3 iii
4 iv
5 ACKNOWLEDGEMENTS
My first acknowledgment goes to my supervisor, Doutor Ricardo Dinis, a humble and
vibrant professor, whose ideas and encouragement were essential for the development of
this work. It was a real privilege and an honour, to share of his notable scientific
knowledge.
I also express my gratitude to Professor Nuno Lunet, for helping me in the first steps of
this scientific demand.
And, finally, my last words go...
… to my mother, my father, my brothers Vítor and Tiago... pelas memórias, pela presença, pelo sentido de união…
… to Manel… por seres sempre um trator para mim… por me deixares adormecer debaixo da tua manta… por me mostrares os pássaros a cuidar dos bebés… por brincares comigo aos riachos… por me mostrares os avós… por seres o meu dragão preferido… por me mostrares o mundo todos os dias com o teu coração grande… obrigado Manel…
obrigado Rosinha…
6 TITLE: CAUSES OF DEATH IN HOMELESS POPULATIONS
Running Head: Pinho-Oliveira & Dinis-Oliveira
Author’s name and institutional addresses:
Luís Pinho-Oliveira1,2*, Ricardo Jorge Dinis-Oliveira1,3,4*
1Department of Public Health and Forensic Sciences, and Medical Education, Faculty of
Medicine, University of Porto, Porto, Portugal.
2School of Nursing, University of Minho, Braga, Portugal.
3UCIBIO, REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences,
Faculty of Pharmacy, University of Porto, Porto, Portugal.
4IINFACTS - Institute of Research and Advanced Training in Health Sciences and
Technologies, Department of Sciences, University Institute of Health Sciences (IUCS),
CESPU, CRL, Gandra, Portugal.
*Corresponding authors:
Luís Pinho-Oliveira: lpinhooliveira@gmail.com
Ricardo Jorge Dinis-Oliveira: ricardinis@sapo.pt; ricardinis@med.up.pt
Department of Public Health and Forensic Sciences, and Medical Education, Faculty of
Medicine, University of Porto, Porto, Portugal,
Alameda Prof. Hernâni Monteiro,
7 ABSTRACT
Homeless are vulnerable populations, strongly associated with poverty,
discrimination and health problems. It is an urban and complex phenomenon, estimated
in 100 million people worldwide that results from an interplay between individual and
structural factors, such as family breakdown, mental illness, substance abuse,
unemployment, absence of low-cost housing or incarceration history. Homelessness has
been also described as an important health determinant. Homeless people, particularly
chronic rough sleepers, have an increased risk of premature death, due to cardiovascular,
infectious and alcohol-related disease, unintentional injuries, substance misuse and
suicide. Several obstacles, as lack of awareness of healthcare problems, difficulties in
accessing to medical care and to adhere to therapeutic also contributes to the homeless
poor health status.
A review of mortality causes data on homeless persons was performed aiming to
better understand the extreme burden of disease experienced by these marginalized
populations. This broad understanding of the impact of homelessness on risk of death,
may contribute to influence public health policies, and subsequently to improve the
surveillance of morbidity and mortality in this underprivileged population. Further studies
should evaluate the effectiveness of healthcare and social interventions programs, and
their impact on health status and on social integration of homeless persons.
8 INTRODUCTION
Homelessness is a complex phenomenon of social discrimination, in modern
societies, that is more than the absence of a safe and adequate place to live 1-6. Strongly
associated with poverty, homelessness is caused by an interaction of individual and
structural factors that progressively interfere with the satisfaction of essential needs as
housing, food, child-care, healthcare or education, with profound social, physical and
mental implications 2,6-10.
Homeless people in comparison with general population, have an increased risk of
physical and mental diseases, as well as an increased risk of mortality and premature
2,4,9,11-18. Despite the increased mortality risks can partly be explained by the by high
exposure to risk factors and high prevalence of morbidity in homeless individuals,
findings from several studies have shown that homelessness itself is an independent risk
factor for death 19,20.
Difficulties in identifying and screen these individuals, as well the social variability
of these populations, poses important governance challenges, namely on diagnosis,
treatment and mostly on prevention of main homeless health problems. The present study
aims to present an overview of whether homelessness characteristics affects morbidity
and mortality causes and rates, in comparison with general population. With this review,
we also intended to identify “turning points” where social interventions programs can
focus on. The understanding of the mortality causes among homeless adult’s populations,
may alert political decisions makers about the impact of social inequalities on health
9 METHODOLOGY
Search was performed in Medline to identify articles published between January 1,
2008, and December 31, 2018, using the following searching expression: (mortality OR
death) AND (homeless OR roofless OR unsheltered). To be eligible, the studies had to be
written in English, Spanish, or Portuguese, and had to report mortality outcomes in
population-based samples of homeless adults. Systematic reviews and meta-analysis were
also included. Opinion papers and editorials were excluded. Only the studies providing
data for “roofless” and/or “houseless” population, as defined by the European Typology of Homeless and Housing Exclusion, were considered. We excluded articles that limited
the study population to homeless individuals with a specific health condition or homeless
that were recruited exclusively from intensive care or high dependency hospital units.
