajectory of depressive symptoms across the years of CCU follows a U-shaped curve. Older adults in the first year of using community care reported the highest level of depressive symptoms. However, a significant and steady decrease in depressive symptoms was observed during the following 9 years of CCU, which then gradually increased. The level of depressive symptoms at the 14th year of using community care remains significantly lower than the level at the outset of its utilization.
Conclusions
This finding implies that CCU could be beneficial for improving mental health among older adults.; Summary

Korean summary
한국복지패널조사(2006-2019년)를 활용하여 지역사회 돌봄서비스의 이용기간(14년 간)에 따른 우울변화궤적을 분석하였다. 분석결과, 지난 14년간 돌봄서비스 이용기간에 따른 우울증상의 궤적은 U자형을 따랐다. 즉 노인은 돌봄서비스를 이용한 첫 해에 가장 높은 우울 수준을 보고하였으며, 이후 9년간 지속적으로 감소하였다가, 점차 증가하는 추세를 보였다.

Key Message
Using the 2006-2019 Korean Welfare Panel Survey, this study focuses on the trajectory of depressive symptoms across years of CCU among older adults in Korea. The trajectory of depressive symptoms across the years of CCU follows a U-shaped curve. Older adults in the first year of using community care reported the highest level of depressive symptoms. However, a significant and steady decrease in depressive symptoms was observed during the following 9 years of CCU, which then gradually increased.

An Important Strategy to Improve Adolescent Health Literacy: COVID-19 Modules in High School in Indonesia: Nurina Hasanatuludhhiyah, Visuddho Visuddho, Abdul Khairul Rizki Purba, Annette d’ Arqom, Ancah Caesarina Novi Marchianti; J Prev Med Public Health. 2023;56(6):523-532. Published online November 1, 2023; DOI: https://doi.org/10.3961/jpmph.23.113; Funded: Faculty of Medicine, Universitas Airlangga

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Abstract Summary PDF: Objectives
During the second coronavirus disease 2019 (COVID-19) surge, cases increased sharply due to low awareness and compliance with measures to limit disease spread. Health literacy (HL) is an important component of public health initiatives, and schools are potential sources of health education to increase HL via the presentation of COVID-19 educational modules.
Methods
This cross-sectional study involved an online questionnaire administered to students from 5 high schools in Surabaya and Sidoarjo, Indonesia, 6-7 weeks after the start of government-issued directives restricting public gatherings. We collected data on each respondent’s age, gender, parental education, and socioeconomic variables. HL was determined by the Health Literacy Measure for Adolescents. We additionally measured their attitudes and behaviors related to preventing the spread of COVID-19. The students were asked if they watched the COVID-19 module at school, their feelings about vaccination, and preferred online sources of COVID-19-related information.
Results
Most of the 432 respondents had viewed COVID-19 modules at school. Module exposure was associated with significantly higher total and domain-specific HL and more positive attitudes toward government-issued COVID-19 restrictions on travel and public gatherings (p<0.05). However, behaviors to prevent COVID-19 spread and vaccine acceptance were not associated with module exposure. Most students chose social media as their source of COVID-19-related information.
Conclusions
Schools can provide information to increase adolescents’ HL and the public’s support for health initiatives to prevent or limit the spread of COVID-19.; Summary

Key Message
A cross-sectional study carried out on high school students during the second surge of COVID-19 in Indonesia revealed that they benefitted from the COVID-19 module. Students who viewed the module had higher scores on health literacy measures of adolescents (HELMA), had a more favorable attitude toward government-issued restrictive policies, and were more likely to have adequate health literacy, in regard to the ability to use health information. These imply schools as part of the public health response by providing education to increase adolescents’ health literacy and the public’s support for health initiatives to prevent and limit the spread of COVID-19.

