Journal of Preventive Medicine and Public Health

Volume 57(6); November 2024

Special Article

P>0.05 Is Good: The NORD-h Protocol for Several Hypothesis Analysis Based on Known Risks, Costs, and Benefits: Alessandro Rovetta, Mohammad Ali Mansournia; J Prev Med Public Health. 2024;57(6):511-520. Published online September 20, 2024; DOI: https://doi.org/10.3961/jpmph.24.250

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Abstract Summary PDF Supplementary Material: Statistical testing in medicine is a controversial and commonly misunderstood topic. Despite decades of efforts by renowned associations and international experts, fallacies such as nullism, the magnitude fallacy, and dichotomania are still widespread within clinical and epidemiological research. This can lead to serious health errors (e.g., misidentification of adverse reactions). In this regard, our work sheds light on another common interpretive and cognitive error: the fallacy of high significance, understood as the mistaken tendency to prioritize findings that lead to low p-values. Indeed, there are target hypotheses (e.g., a hazard ratio of 0.10) for which a high p-value is an optimal and desirable outcome. Accordingly, we propose a novel method that goes beyond mere null hypothesis testing by assessing the statistical surprise of the experimental result compared to the prediction of several target assumptions. Additionally, we formalize the concept of interval hypotheses based on prior information about costs, risks, and benefits for the stakeholders (NORD-h protocol). The incompatibility graph (or surprisal graph) is adopted in this context. Finally, we discuss the epistemic necessity for a descriptive, (quasi) unconditional approach in statistics, which is essential to draw valid conclusions about the consistency of data with all relevant possibilities, including study limitations. Given these considerations, this new protocol has the potential to significantly impact the production of reliable evidence in public health.; Summary

Key Message
The p-value is largely misused in medicine to classify results as “significant” and “non-significant” according to a sharp arbitrary threshold (typically 0.05), focusing only on the null hypothesis of exactly zero effect. Conversely, the NORD-h protocol offers an easy method to assess the degree of incompatibility (disagreement) between data and various meaningful effect sizes using the “s-value”. Unlike the p-value, the s-value is intuitive, representing the number “s” of consecutive heads in as many fair coin tosses. A simple graphical approach is proposed to avoid rigid cutoffs, promoting a nuanced interpretation of statistical findings based on cost-benefit analysis.

Scoping Review

Is Farming a Risk Occupation for Cardio-cerebrovascular Diseases? A Scoping Review on Cardio-cerebrovascular Disease Risk in Farmers: Hyeonjun Kim, Wongeon Jung, Sunjin Jung, Seunghyeon Cho, Inho Jung, Hansoo Song, Ki-Soo Park, Seong-Yong Yoon, Joo Hyun Sung, Seok-Ju Yoo, Won-Ju Park; J Prev Med Public Health. 2024;57(6):521-529. Published online August 23, 2024; DOI: https://doi.org/10.3961/jpmph.24.302

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Abstract Summary PDF Supplementary Material: Objectives
In Korea, cardio-cerebrovascular disease (CCVD) is recognized as an occupational disease when sufficient evidence of a work-related burden exists. In 2021, approximately 26.8% of the payments from occupational disease insurance under the Industrial Accident Compensation Insurance Act were allocated to CCVDs. However, due to the specific nature of insurance policies for farmers, CCVD is not acknowledged as an occupational disease in their case.
Methods
We reviewed studies on the differences in the incidence, prevalence, and mortality rates of CCVDs between farmers and the general population or other occupations and described the exposure of farmers to risk factors for CCVDs.
Results
Several studies showed that farming is a high-risk occupation for CCVDs, with the following risk factors: long working hours, night work, lack of holidays, and strenuous physical labor; physical factors (noise, cold, heat, humidity, and vibration); exposure to hazardous gases (diesel exhaust, carbon monoxide, hydrogen sulfide, carbon disulfide, nitrogen oxides, and polycyclic aromatic hydrocarbons), pesticides, and dust (particulate matter, silica, and organic dust); exposure to a hypoxic environment; and job-related stress. Social isolation and lack of accessible medical facilities also function as additional risk factors by preventing farmers from receiving early interventions.
Conclusions
Farmers are exposed to various risk factors for CCVDs and are an occupation at risk for CCVDs. More studies are needed in the future to elucidate this relationship. This study lays the groundwork for future research to develop guidelines for approving CCVDs as occupational diseases among farmers.; Summary