The articles were first selected by the titles and abstracts. In a second phase, the complete
article was read and the information to be included in this literature review was extracted.
The database review yielded 225 articles, and according to inclusion/exclusion criteria,
29 articles were finally included in the review.
RESULTS
Homeless definition
The homeless are considered “rare”, “hidden” or “hard-to-reach” populations, since generally, it is difficult to identify, sample and interview/evaluate their members,
10 different approaches to data collection 9,21,22. Homelessness, as a social and non-static
phenomenon, related to economic, political, social and cultural contexts, strongly related
to the housing conventions of a particular community, is conceptualized differently in
most countries 5,6,23,24.
The United Nations Statistical Division classifies homeless people into two
categories, primary homelessness or rooflessness, which includes persons that live in
streets or without a shelter or living quarters, and secondary homelessness, category that
includes persons with no fixed residence, residents of long-term ‘transitional’ shelters and
persons living in private dwellings but reporting ‘no usual address’ on their census form
25. A similar definition is used by the U.S. Department of Health and Human Services,
which considers homeless the subjects without permanent housing who may live on the
streets; stay in a shelter, mission, single room occupancy facilities, abandoned building
or vehicle; or in any other unstable or non-permanent situation 26. In Australia,
homelessness is defined as primary (without regular accommodation), secondary (living
in shelters or temporarily with family or friends or boarding houses) or tertiary (living in
under-standard housing-e.g. boarding houses) 25. In 2005 the European Federation of
National Organizations Working with the Homeless (FEANTSA) had developed a
European Typology of Homelessness and housing exclusion (ETHOS) that have been
used in European Union Countries to classify and screen situations of homelessness and
housing exclusion 6. The ETHOS categories attempt to cover all living situations, namely:
rooflessness (without a shelter of any kind, sleeping rough); houselessness (with a place
to sleep but temporary in institutions or shelter); living in insecure housing (threatened
with severe exclusion due to insecure tenancies, eviction, domestic violence); living in
inadequate housing (in caravans on illegal campsites, in unfit housing, in extreme
11 family can exercise exclusive possession (physical domain), that meets conditions that
allow privacy and establishment of social relations (social domain), and on which person
has the legal title of occupation (legal domain) 6. Some authors considered that besides
the living place, it is important to take into account the duration time of homelessness,
therefore, three categories of homelessness had been defined: chronic homelessness (an
episode of homelessness lasting more than a year, or four episodes of homelessness in the
previous 2 years), intermittent homelessness (individuals who cycle in and out of
homelessness repeatedly, with episodes of homelessness alternating with housing and
institutional care (jails, hospitals, treatment programs), and crisis or transitional
homelessness (individuals who are only homeless once or twice and for a relatively short
period of time (less than a year) 27.
Sociodemographic characteristics and causes of homelessness
An estimated 100 million people worldwide have no place to live, and more than one
billion have insufficient housing 9,24. More than 400 000 people in the European Union
are homeless on any one night, and more than 600 000 are homeless in the United States
6,9. This numbers may be underestimated, due to the economic and social crisis that has
affected many countries in recent years, as well to the migratory fluxes from the
low-income countries, that may contribute to an increasing number of individuals
experiencing homelessness worldwide 28,29.
Homelessness appears to affect mostly men between 30 and 60 years, unmarried,
12 The causes of homelessness are complex 5,6,24. This phenomenon has been described
as an interaction of individual and socioeconomic factors, including the presence or
absence of a safety net, which increases the vulnerability to social exclusion 5,6,24. Poverty,
family breakdown, sexual abuse, mental health and substance misuse problems, personal
history of violence and previous institutional history (e.g. prisons, reformatories or
psychiatric hospitals) have been reported as individual factors associated to
homelessness. As structural determinants, unemployment, low salaries, the absence of
low-cost housing, and the lack of institutional support are the most prevalent 1,5-7,24,30,34.
As a result, these people are often associated with illegal or socially sanctioned
activities such as begging, prostitution or theft 13. All these factors became also a blank
wall to the recovery of the work activity, family relationships, health status, and to the
restoration of schedules, routines and social norms with obvious implications to social
inclusion 5.
Health Status
Homeless populations suffer from the same spectrum of medical illness as the general
population, however, homeless individuals, particularly rough sleepers, had an increased
risk of physical and mental diseases, due to the living conditions and risk/unhealthy
behaviours 2,8,9,12,16,35-37.
Environmental insults such as violence, injuries, animal bites, overdose, and heat and
cold exposure complications are described as additional causes to seek healthcare
institutions 16,38-44. All these factors contribute to premature mortality in this population,
register-13 based cohort study of Danish homeless people revealed more than 5–6 times higher
mortality rates among homeless people than among the general population 48. Studies
conducted in other European countries, Canada, Australia and United States reported
mortality rates 3 to 13 times higher than in general population 42.