Impact of Physical Activity on the Association Between Unhealthy Adolescent Behaviors and Anxiety Among Korean Adolescents: A Cross-sectional Study: Hyo-jung Lee, Jeong Pil Choi, Kunhee Oh, Jin-Young Min, Kyoung-Bok Min; J Prev Med Public Health. 2023;56(6):552-562. Published online November 15, 2023; DOI: https://doi.org/10.3961/jpmph.23.313; Funded: National Research Foundation of Korea, Ministry of Education

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Abstract Summary PDF: Objectives
Adolescents who engage in unhealthy behaviors are particularly vulnerable to anxiety. We hypothesized that participation in physical activity could influence the relationship between anxiety and unhealthy behaviors in adolescents. These behaviors include smoking, alcohol consumption, and unsafe sexual activity.
Methods
This study included 50 301 students from the first year of middle school to the third year of high school, all from Korea. The unhealthy adolescent behaviors examined included current alcohol consumption, current smoking, and unsafe sexual behavior. Anxiety levels were assessed using the Generalized Anxiety Disorder-7 questionnaire (GAD-7).
Results
The participants had a mean age of 15.19 years and an average GAD-7 score of 4.23. No significant differences were observed in GAD-7 score among exercising participants when categorized by smoking status (p=0.835) or unsafe sexual behavior (p=0.489). In contrast, participants in the non-exercise group who engaged in these behaviors demonstrated significantly higher GAD-7 scores (p<0.001 and 0.016, respectively). The only significant interaction was found between unsafe sexual behavior and exercise (p=0.009). Based on logistic regression analysis, within the non-exercise group, significant positive associations were observed between current smoking and anxiety (odds ratio [OR], 1.36; 95% confidence interval [CI], 1.18 to 1.57), as well as between unsafe sexual behavior and anxiety (OR, 1.33; 95% CI, 1.02 to 1.73). However, within the exercise group, no significant association was found between anxiety and either smoking or unsafe sexual behavior. Furthermore, no significant interaction was observed between unhealthy behaviors and exercise.
Conclusions
These findings are insufficient to conclude that physical activity influences the relationship between unhealthy behaviors and anxiety.; Summary

Korean summary
이 연구는 신체활동이 한국 청소년들사이에서 불안과 불건강행태간의 관계에 어떠한 영향을 미치는지 조사하였다. 이 연구에서 신체활동을 하지 않는 청소년에서만 흡연 및 불안전한 성행위와 같은 불건강행태와 불안 간의 유의미한 연관성을 보였음에도 불구하고, 이러한 불건강행태와 운동 간에는 같은 방향의 유의미한 상호작용이 관찰되지 않았다. 따라서 이 연구는 신체 활동이 청소년들의 불건강행태와 불안간의 관계에 직접 미치는 영향에 대해 명확하게 결론을 내릴 수 없었다.

Key Message
Among Korean adolescents, this study found that significant associations between unhealthy behaviors such as smoking and unsafe sex, and anxiety were only observed in adolescents who did not engage in physical activity. Despite this, no significant interaction was observed between these unhealthy behaviors and exercise. Contrary to popular belief, this study concludes that the evidence is insufficient to definitively say that physical activity influences the relationship between adolescent unhealthy behaviors and anxiety.

Risks for Readmission Among Older Patients With Chronic Obstructive Pulmonary Disease: An Analysis Using Korean National Health Insurance Service – Senior Cohort Data: Yu Seong Hwang, Heui Sug Jo; J Prev Med Public Health. 2023;56(6):563-572. Published online November 10, 2023; DOI: https://doi.org/10.3961/jpmph.23.346; Funded: PatientCentered Clinical Research Coordinating Center, Ministry of Health and Welfare

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Abstract Summary PDF: Objectives
The high readmission rate of patients with chronic obstructive pulmonary disease (COPD) has led to the worldwide establishment of proactive measures for identifying and mitigating readmissions. This study aimed to identify factors associated with readmission, as well as groups particularly vulnerable to readmission that require transitional care services.
Methods
To apply transitional care services that are compatible with Korea’s circumstances, targeted groups that are particularly vulnerable to readmission should be identified. Therefore, using the National Health Insurance Service’s Senior Cohort database, we analyzed data from 4874 patients who were first hospitalized with COPD from 2009 to 2019 to define and analyze readmissions within 30 days after discharge. Logistic regression analysis was performed to determine factors correlated with readmission within 30 days.
Results
The likelihood of readmission was associated with older age (for individuals in their 80s vs. those in their 50s: odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19 to 2.12), medical insurance type (for workplace subscribers vs. local subscribers: OR, 0.84; 95% CI, 0.72 to 0.99), type of hospital (those with 300 beds or more vs. fewer beds: OR, 0.77; 95% CI, 0.66 to 0.90), and healthcare organization location (provincial areas vs. the capital area: OR, 1.66; 95% CI, 1.14 to 2.41).
Conclusions
Older patients, patients holding a local subscriber insurance qualification, individuals admitted to hospitals with fewer than 300 beds, and those admitted to provincial hospitals are suggested to be higher-priority for transitional care services.; Summary

