Summer Restoration in a Bolivian Winter

                                 El Hospital Pietro Gamba in Anzaldo, Bolivia Credit: Duke

My biggest accomplishment this summer was being able to call the mountains of Bolivia home. Far away from the lecture halls of Duke, I encountered a profound, alternative education that included everything from learning traditional dances to working in a rural hospital laboratory to raising pigs.

Of course, living in Bolivia for two months had its challenges, like a diet in which potatoes were considered vegetables, repeated food poisoning from chicha, the local alcoholic drink consisting of fermented corn, lack of a consistent water source, many near-car accidents, and most of all a deep-seated machismo, but I feel that these were all almost inextricable aspects of a culture that left such a positive impression upon me.

Of course, the inextricability of such factors posed a problem for me as an intern at El Hospital Pietro Gamba encouraging sustainable development to promote public health. Although 80% of children had head lice, a vast majority contracted repeated gastrointestinal bacterial infections, and countless had scabies, the community seemed to get along contentedly. Regardless, with support from the Foundation for Sustainable Development and DukeEngage, my sponsor organizations, I leveraged the relatively new running water system, implemented only 25 years ago, to set in motion a comprehensive lice campaign, to obtain government funding of soap in public restrooms for at least two years, and to create preventative medicine informational materials.

The majority of my education, though, occurred outside the scope of my project. Most importantly, I’ve learned to openly embrace different forms of learning, like relaxation or soccer, that energize me to wholeheartedly pursue my rigorous biophysics career, which I am so fortunate to have at one of the best universities in the world.

The idea of the Aymara New Year illustrates my mentality poignantly: on the first day of the Aymara New Year, traditional Bolivians wish for health, prosperity, and happiness, just as we do in the United States. However, they have a deeper connection with Pachamama, or Mother Nature: on New Year’s Day, they wake up early in the morning to stand on the ground barefoot, awaiting the first rays of the sun. They believe that watching these rays rise above the horizon and light the earth will bring them energy for the entire year. In this, the Aymara New Year represents both personal aspiration and attenuation with the environment.

Similarly, I now aim to maintain a balance between self and surroundings: I hope to be more attuned to the world around me rather than single-mindedly submersing myself in quantum physics, as I believe that varied experiences will infuse me with energy in whatever I pursue. Now, back at Duke for the start of my junior year, I’m excited to begin blogging again and to continue my adventures and education here on campus.

Source: Duke University

UA to Serve Up Fresh Approach to Health

The commitment of the Department of Nutritional Sciences to promoting and adapting Mediterranean diet principles will continue through all three areas of the University’s land grant mission: academic programs, research and Cooperative Extension outreach programs. Credit: UA

The Mediterranean diet has seen growing global popularity as researchers find that the dietary pattern can help prevent or reduce obesity, heart disease, type 2 diabetes and certain types of cancer.

Responsive to that popularity, the University of Arizona Department of Nutritional Sciences is hosting a series of events meant to explore and share current research related to the dietary pattern, which focuses on fresh fruits and vegetables, whole grains, beans and nuts, along with lesser amounts of lean fish, meats, dairy, olive oil and red wine.

"We want to emphasize how this pattern of eating has been demonstrated to contribute to disease prevention," said Donato Romagnolo, a professor in the Arizona Cancer Center and the nutritional sciences department, which is housed in the UA College of Agriculture and Life Sciences. 

National Geographic Blue Zones speaker Rudy Maxa, a Washington Post reporter and columnist, and five Tucson-area celebrity chefs will kick off the Jan. 28 opening-night reception, "A Food, Wine and Healthy Living Event," at the Tucson Museum of Art.

The 6-8 p.m. event is open to the public and will feature food prepared by the chefs, award-winning wine provided by the Arizona Wine Growers Association and live flamenco and Spanish guitar.

Then the UA will will host the Jan. 29-30 "Health Benefits of the Mediterranean Diet – Bringing Science to the Plate (With an Arizona Twist!)" scientific conference at the Student Union Memorial Center.

Supported in part by a grant from the U.S. Department of Agriculture, the conference is geared toward public health and nutrition professionals, nurses, physicians, physical therapists and chiropractors, and it is offered for continuing professional credit. The event is also open to students and features a student showcase.

A full agenda and registration for the conference are available online.