Several studies report an age estimated life expectancy of 42 to 52 years for
chronically homeless individuals 8,49,50. Men are more likely to experience unsheltered
homelessness and accounted the majority of homeless deaths, and homeless women have
a higher prevalence of chronic medical conditions and a greater risk of premature
mortality, although the association between gender and mortality in homeless populations
is not consistent 8,9,18,48,49,51.
Lower educational level, history of incarceration, live in unsheltered situations, and
experience of chronic homelessness, are also associated with an increased risk of
premature mortality 8,13,48,52,53. Some studies also report that mortality rates of homeless
individuals living in deprived areas, are higher than those verified in the least deprived
areas, and that this risk is higher in winter and in fall 10,17,42,54,55.
Regarding the common causes of death in homeless populations, as observed in
general population, the social context, the living conditions and the national healthcare
system have an important impact on the morbidity and mortality outcomes. Therefore, in
India, Tunisia or Turkey infectious disease or homicides are the main causes of death
among homeless individuals, while in USA, Canada, Netherlands or France,
cardiovascular disease and overdoses are major causes 10,13,18,49,54,56-58.
Cardiovascular disease
Cardiovascular disease is a frequent cause of morbidity and mortality among the
14 cardiovascular diseases at younger ages than the general population, namely ischemic
heart and cerebrovascular disease. This can be explained by a high prevalence of
traditional cardiovascular risk factors like hypertension, diabetes and
hypercholesterolemia 13,19,42,59-69. Low socioeconomic status and chronic stress, typically
of homeless populations, are also associated with an increased cardiovascular risk 70.
However, in accordance with majority of studies, this increased risk, is principally
explicated by heavy smoking habits, and a tendency for higher alcohol intake (the
prevalence of smoking habits and alcohol abuse is consistently above 50%), and
indirectly to obstacles on normally access to healthcare services or medications, which
results in a poor controlled hypertension, diabetes, and hypocholesteraemia62,64,66-68. A
high prevalence of mental illness and drugs abuse are also linked to this increased risk.
Data analyses of Toronto homeless people with mental illness revealed a highly elevated
30-years cardiovascular disease risk particularly among individuals with substance
dependence experiencing mental illness 58.
Infectious disease
The proportion of death due to infectious disease is higher among homeless persons
than non-homeless person 10,16,49. Higher frequencies of tuberculosis, an increased risk of
HIV, Hepatitis B or C infection have been reported in these individuals13,16,39,42,54,63,71-77.
A Portuguese study revealed a tuberculosis incidence among homeless persons five times
higher than among the non-homeless, and that almost one-third of these presented HIV
co-infection 75. Malnutrition, immune-compromised host, poor medication adherence,
risk behaviours, as needle sharing, unprotected sex, multiple sexual partners, and
prostitution, are associated with these individuals, and possibly explain the high
15 rough sleepers, also present a high prevalence of skin lesions and infections, such as
fungal infections, pediculosis or traumatic injuries 16,38,39.
Unintentional injuries
Unintentional injuries are common among homeless populations and are the major
cause of emergency department use 48,78. Traumatic and temperature-related injuries, as
well as medication and illicit substances intoxication, are frequent causes to seek medical
care 44,48,49,56,63,79,80. The results of several studies show that accidental death among
homeless persons are more frequent than those of non-homeless persons, namely due to
hypothermia, and heatstroke, whereas death by traffic accident was lower than
non-homeless persons 57,63,74,81. In a representative sample of homeless deaths database in
France, violent deaths were one of the leading causes of mortality, while homicides
represented 1% of the total of deaths 50.
Psychiatric disease
The prevalence of psychiatric disease in homeless individuals is also strongly higher
than in general population 48. Mental health disorders increase the risk of, and is
exacerbated by homelessness, it is known that approximately half of all homeless
individuals have had mental illnesses at some time in their lives and that the co-existence
of multiple mental problems is also frequent 82. The drug and alcohol dependence and
episodes of depression and schizophrenia are much more frequent among these
individuals than in the general population, in fact, the New York City homeless
surveillance system reports that drug overdose is the leading cause of death among single
adults living in shelters 42,48,64,82-84. A large number of studies highlights that individuals
16 general psychiatric population 48,58,82,85,86. Regarding the suicide among homeless
persons, several studies reported that this prevalence is lower than the verify on
non-homeless populations, however, data about matter shows proportions of suicide very
distinct, ranging between 1% and 50% 42,46,57,78,87.
Cancer disease
Although the dearth of data on cancer prevalence and mortality among homeless
people, some studies have reported cancer-related death rates being twice as high in
homeless adults as in the general population 42,88-90. Moreover, in result of inappropriate
cancer screening, the little data available indicate a more advanced cancer stage at
diagnosis and higher mortality rates among homeless people compared with the general
population 90,91.