Korean summary
국내 만성폐쇄성폐질환(COPD)의 위험도 표준화 재입원율은 12.7%로, 주요 진단군 가운데 재입원율이 가장 높다. 국민건강보험공단 노인코호트를 활용하여 COPD로 입원한 환자의 재입원 위험 요인을 파악한 결과 고령 환자, 국민건강보험 지역가입자, 300병상 미만 규모 병원 또는 도 지역 소재 병원 에 입원한 환자의 경우 재입원 위험이 높았다. 재입원 위험이 높은 환자에 대하여 우선적으로 퇴원환자관리 서비스가 제공될 필요가 있다.

Key Message
The risk-standardized readmission rate for COPD in Korea is 12.7%, the highest among major diagnostic groups. Using the National Health Insurance Service Senior Cohort to identify risk factors for the readmission of patients hospitalized with COPD, it was found that older patients, local health insurance subscribers, those hospitalized in facilities with fewer than 300 beds, or in hospitals located in provincial areas had a higher risk of readmission. It is necessary to prioritize transitional care services for patients at a high risk of readmission.

Correlations Among Maternal and Infant Factors, Lead Exposure, and Serum Prolactin Levels During Lactation: A Cross-sectional Study in Indonesia: Linda Ratna Wati, Djanggan Sargowo, Tatit Nurseta, Lilik Zuhriyah, Bambang Rahardjo; J Prev Med Public Health. 2023;56(5):422-430. Published online August 22, 2023; DOI: https://doi.org/10.3961/jpmph.23.238; Funded: Universitas Brawijaya

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Abstract Summary PDF: Objectives
Prolactin is vital for breastfeeding and milk production, and its secretion is influenced by factors related to the mother, infant, and environment. To date, no study has concurrently investigated the correlation of these factors with serum prolactin levels during lactation. Therefore, the objective of this study was to investigate the correlations among maternal and infant factors, lead exposure, and serum prolactin levels during lactation.
Methods
A cross-sectional approach was employed in Surabaya, Indonesia, among 110 exclusively lactating mothers. The mothers’ daily diets were determined using multiple 24-hour recalls, while blood lead levels were measured with inductively coupled plasma mass spectrometry. Serum prolactin levels were assessed using the electrochemiluminescence immunoassay. For bivariate analysis, we employed the Spearman correlation, Mann-Whitney, and Kruskal-Wallis tests, while for multivariate analysis, we utilized multiple linear regression.
Results
The average serum prolactin level of the lactating mothers was 129.19±88.96 ng/mL. Positive correlations were found between serum prolactin levels and breastfeeding frequency (p < 0.001), protein intake (p < 0.001), and calcium intake (p = 0.011) but had negative correlation with blood lead levels (p < 0.001) and vitamin B6 intake (p = 0.003). Additionally, prolactin levels were not significantly associated with maternal age; parity; intake of calories, vitamin D, vitamin E, zinc, folic acid, magnesium, or iron; infant age; or infant sex.
Conclusions
Breastfeeding frequency had a stronger positive relationship with serum prolactin levels than protein and calcium intake. However, lead exposure was associated with reduced serum prolactin levels during lactation. Consequently, specific interventions from policymakers are necessary to manage breastfeeding in mothers exposed to lead.; Summary

Key Message
Prolactin secretion is influenced by factors related to the mother, infant, and environment, and this study was to investigate the correlations among maternal and infant factors, lead exposure, and serum prolactin levels during lactation. In total 110 exclusively lactating mothers were included, with information on their socio-demographic, daily diet, blood lead level, prolactin level, and infant characteristics. Breastfeeding frequency had a stronger positive relationship with serum prolactin levels than protein and calcium intake. However, lead exposure was associated with reduced serum prolactin levels during lactation. Consequently, specific interventions from policymakers are necessary to manage breastfeeding in mothers exposed to lead.