Korean summary
이 연구는 농업이 뇌심혈관질환과 연관된 고위험 직업임을 입증하는 근거를 검토하였습니다. 농업인은 긴 근무 시간, 격렬한 신체 노동, 유해 가스 및 살충제 노출 등 다양한 위험 요인과 더불어 의료 접근성 부족과 같은 문제에 직면해 있습니다. 이는 뇌심혈관질환을 농업인의 업무 관련 질병으로 인정하기 위한 가이드라인 개발에 중요한 기초를 제공합니다.

Key Message
This study reviewed evidence supporting that farming is a high-risk occupation associated with cardio-cerebrovascular diseases. Farmers face various risk factors, including long working hours, strenuous physical labor, exposure to hazardous gases and pesticides, and challenges such as limited access to medical care. This provides an essential foundation for developing guidelines to recognize cardio-cerebrovascular diseases as work-related illnesses among farmers.

Original Articles

Global Trends in Childhood Sexual Abuse and Bullying Victimization in 204 Countries: A Comprehensive Analysis From 1990 to 2019: Nasrin Borumandnia, Mohammadamin Sabbagh Alvani, Payam Fattahi, Mahmood Reza Gohari, Yashar Kheirolahkhani, Hamid Alavimajd; J Prev Med Public Health. 2024;57(6):530-539. Published online August 15, 2024; DOI: https://doi.org/10.3961/jpmph.24.007

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Abstract Summary PDF: Objectives
No comprehensive analysis has yet been published regarding global trends in childhood sexual abuse (CSA) and bullying victimization (BV). The present study offers a longitudinal perspective on their prevalence worldwide.
Methods
CSA and BV rates were extracted from the Global Burden of Disease study, spanning the years 1990 to 2019 across 204 countries. Trends by gender, region, and human development index (HDI) were examined.
Results
For both boys and girls, and in both high-HDI and low-HDI countries, CSA rates did not significantly change from 1990 to 2019 (p>0.05). However, BV rates increased significantly in high-HDI and low-HDI countries for both genders (p<0.001). Subsequently, we analyzed trends separately by gender across all countries, without considering development level. In this analysis, CSA rates among girls decreased from 1990 to 2000, followed by an increasing tendency after 2000; overall, an upward trend was evident between 1990 and 2019 (p=0.029). In contrast, no significant pattern was observed for boys. Notably, BV demonstrated an increasing trend across all regions when HDI was not considered (p<0.05), with African populations experiencing the most pronounced rise (p<0.001). Globally, boys consistently exhibited higher BV rates than girls.
Conclusions
Our research indicates that, on a global scale, rates of CSA among girls have been rising. Additionally, BV rates have increased in all regions for both boys and girls. Notably, this trend in BV rates is occurring irrespective of HDI. These findings underscore the necessity for targeted interventions in areas with high rates of CSA and BV.; Summary

Key Message
This study analyzes global trends in childhood sexual abuse (CSA) and bullying victimization (BV) from 1990 to 2019 across 204 countries. Results indicate a significant rise in BV rates globally, with boys consistently exhibiting higher rates than girls. While CSA rates among girls show an upward trend, no significant change is observed for boys. These findings highlight the urgent need for targeted interventions to address CSA and BV worldwide.

Incidence and Influencing Factors of Avoidable Mortality in Korea From 2013-2022: Analysis of Cause-of-death Statistics: Jeong Min Yang, Jieun Hwang; J Prev Med Public Health. 2024;57(6):540-551. Published online September 23, 2024; DOI: https://doi.org/10.3961/jpmph.24.232