Homeless individuals have a higher risk of developing lung, liver, colon, oral cavity
and cervical cancers, which may be explained by the high prevalence of smoking, alcohol
consumption, B and C hepatitis, and multiple sexual partners 39,64,77,89-92 .
Access to health services
The homeless poor health status may also be justified and/or exacerbated due to lack
of awareness of healthcare problems, difficulties in accessing to medical care and to
adhere to therapeutic prescriptions 7,93,94. As observed among socioeconomically
disadvantaged groups, illiteracy, inability to pay for medical care or medications, little or
no access to health-care system, suboptimal counselling by health-care practitioners, or
merely the absence of a postal address, or identity card, are some of multiple structural
17 Primary or secondary health prevention programs are often lacking in the homeless
populations, as result the medical treatment of these individuals in mainly focused on the
acute treatment of health problems, and prevention or treatment of chronic diseases plays
a minor role. Therefore, homeless individuals typically attend to emergency department
more often and have longer hospital stays than non-homeless 40,41,80,94-98.
CONCLUSIONS AND FUTURE PERSPECTIVES
This revision emphasizes that roofless and houseless people have much higher
mortality and shorter life expectancy than general population. Cardiovascular,
pulmonary, infectious and alcohol-related diseases, substance misuse, unintentional
injuries, suicides, homicides, and intoxication, seems to be the common causes of death
on these populations. Individual and structural factors, as lower educational level,
unsheltered situations, chronic homelessness or access to national healthcare system, have
also a significant impact on health status and on capacity to recover the homeless
individuals.
The signalling, diagnoses, treatment and follow-up of homeless individuals are
challenging and difficult questions placed to health policies of modern cities. Current
social support based on providing house, food or clothes, have certain benefits but per se
does not reduce health inequity, and cannot provide a survival advantage for the
chronically homeless persons. The evaluation of the effectiveness of current healthcare
and social interventions programs is important to change established policies, practices
and models of care, to improve the health of homeless and reduce mortality trends among
18 The fact that homeless people encounter numerous physical, social and political
barriers in access to health care is also well established, further studies should focus on
patients’ experiences, perceptions and needs, with the intend to adequate or develop homeless-centered health-care services.
DISCLOSURE STATEMENT
The authors have no relevant affiliations or financial involvement with any organization
or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employment, consultancies,
honoraria, stock ownership or options, expert testimony, grants or patents received or
pending or royalties. No writing assistance was utilized in the production of this
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69. Bernstein R. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. American journal of public health. 2015;105:e46-60.
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71. Bloss E, Holtz TH, Jereb J, et al. Tuberculosis in indigenous peoples in the U.S., 2003-2008. Public Health Rep. 2011;126(5):677-689.
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ANEXO
AJPH (American Journal of Public Health) Instructions for Authors
AJPH (American Journal of Public Health)
Instructions for Authors
ISSN: 1541-0048 (electronic); 0090-0036 (print)
Publication Frequency: 12 issues per year plus supplements with external support
Editor-in-Chief: Alfredo Morabia, MD, PhD
TABLE OF CONTENTS
AJPH (American Journal of Public Health) ... 1
Instructions for Authors... 1 TABLE OF CONTENTS ... 1 MANUSCRIPT PREPARATION AND SUBMISSION ... 3 Initial submission ... 3
Formatted submission ... 4
Style ... 4
Manuscript File Formats ... 4 Types of submissions ... 4 Sections ... 8 MANUSCRIPT COMPONENTS ... 16 Title Page ... 16
Abstract ... 17
Abbreviation and acronyms ... 17
Body of the manuscript ... 17
References ... 18
Figures ... 19
Images and Photos ... 19
Supplemental Files ... 19
Statistics in Tables and Text ... 19
Reproduced Material ... 20
EDITORIAL AND PUBLICATION POLICIES ... 20 Mission... 20 Authorship ... 21
Conflicts of Interest ... 21
Nondiscriminatory Language ... 22
The CONSORT Statement... 23
The TREND Statement ... 23
Embargo Policy ... 23
Publications Resulting from NIH-Funded Research ... 23
Mandates Resulting from White House Office of Science and Technology Policy Directive ... 24
Copyright... 24
MANUSCRIPT PREPARATION AND SUBMISSION
Initial submissionThe initial submission should be clean and complete and must comply with 4 requirements:
a) a blinded title page which includes the title of the manuscript only without any author names or affiliations,
b) numbered pages and lines (in Word, > Page Setup > Line Numbers > Continuous) throughout the text of the manuscript,
c) 1.5 or double spaced with a font size of 12
d) a Cover Letter with concise text (maximum 150 words) that addresses the following three topics:
(1) A description of what the paper adds to current knowledge, in particular with respect to material previously published in AJPH, and if systematic reviews exist on the topic.
(2) The public health importance of the paper.
(3) One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media. Manuscripts must be submitted online at http://www.editorialmanager.com/ajph.