Brief Report

Characteristics and Health Care Spending of Persistently and Transiently High-cost Older Adults in Korea: Sungchul Park, Giryeon Bae; J Prev Med Public Health. 2023;56(5):475-480. Published online September 4, 2023; DOI: https://doi.org/10.3961/jpmph.23.270; Funded: Korea University

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Abstract Summary PDF: Objectives
This study examined differences in health care spending and characteristics among older adults in Korea by high-cost status (persistently, transiently, and never high-cost).
Methods
We identified 1 364 119 older adults using data from the Korean National Insurance Claims Database for 2017-2019. Outcomes included average annual total health care spending and high-cost status for 2017-2019. Linear regression was used to estimate differences in the outcomes while adjusting for individual-level characteristics.
Results
Persistently and transiently high-cost older adults had higher health care spending than never high-cost older adults, but the difference in health care spending was greater among persistently high-cost older adults than among transiently high-cost older adults (US$20 437 vs. 5486). Despite demographic and socioeconomic differences between transiently high-cost and never high-cost older adults, the presence of comorbid conditions remained the most significant factor. However, there were no or small differences in the prevalence of comorbid conditions between persistently high-cost and transiently high-cost older adults. Rather, notable differences were observed in socioeconomic status, including disability and receipt of Medical Aid.
Conclusions
Medical risk factors contribute to high health care spending to some extent, but social risk factors may be a source of persistent high-cost status among older adults in Korea.; Summary

Korean summary
- 한국에서 65세 이상의 고령층 고비용 환자 그룹 내에서 두 개의 이질적인 그룹을 발견하였다. - 지속적으로 고비용인 환자는 일시적으로 고비용인 환자보다 의료비 지출이 유의미하게 더 많았다. - 두 그룹의 특성을 비교한 결과, 건강요인의 차이도 있었지만 그보다는 사회적 요인의 차이가 더 컸다.

Key Message
- High-cost older adults are heterogeneous in terms of health care spending and sample characteristics in Korea. - Persistently high-cost older adults had significantly higher health care spending than transiently high-cost older adults. - Medical risk factors contribute to high health care spending to some extent, but social risk factors may be a source of persistent high-cost status among older adults.

Original Article

Health-related Quality of Life in Elderly Asian American and Non-Hispanic White Cancer Survivors: Suzanne Vang; J Prev Med Public Health. 2023;56(5):440-448. Published online September 13, 2023; DOI: https://doi.org/10.3961/jpmph.22.464; Funded: American Cancer Society

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Abstract Summary PDF: Objectives
The purpose of this study was to assess predictors of health-related quality of life (HRQoL) in elderly Asian American and non-Hispanic White cancer survivors.
Methods
We conducted cross-sectional secondary data analyses using the combined datasets from the Surveillance, Epidemiology, and End Results program and the Medicare Health Outcomes Survey.
Results
Elderly Asian American cancer survivors reported a lower mental HRQoL but a comparable physical HRQoL relative to elderly non-Hispanic White cancer survivors. Stress factors, such as comorbidities, difficulties with activities of daily living, and a history of depressive symptoms, along with coping resources like self-rated health and the ability to take the survey in English, were significantly associated with mental and physical HRQoL. Among elderly Asian American cancer survivors, a significantly lower mental HRQoL was observed among those taking the survey in the Chinese language.
Conclusions
The findings suggest that race exerts a differential impact on HRQoL. Interventions should be designed to address the distinct cultural, linguistic, and systemic needs of elderly Asian American cancer survivors. Such an approach could assist in reducing cancer-related health disparities.; Summary

Key Message
Secondary data analyses of the Surveillance, Epidemiology, and End Results program and the Medicare Health Outcomes Survey combined datasets reveal that elderly Asian American cancer survivors had poorer mental health-related quality of life (HRQoL) compared to their non-Hispanic White counterparts. Elderly Asian American cancer survivors who did not complete the survey in English had significantly worse mental HRQoL than their Asian American counterparts who did. These findings point to the need for increased research to identify and address the distinct cultural, linguistic, and system-related needs of elderly Asian American cancer survivors in order to optimize HRQoL in this population.

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