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Abstract Summary PDF Supplementary Material: Objectives
This study aimed to identify trends in avoidable mortality (AVM) in 16 provincial and metropolitan regions of Korea and determine the factors influencing AVM.
Methods
First, the avoidable mortality rate (AVMR) was calculated using the Statistics Korea cause-of-death and population data by age and region from 2013 to 2022. Second, a health determinants model was built, and we identified the factors influencing AVM using generalized estimating equations analysis.
Results
Although the AVMR per 100 000 people displayed a steadily decreasing trend from 2013 to 2020, it began to increase in 2021. Meanwhile, Jeonnam, Jeonbuk, Gyeongnam, Gyeongbuk, Chungnam, Chungbuk, and Gangwon Provinces showed a higher AVMR than the national average. The analysis revealed that each 1-unit increase in the older adult population, smoking, perceived stress, or non-local medical utilization was associated with an increase in the AVMR. Conversely, 1-unit increases in the male-to-female ratio, marriage rate, positive self-rated health, local medical utilization, doctor population, influenza vaccination rate, cancer screening rate, or financial independence were associated with decrease in the AVMR.
Conclusions
This study established that the AVMR, which had been continuously decreasing across the 16 regions, shifted to an increasing trend in 2021. We also identified several factors influencing AVM. Further studies are needed to confirm the reasons for this shift in the AVMR and explore the factors that influence AVM across Korea’s 16 provincial and metropolitan regions.; Summary

Korean summary
본 연구는 전국 및 16개 시도의 회피가능사망률 추이를 파악하고 건강결정요인 모형을 통해 영향요인을 파악하기 위함이다. 분석 결과, 전반적으로 2013년부터 2020년까지 회피가능사망률은 감소 추세를 보였으나, 2021년을 기점으로 회피가능사망률이 증가하였으며, 지역별 회피가능사망률의 편차가 존재하였다. 본 연구를 통해 우리나라의 회피가능사망 현황을 파악할 수 있으며, 향후 조기사망 감소를 위한 기초 근거로 활용될 수 있을 것으로 판단한다.

Key Message
This study examines trends in avoidable mortality (AVM) rates across Korea and its 16 provinces, identifying factors using a health determinant model. From 2013 to 2020, AVM rates declined, but an increase was observed from 2021. These findings highlight the current state of AVM in Korea and offer key insights for strategies to reduce premature deaths.

SARS-CoV-2 Infection Risk Imposed by Fully-vaccinated Air Travelers Attending an Island-confined Quarantine System Enabling Tourism During the Pandemic: A Retrospective Cohort Study: Thunyaporn Sirijantradilok, Chanapong Rojanaworarit, Isabella Andrade, Worawaran Kallayanasit, Panunda Yodkhunnathum, Somruethai Khamsakhon, Supasit Suerungruang, Nuttawoot Photisan; J Prev Med Public Health. 2024;57(6):552-563. Published online September 23, 2024; DOI: https://doi.org/10.3961/jpmph.24.351

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Abstract Summary PDF: Objectives
This study aimed to identify the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among fully vaccinated air travelers participating in an island-confined quarantine system (Phuket Sandbox Program). It also compared the differential risk of SARS-CoV-2 infection across different coronavirus disease 2019 (COVID-19) vaccines and the difference in time-to-detection periods between asymptomatic and symptomatic cases.
Methods
This retrospective cohort study determined the cumulative incidence of SARS-CoV-2 infection among 63 052 air travelers who participated in a quarantine program from July 1, 2021 to October 31, 2021. Using Poisson regression with robust standard errors, we estimated the relative risk of SARS-CoV-2 infection across different brands and types of COVID-19 vaccines, adjusting for relevant covariates. We visualized the time-to-detection periods for SARS-CoV-2 infection using Kaplan-Meier failure curves and compared these curves for asymptomatic and symptomatic travelers using the log-rank test.
Results
The overall incidence of SARS-CoV-2 infection was 0.3%. Individuals vaccinated with Ad26.COV2.S, Gam-COVID-Vac, CoronaVac, and replicating viral vector vaccines faced a significantly higher risk of infection than those who received the BNT162b2 and mRNA vaccines. The time-to-detection periods for asymptomatic and symptomatic cases did not differ significantly.
Conclusions
Despite the relatively low risk of SARS-CoV-2 infection, a risk of breakthrough cases remained with certain vaccines. Given the high proportion of asymptomatic cases, quarantine and intermittent testing should be implemented. The mandatory quarantine system proved effective in managing positive cases without necessitating a complete shutdown of travel. Implementing an island quarantine could be a viable strategy for reintroducing travel and tourism during a future COVID-19 outbreak or a new pandemic.; Summary

Key Message
"This study evaluated the SARS-CoV-2 infection rate among 63,052 fully-vaccinated air travelers participating in the Phuket Sandbox Program in 2021. A breakthrough SARS-CoV-2 infection rate of 0.3% was identified. Travelers vaccinated with Ad26.COV2.S, Gam-COVID-Vac, CoronaVac, and replicating viral vector vaccines exhibited a higher risk of breakthrough infections than those vaccinated with BNT162b2 or other mRNA vaccines. The island-confined quarantine system combined with confirmatory COVID-19 testing effectively identified post-arrival infected travelers, demonstrating its potential as a model enabling safe tourism while preventing importation of cases into communities beyond the island during the pandemic."