A first triage done by the Editor-in-Chief and the Senior Deputy Editor identifies manuscripts of sufficient priority. Common causes of insufficient priority are: outdated data (e.g., pre-ACA, data collection completed >3 years before), analysis of surveys not based on the latest data release, results of primarily etiologic interest, small samples, and convenience samples. These are not hard and fast rules. Addressing the 3 questions requested in the cover letter helps us realize when some exception is warranted.
Beyond the triage, manuscripts considered for potential publication in the journal will be submitted to a technical check. Authors will be informed if their manuscripts need reformatting and will be given 7 days to make specific changes. To assure smooth and
timely processing, ensure that all identifying information has been removed from the submission files (including tables, figures, and supplemental files)—from within the file to the file name itself. This includes author names and initials, IRB information, clinical registration information, acknowledgments and any other details that might potentially unblind the paper to our reviewers. Our online submission system will collect this information via a questionnaire so that the Editors can retrieve the information.
Visit www.ajph.org for online manuscript submission instructions, or submit directly at www.editorialmanager.com/ajph. Questions? Write ajph.submissions@apha.org.
Revised Submissions
Revised manuscripts must be formatted as per AJPH specifications. Citation Style
With the exception of History Essays, all AJPH articles follow the AMA Manual of Style,
10th Edition. Substantive notes and footnotes are not permitted.
Manuscript File Formats
All manuscripts should be submitted in Word document format to
http://www.editorialmanager.com/ajph. Submissions sent to an email address will not be accepted.
Types of submissions
There are 13 submission categories: Research Articles, Brief Articles, Systematic Reviews, Letters and Responses, Editor’s Choice, Opinion Editorials,
Commentaries, Analytic Essays, History Essays, Public Health Practice, Voices, News, and Images. Word totals apply to the main body of the paper and exclude citations, tables, and figures.
Research Articles report the results of original public health research in up to 3500 words in the text, a structured abstract, up to 4 tables & figures combined, and no more than 35 references. The structured abstract must provide the date(s) and location(s) of the study. The text must have an introduction and separate sections for Methods,
statement below. For non-randomized interventions, see TREND statement below. Research Articles have the highest priority for AJPH.
Brief Articles are not different than a Research paper in terms of quality, importance, priority, etc., but they have up to 1200 words in the main text, a structured (except if justified otherwise in the cover letter) abstract, up to 1 table or figure, and no more than 12 references. A Brief Article is more effective than a full Research paper when the paper is about one specific finding, which can be shown in one table or one figure. In general, AJPH does not publish pilot studies or preliminary results. There may be exceptions, but we are interested in the full study that comes after the piloting. Brief Articles must have an introduction and separate sections for the Methods, Results, Discussion, and Public Health Implications. Some policy-focused Brief Articles that are short essays and do not report study results do not require the latter “Method, Results, Discussion, Public Health Implications” formatted subheadings.
Systematic Reviews, including quantitative and qualitative reviews, have clearly formulated questions and use systematic and explicit methods to identify, select, and critically appraise relevant research and to collect and analyze data from the studies that are included in the reviews. The text word limit is to 4000 words,4 Tables/Figures, and 60 references. Statistical methods (meta-analysis) may or may not be used to analyze and summarize the results of the included studies. To better ensure conformance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, AJPH recommends using these headings—Title, Abstract, Methods, Results, Discussion, Funding—in an expanded research article format, with flexibility when needed for clear assessment and presentation. Systematic reviews should be preferably registered in PROSPERO (http://www.crd.york.ac.uk/PROSPERO), and any changes from the registered protocol reported in the article. References, tables, and figures ought to be pertinent to the topic at hand, but no hard limit will be placed on authors; thus, full compliance with the PRISMA statement can be better ensured. The text, tables, and figures of the accepted systematic review are published online.
However, very big tables may only be made available as supplemental material. Authors whose studies are accepted for publication in the journal will be asked to prepare a 1- page Abridged Version to be published in the print issue. The abridged version comprises: (a) a 400-word Abstract that includes Background, Objectives, Search
Methods, Selection Criteria, Data Collection and Analysis, Main Results, Author’s Conclusions, and Public Health Implications, (b) a small Table or Figure summarizing a relevant finding of the review, and (c) a 200-word plain-language summary. The Abstract can be 600-words long if the abridged version has no table or figure.
Letters to the Editor are reserved for requiring clarifications on at least one recent AJPH article and are encouraged. They cannot be used to present preliminary results or
develop opinions that are not directly related to a recent AJPH publication. By submitting a Letter to the Editor, the author gives permission for its publication in AJPH. Letters should not duplicate material being published or submitted elsewhere. The editors reserve the right to edit and abridge accepted Letters and to publish Responses. Text is limited to 400 words and 7 references. A single table, figure, or image is permissible. Some letters are published in print and others online only, as per the decision of the Editor-in-Chief.
The Editor’s Choice is commissioned. The text is limited to 600 words with maximum 2 references (but preferably none) and a portrait of the author(s). A conversational and inspirational style is preferred.