Factors Associated With Post-term Birth and Its Relationship to Neonatal Mortality in Japan: An Analysis of National Data From 2017 to 2022: Tasuku Okui, Naoki Nakashima; J Prev Med Public Health. 2024;57(6):564-571. Published online September 24, 2024; DOI: https://doi.org/10.3961/jpmph.24.355

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Abstract Summary PDF Supplementary Material: Objectives
Prior research has not yet examined the relationship between post-term birth and neonatal mortality in Japan, along with factors associated with post-term birth. We investigated these associations utilizing nationwide birth data from Japan.
Methods
Birth and mortality data were obtained from the Vital Statistics of Japan for the years 2017 to 2022. The post-term birth rate was calculated by birth characteristics, and the neonatal mortality rates for post-term and term births were computed. Additionally, log-binomial regression analysis was employed to explore the associations between post-term birth and neonatal mortality, as well as between various characteristics and post-term birth. The characteristics considered included infant sex, maternal age group, parity, maternal nationality, maternal marital status, and household occupation.
Results
This study analyzed data from 4 698 905 singleton infants born at 37 weeks of gestational age or later. Regression analysis revealed that post-term birth was positively associated with neonatal mortality. The adjusted risk ratio for neonatal mortality in post-term compared to term births was 8.07 (95% confidence interval, 5.06 to 12.86). Factors positively associated with post-term birth included female infant sex, older maternal age, primiparity, non-Japanese maternal nationality, unmarried status, and various household occupations, including farmer, full-time worker at a smaller company, other type of worker, and unemployed. Younger maternal age was inversely associated with post-term birth.
Conclusions
In Japan, post-term birth represents a risk factor for neonatal mortality. Additionally, socio-demographic characteristics, such as maternal marital status, nationality, and parity were found to be predictors of post-term birth.; Summary

Key Message
This study investigated the relationship between post-term birth and neonatal mortality in Japan, along with factors associated with post-term birth. Regression analysis revealed that post-term birth was significantly and positively associated with neonatal mortality. Additionally, socio-demographic characteristics, such as older maternal age, primiparity, non-Japanese maternal nationality, and unmarried status were found to be predictors of post-term birth.

Provider Perspectives, Barriers, and Improvement Strategies for Hospital Discharge Support Programs: A Focus Group Interview Study in Korea: Jae Woo Choi, Aejung Yoo, Hyojung Bang, Hyun-Kyung Park, Hyun-Ji Lee, Hyejin Lee; J Prev Med Public Health. 2024;57(6):572-585. Published online October 4, 2024; DOI: https://doi.org/10.3961/jpmph.24.275

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Abstract Summary PDF Supplementary Material: Objectives
Transitional periods, such as patient discharge, are notably challenging. This study aimed to explore the perceptions of providers involved in hospital discharge support programs, identify the primary obstacles, and propose strategies for improvement.
Methods
In this qualitative cross-sectional study, we interviewed 49 healthcare professionals, comprising doctors, nurses, and social workers, who participated in two pilot programs. We organized focus group interviews with 3-6 participants per group, segmented by the type of discharge support program and profession. For data analysis, we employed phenomenological analysis, a qualitative method.
Results
Participants recognized the importance of the discharge support program and anticipated its benefits. The Rehabilitation Hospital Discharge Patient Support program saw more active involvement from doctors than the Establishment of a Public Health-Medical Collaboration System program. Both programs highlighted the critical need for more staff and better compensation, as identified by the doctors. Nurses and social workers cited the heavy documentation burden, uncooperative attitudes from patients and local governments, and other issues. They also anticipated that program improvements could be achieved through the standardization of regional welfare services and better coordination by local governments serving as welfare service regulators. All groups—doctors, nurses, and social workers—underscored the significance of promoting these programs.
Conclusions
Discharge support programs are crucial for patients with functional impairments and severe illnesses, particularly in ensuring continuity of care. Policy support is essential for the successful implementation of these programs in Korea.; Summary