Opinion Editorials may be commissioned or reformatted as editorials from submitted papers. They are 1200 words of text with subheadings, 1 small table or figure, and no more than 7 references.
Commentaries are scholarly essays and critical analyses of up to 2500 words in the main text, an unstructured abstract, up to 2 table(s)+figure(s) altogether, and no more than 25 references. They are not long opinion editorials.
Analytic Essays provide critical analyses of public health issues. They have an unstructured abstract, up to 4000 words of text with subheadings, up to 4
table(s)+figure(s), and no more than 40 references. Appropriately acknowledged photographs are encouraged in addition to the tables and figures.
History Essays are reserved for history scholars who use original sources. They have an unstructured abstract, up to 4000 words of text with subheadings, and up to 4 table(s)+figure(s)+ image(s). References (but not extensive notes) must be formatted according to the Chicago Manual of Style, 15th Edition. Authors are asked to cite the indispensable references in the main text and list the important but nonessential ones,
ordered by topic but unnumbered, in an online appendix made available as an online- only supplemental file for the readers.
Public Health Practice (PHP) Vignettes have a maximum of 1,200 words, withan 80- word abstract, up to 7 references, and up to 2 table(s)+figure(s) altogether that
emphasize the practice of public health and cover the following items, using the following subheadings: (1) Intervention: describe the goals and objectives of the program; (2) Place and Time: provide the geographic location and the years when the program was implemented; (3) Person: define the population subject to the intervention; Purpose: explain the motivation behind the program (5) Implementation: describe how the program was implemented in practice; (6) Evaluation: provide evidence on whether the program worked or not; (7) Adverse Effects: describe whether the implementation of the program had adverse or other unintended consequences; (8) Sustainability: if it is desirable for the practice to continue, describe the factors that indicate why the
intervention is felt to be sustainable; and (9) Public Health Significance: describe the importance of this program for public health, locally and/or more generally.
Voices present brief extracts from the works of public health figures that are republished with an accompanying biographical sketch (up to 1200 words in text, no abstract, 2 figures or images). In the History section, “Voices from the Past” can be up to 2500 words.
News summarizes the content of articles published in other public health journals around the world. They have up to 100-120 words and cover timely global public health topics submitted from a wide range of international (and domestic) editors, practitioners,
investigators, policy makers, field-based practitioners, and students in collaboration with an academic advisor. A single table, figure, or image is permissible and encouraged.
Images: We encourage readers and authors to submit images that can be used as illustrations in the journal or on the AJPH website or social media. Any submitted images must be print quality resolution: 300 dpi minimum with a 150-line screen. Also, AJPH prints evocative, documentary photos on the cover each month. Submissions for cover images must be of print quality resolution 300 dpi minimum with a 150-line screen sized 11x17 or larger. All images and photos should be submitted online as with any other
Sections
AJPH Forums present critical debates about timely topics. They usually have multiple contributions published in the same or consecutive issues of the Journal. They are formatted as Opinion Editorials. The Editor-in-Chief may encourage an exchange of text between authors prior to acceptance to ensure the debate is useful to the broader public health community. Forum themes are usually announced in an editorial by an Editor.
AJPH Depicting Data is a didactic section discussing ways of summarizing study findings graphically and is edited by Section Editor Roger Vaughan. Authors are
encouraged to propose ways to improve the presentation of articles previously published in the journal. Submissions are formatted as Brief Articles.
AJPH Practice highlights the fieldwork of public health practitioners describing innovative, successful, and cost-effective programs conducted by national, state, and local public health agencies and community-based organizations and groups. Their purpose is to share experiences that others may learn from and replicate. The program preferably should be in operation long enough to permit a rigorous assessment of its impact, factoring in the cost of startup and operation. Authors must include practical experiences and applications for others. Articles are tightly formatted as Public Health Practice Vignettes but can also comprise up to 2 images, especially photographs showing examples of project participants in context; logos; and examples of informational flyers or other educational materials.
AJPH Ethics and Law is edited by Section Editor Mark Rothstein. Papers are usually but not only formatted as Analytic Essays.
AJPH Policy is edited by Associate Editors Colleen Grogan and Daniel M. Fox. Papers usually are formatted as Editorials, Commentaries, Analytic Essays, or Brief Policy Articles.
AJPH Perspective from the Social Sciences, edited by Section Editors Deborah Holtzman and Kenneth McLeroy, features social science scholarship, the work of new disciplines within public health, and critical perspectives of public health problems. Papers are formatted as Analytic Essays.
AJPH History is edited by Section Editors Theodore Brown and Elizabeth Fee and is devoted to history that bears on contemporary public health. Papers are formatted either as History Essays or as Voices.
AJPH Images of Health consists of provocative pictures, posters, and graphics inspiring readers to ask, What makes an image effective? What images might enhance current or future public health initiatives or materials? How might the power of pictures be
harnessed to improve the public’s health? Section Editors Theodore Brown and Elizabeth Fee edit historical Images of Health columns, and Image Editor Aleisha Kropf edits
contemporary Images of Health columns. Papers are formatted as Editor’s Choice articles but with the specific image(s) in place of the author’s picture. It is possible for
authors to include more than 1 image for this section.
AJPH Global News focuses on news and views from around the world about public health and have a specific format (see p.7). The Section is currently edited by Mila González Dávila, Victor Puac Polanco, and Luis Segura, DrPH students, Mailman School of Public Health, Columbia University, New York, NY\:
AJPH Surveillance and Survey Methods is edited by Associate Editor Denys T. Lau and disseminates information on the design of major surveillance and survey programs and the evolution of methodological novelties that these programs are adopting for public health surveillance objectives to guide actions and policies to improve population health.
Scope: This section publishes peer-reviewed papers on the latest designs and
methodological approaches that major public health surveillance and survey programs —whether new or existing—are testing, developing, and adopting to advance health and healthcare data collection, analysis, interpretation, and dissemination. Surveillance and survey programs can range from gathering data on major life events and disease and wellness progression to tracking health care access, quality, and utilization over time at the local, national, or global level. The intent of this section is to spotlight evolving methods in data collection, analysis, and dissemination for informing the planning, implementation, and evaluation of public health practices and policies.
data sources:
a) Health surveys on environmental, behavioral, and biological risk factors of populations;
b) Routine health administrative and clinical data, such as those from vital record
systems, provider-based clinical encounter systems including electronic health record information, and payer-based billing and claims systems;
c) Mandatory health reports, such as those on communicable disease cases; and d) Voluntary health reports, such as those on adverse outcomes resulted from drugs,
consumer products, accidents, and notifiable diseases.
This section welcomes the following 3 types of articles: Design Description, Methods Research, and Perspectives.
1) Design Description: Design Description articles describe major design and methodological updates that new or continuing public health surveillance and survey programs have implemented. These articles should describe current approaches employed by established surveillance and survey programs in data collection
procedures, as well as data processing, reporting, and dissemination. These articles should clearly emphasize the public health significance by explaining the impetus and strengths of the design and methodological descriptions and the implications of these updates on population health research, practice, and/or policy. Design Descriptions that address surveillance and survey programs using multiple data sources or different
localities or nations are welcome. Design Description articles should focus on the current design and methodologies used in established surveillance and survey programs. Along with Design Description articles, researchers are encouraged to submit other article types (concurrently or sequentially) if they are interested in, for example, describing an evaluation study that informs the latest design updates of a surveillance or survey
program (e.g., submit a Methods Research article, see p. 13) or describing the historical contexts, policy/research environments, and multiple initiatives taken that have led to the latest development of the established surveillance system (e.g., submit a Perspectives article, see p. 16). In doing so, each article would be reviewed on its merit independently. Depending on the outcome of the peer-review process, one or both of the articles could be published in this section in a coordinated manner. These articles require a structured abstract of up to 180-words with the following four subheadings and brief summary
within those subheadings: Data System (name, sponsor, purpose); Data
Collection/Processing (data sources and collection mode, population and geographic coverage, sampling approach, and frequency); Data Analysis/Dissemination (data release/accessibility); and Implications (public health significance of the program).
Furthermore, these articles require structured text with a limitation of 3500 words of text and 35 references. There is a limit of 4 tables/figures for this article type. These articles should be written in a narrative format presenting items according to the order of the Checklist of Information for Describing Public Health Surveillance Systems (see the box
on this page). Articles should have the following 4 subheadings: Data System, Data
Collection/Processing, Data Analysis/Dissemination, and Implications. Additional subheadings within these four sections are welcome to help organize the write-up.
Checklist of Information for Describing Public Health Surveillance/Survey Programs
The following checklist of information should be included to the greatest extent possible when describing a public health surveillance/survey program. Depending on the scope of the submission, many of these items should be presented as a narrative in the manuscript text.
Tables and figures may be used to help clarify and complement presentation of information. On occasions, more technical, statistical items may be provided in an appendix or referred elsewhere with proper citations. When providing the following information, survey descriptions, definitions, and outcome metrics should use standards proposed by the American Association for Public Opinion Research’s 2015 8th Edition Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys
(https://www.aapor.org/AAPOR_Main/media/MainSiteFiles/Standard- Definitions2015_8thEd.pdf).
1) DATA SYSTEM
A. Name/sponsor(s): What is the full name of the surveillance/survey program? What is the full name of the organization(s) sponsoring and conducting the program?
B. Purpose: What is the purpose of the surveillance/survey program and what is it designed to do?
C. Public health significance: What is the surveillance/survey program’s public health significance? How can the program address a public health priority?