Korean summary
퇴원 지원 사업에 참여하는 의사, 간호사, 사회복지사 등 퇴원지원사업 담당자를 대상으로 시범사업 수행에 있어 주요 문제점과 개선방안을 인터뷰를 통해 조사하였을 때 참가자들은 퇴원 지원 사업이 필요하고 특히 기능 저하가 심한 환자들에게 도움이 될 것이라고 응답하였다. 그러나, 의사의 참여 부족, 연계 가능한 서비스의 부족, 다학제 팀구성이 어려운 보상 수준, 의료기관 간 의사소통의 문제 등 어려움을 지적하였다. 다학제팀 구성과 안정적인 운영을 위한 적절한 수가와 인센티브 구조 마련, 지역과의 네트워크와 지방정부 중심의 조정기능 강화가 문제 해결에 도움이 될 수 있을 것이다.

Key Message
Interviews with doctors, nurses, and social workers involved in discharge support programs revealed key challenges and improvement strategies during pilot projects. Participants acknowledged the necessity of discharge support programs, particularly for patients with severe functional impairments. However, they pointed out difficulties such as insufficient participation from doctors, a lack of available services, inadequate compensation hindering multidisciplinary team, and communication issues between medical institutions. Establishing appropriate reimbursement and incentive structures for stable multidisciplinary team operation, strengthening networks with local communities, and enhancing coordination led by local governments could help address these challenges.

Knowledge, Attitudes, and Practices Regarding Influenza Vaccination Among Healthcare Workers in Saudi Arabia: A Cross-sectional Study: Laila M. Almutairi, Mona A. Almusawi, Abeer M. Albalawi, Musallam Y. Abu Hassan, Adel F. Alotaibi, Tariq M. Almutairi, Randah M. Alalweet, Abdullah M. Asiri; J Prev Med Public Health. 2024;57(6):586-594. Published online November 8, 2024; DOI: https://doi.org/10.3961/jpmph.24.283

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Abstract Summary PDF Supplementary Material: Objectives
Influenza vaccination is important for healthcare workers in order to prevent both the illness itself and transmission to patients. Previous studies in Saudi Arabia have revealed low influenza vaccine coverage among healthcare workers due to misconceptions. This study aimed to assess knowledge, attitudes, and practices regarding influenza vaccination among healthcare workers during 2021, addressing the current data gap.
Methods
A cross-sectional study was conducted, including 1273 healthcare workers from the Ministry of Health in Saudi Arabia. A self-administered questionnaire was distributed to participants via email.
Results
Most participants had an appropriate extent of knowledge, with 37.1% having a high level and 26.6% having a moderate level. Positive attitudes toward the influenza vaccine were observed in 41.2% of participants, and 80.2% demonstrated good vaccine practices. However, the vaccine coverage was 50.8% in the past 12 months. Factors associated with vaccine uptake included previous vaccination, workplace availability, awareness of guidelines, engagement in training programs, type of workplace settings, and having positive attitudes toward the vaccine. The most common reason for not getting vaccinated was the perception of being at low risk, making vaccination unnecessary.
Conclusions
Participants exhibited positive knowledge, attitudes, and practices regarding influenza vaccination. However, the observed vaccine uptake rate fell below the recommended coverage rate, indicating the presence of a knowledge-behavior gap. Targeted interventions are recommended to improve vaccination uptake among healthcare workers in Saudi Arabia.; Summary

Key Message
This study assesses knowledge, attitudes, and practices regarding influenza vaccination among healthcare workers in Saudi Arabia, and reveals that most participants had an appropriate extent of knowledge, positive attitudes toward the influenza vaccine, and good vaccine practices. However, the vaccine uptake rate was below the desired coverage target, indicating a knowledge-behavior gap. Our findings suggest implementing interventions that enhance accessibility, provide workplace support, conduct awareness campaigns, and tackle barriers impeding vaccination, to improve uptake rates among healthcare workers in Saudi Arabia.