2) DATA COLLECTION/PROCESSING
A. Data sources and collection mode: How are the data in the surveillance/survey program collected and from what sources? For example, are the data collected from in-person, telephone, web-based, or mail surveys; physical examinations and laboratory testing; manual review of patient medical chart or extraction of electronic medical and administrative billing records; state vital registrations; mandatory or volunteer case reporting from care providers? What are the procedures for collecting the data and what developmental work such as pretesting, if any, has been completed on these adopted methods? Are the data an integration of multiple systems and if so, what are the data sources?
B. Ethical procedures: What informed consent procedures were followed or what institutional ethical review board approvals have been obtained, if any, to collect data in the surveillance/survey program?
C. Population(s) and geographic coverage: What population(s) or subpopulation(s) does the surveillance/survey program include/exclude and in what geographic areas (coverage and granularity)? If the program collects data on sampled cases, what is the sample frame, sampling technique, and target respondents for demonstrating how representative the sample is to the population of inference? What subpopulations, if any, are oversampled or followed up over time?
D. Unit of data collection and sample size: What is the unit of data collection in the surveillance/survey program, how complete are the data according to the intended coverage, and what is the total number of cases over a time period? If the program collects data on sampled cases, what is the target sample size and response rate (overall and multistage, if applicable)? How are the nonresponse cases handled to address generalizability? E. Surveillance design and frequency of data collection: How are the data collected in the
surveillance/survey program and how often? For example, are the data collected cross- sectionally or longitudinally; in an overlapping panel design; retrospectively or prospectively in real-time? Are they data collected continuously, annually, biennially, etc?
F. Key data elements and data quality/editing: What are some of the key data elements of interest collected in the surveillance/survey program? What is the data quality of the program in regards to sensitivity, specificity, and reliability? Are definitions used to identify cases or to define variables based on accepted standards? What are the patterns of missing data and what imputations if any are used? What masking techniques or other data
editing/processing have taken place for quality control purposes or managing disclosure risks?
3) DATA ANALYSIS/DISSEMINATION
A. Interpretation issues: What interpretation issues should be highlighted that may be associated with the way data are collected, or definitional, procedural, or instrument-related changes over time in the surveillance/survey program?
B. Linkage ability: To what other data sources, if any, can the data in the surveillance/ survey program be linked for analytical purposes? What are the restrictions and procedures to follow to link these multiple data systems?
C. Data release/accessibility: What years of data are collected, available currently for analysis, and planned for future release if any? How are the data in the surveillance/survey program released and can be accessed? For example, what is the website and/or address where the data can be obtained? What key data elements are publicly available, released under restricted conditions, or withheld by sponsoring organization(s)? What is the fee schedule, if any, for accessing the data?
D. Key references/other information: What published methodological reports can be cited on the surveillance/survey program? What other relevant information, especially on the data limitation and quality on identifying cases, may help improve the understanding of the program?
4) IMPLICATIONS
A. Impact: What is the evidence on impact that the surveillance/survey program has on public health research, policy, and practice? For example, does the program detect diseases, outbreaks, injuries, or adverse exposures to permit accurate diagnosis or identification, and effective prevention or
treatment programs? Does the program promote research by providing estimates and detecting trends on morbidity and mortality as well as identifying their associated factors?
2) Methods Research: Methods Research articles report testing of novel methodologies that established public health surveillance/survey programs are evaluating to inform significant design updates that have been implemented in these programs. Different from Design Descriptions articles that describe the surveillance/survey program in detail,
Methods Research articles focus on the scientific testing and findings of new methods that have led to design updates in the surveillance/survey program. Methods research, for example, can include experimental tests of new surveillance methods, evaluations of new data collection or analytical techniques, and empirical studies that contribute to survey statistical theory. These articles should clearly emphasize the public health significance by explaining what the impetus and rationale are for the methods research and how the findings are used to inform the established surveillance/survey program and advance the overall field. Methods Research articles comparing multiple surveillance data sources or different localities or countries are welcome. Because Methods Research articles would need to describe an established public health surveillance/ survey program on which the testing is based, researchers are encouraged to submit the following 2 types of article to this section for publication consideration:
a) Design Description article on the public health surveillance/survey program (see p. 10); and
b) Methods Research article that describes the testing of methodologies that eventually inform the development and design updates to the public health surveillance/survey program.
In doing so, each article would be reviewed on its merit independently. Depending on the outcome of the peer-review process, 1 or both of the articles could be published in this section in a coordinated manner. If the researchers choose not to submit a separate Design Description article on the public health surveillance/survey program, the Methods Research article should provide detailed description of the surveillance/survey program according the Checklist of Information for Describing Public Health Surveillance Systems (see the box on p. 11) in the body of the article. Methods Research articles require a structured abstract of 180 words or fewer and are structured with a limitation of 3500 words of text and 35 references. There is a limit of 4 tables/figures for this article type. The structure of these articles should follow the same format as AJPH’s instructions on Research Articles. The abstract should employ 4 headings: Objectives, Methods, Results, and Conclusions. Policy Implication is optional for the abstract. These articles should have the following 5 separated sections: Instruction, Methods, Results,