Case Report

Pseudoephedrine-induced Fixed Drug Eruption in a Scuba Diver With Recurrent Palmoplantar Exfoliation: Pimpreeya Kajornchaikul, Pattarawat Thantiworasit, Jettanong Klaewsongkram; J Prev Med Public Health. 2024;57(6):595-599. Published online August 8, 2024; DOI: https://doi.org/10.3961/jpmph.24.319

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Abstract Summary PDF: This report presents a case of pseudoephedrine-induced non-pigmented bullous fixed drug eruption (NBFDE) manifesting as recurrent palmoplantar exfoliation in a scuba diver. It emphasizes the importance of considering drug allergies in the differential diagnosis when divers present with peeling hands and soles. A 38-year-old female scuba diver experiencing recurrent palmoplantar exfoliation underwent a clinical evaluation, patch testing, an interferon-gamma enzyme-linked immunospot (ELISpot) assay, and graded drug challenges with pseudoephedrine and phenylephrine. Patch testing yielded negative results; however, the ELISpot assay indicated a strong immune response to pseudoephedrine. A graded challenge involving pseudoephedrine successfully reproduced the symptoms, confirming a diagnosis of pseudoephedrine-induced NBFDE. Subsequently, a challenge with phenylephrine elicited a milder reaction, suggesting it as a potential alternative medication for the patient. This case highlights NBFDE as a potential cause of skin peeling in scuba divers who are allergic to pseudoephedrine. It emphasizes the importance of considering drug allergies when diagnosing palmoplantar exfoliation in divers and underscores the need for a thorough evaluation of medication use in this group. Alternative medications and management strategies should be considered for divers with a pseudoephedrine allergy to prevent ear barotrauma while minimizing the risk of adverse skin reactions.; Summary

Key Message
This case report describes a 38-year-old female scuba diver who experienced recurrent palmoplantar exfoliation due to pseudoephedrine-induced non-pigmented bullous fixed drug eruption. The diagnosis was confirmed based on her clinical history, results of an interferon-gamma ELISpot assay, and a graded drug challenge. The report underscores the importance of considering drug allergies as a cause of skin reactions in divers and suggests phenylephrine as a potential alternative for managing ear barotrauma in patients with pseudoephedrine hypersensitivity, highlighting the need for individualized care in drug allergy management.

Perspective

Addressing Public Health Risks: Strategies to Combat Infectious Diseases After the August 2024 Floods in Bangladesh: Fatema Hashem Rupa, Mosharop Hossian; J Prev Med Public Health. 2024;57(6):600-603. Published online November 3, 2024; DOI: https://doi.org/10.3961/jpmph.24.495

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Abstract Summary PDF: The August 2024 floods in Bangladesh have precipitated a major public health crisis, significantly elevating the risk of waterborne and vector-borne diseases and exacerbating existing health vulnerabilities. This disaster has impacted over 5 million people, causing widespread environmental disruption, population displacement, and strained healthcare resources. The flooding of latrines, sewage systems, and agricultural land has led to the contamination of drinking water sources, increasing the risk of cholera, enterotoxigenic Escherichia coli diarrhoea, shigellosis, and hepatitis. Additionally, stagnant floodwaters have created breeding grounds for mosquitoes, thereby increasing the threat of malaria and dengue fever. The disruption of healthcare services has further compounded the crisis, delaying emergency responses and impeding access to care. The psychological impact on affected communities is profound, with mental health issues such as anxiety, depression, and post-traumatic stress disorder emerging as significant concerns. This perspective provides an analysis of these public health threats, supported by data on the impact of floods and a discussion of the underlying risk factors. This underscores the need for immediate and long-term public health interventions, including restoring clean water access, enhancing disease surveillance, repairing healthcare infrastructure, and addressing mental health needs. The response to this disaster must be rapid and comprehensive, with lessons learned to inform preparedness efforts to better manage similar events in the future.; Summary

Key Message
The August 2024 floods in Bangladesh have caused a severe public health crisis, elevating risks of waterborne and vector-borne diseases like cholera, shigellosis, malaria, and dengue. Over 5 million people have been affected, with contaminated water sources, disrupted healthcare services, and mental health issues worsening the impact. This article highlights the urgent need for clean water restoration, disease surveillance, healthcare system repairs, and mental health support, emphasizing the importance of immediate and long-term interventions to manage the crisis and strengthen disaster preparedness for the future.

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