Promoting the health benefits of the Mediterranean lifestyle is just one of numerous initiatives sponsored by the UA Department of Nutritional Sciences to advance optimal health and well-being for Arizonans and to focus on ways of preventing and treating chronic diseases. 

After the conference, a four-part, hands-on cooking series will be offered to the public during February and March at the UA Cooperative Extension's Garden Kitchen, "The Many Faces of the Mediterranean Diet: Four Evenings," featuring the cuisines of Spain, France, Morocco and Italy. Information is available online. 

Also, the Mediterranean Diet and Health course will be offered for academic credit during summer 2015 (one week in Tucson and three weeks in Verona, Italy) for students through the UA Global Initiatives Study Abroad Program.

Much of the interest in the Mediterranean diet stems from evidence that it can reduce the risk of death associated with heart disease and cancer. Other research indicates that the diet can reduce the incidence of Parkinson's and Alzheimer's diseases.

Romagnolo, also the program director of the Mediterranean Diet and Health Study Abroad Program, said the benefits are especially important given pervasive health concerns across the nation. He noted that about 60 percent of people in the U.S. are overweight and 30 percent are obese.

"The latter is a risk factor for diabetes, cancer and metabolic syndrome," Romagnolo said.
During the conference, more than 20 presenters from the UA College of Agriculture and Life Sciences, the UA College of Medicine, national and international universities, institutes and organizations will talk. 

Presenters will cover four general areas: the Mediterranean diet and regional trends; obesity, diabetes and healthy aging; cancer prevention and control; and methods for translating science to the plate.

Live demonstrations by Arizona growers, vendors and educators will provide attendees with tasting opportunities, meal preparation ideas and information on where to find local products that help make healthful eating easy in the Southwest.

Also, prominent diet researchers from Spain, France and Greece will present current research on the health benefits of the traditional Mediterranean diet and offer ways to adapt it using local agricultural ingredients and cooking techniques. Speakers include:

Lluis Serra-Majem of the University of Las Palmas de Gran Canaria, Spain, who will present the keynote address on "The Mediterranean Diet as an Intangible and Sustainable Food Culture."

Mariette Gerber of the INSERM-Institut du Cancer de Montpellier, France, who will discuss "Implementing the Mediterranean Diet: The French Perspective." 

Antonia Trichopoulou of the University of Athens, Greece, who will speak on "Mediterranean Diet and Longevity."

"The conference is an opportunity to present ideas and concepts that may be adopted by the food industry, nutritionists, researchers and policymakers to help reduce the burden of these chronic diseases," Romagnolo said. "We want to show people how they can do it on their own and apply the basic tenets of the diet here in Arizona."

Source: University of Arizona

HIV testing yields diagnoses in Kenya but few seek care

A sweeping effort in a rural region of Kenya to test all adults for HIV discovered 1,300 new infections, but few of the newly diagnosed people pursued treatment, a study in the journal Lancet HIV reports.
PROVIDENCE, R.I. [Brown University] — Between December 2009 and February 2011, health workers with the AMPATH Consortium sought to test and counsel every adult resident in the Bunyala subcounty of Kenya for HIV. A study in the journal Lancet HIV reports that the campaign yielded more than 1,300 new positive diagnoses, but few of those new patients sought health care.

“Home-based counseling and testing (HBCT) provided a diagnosis to nearly 40 percent of people living with HIV in this subcounty who otherwise most likely would not have gone for HIV testing,” said study lead author Becky Genberg, assistant professor (research) of health services, policy and practice in the Brown University School of Public Health. “They therefore would not have known about their HIV infection and not had the opportunity to change their behavior to protect others.”

AMPATH’s HBCT program is part of a strategy to identify all individuals living with HIV in the catchment area, start them on antiretroviral medication as soon as possible, and help them stay on their medications. Antiretroviral medication not only suppresses HIV infections for most patients but also reduces their ability to transmit the virus.

Genberg with co-author Edwin Sang “We are working on a variety of studies, all designed to understand the barriers facing the newly diagnosed, and to implement and evaluate strategies to increase their engagement and retention in HIV care over time.”

In Bunyala, home to about 66,000 people, the HBCT program tested about 32,000 adults. Among them, 3,482 had HIV. Of those, 2,122 already knew they were infected, but 1,360 did not know it yet.

A major finding of the study is that three years later only 15 percent of the newly diagnosed people had engaged in care for their infection. A likely reason why, Genberg said, is that newly diagnosed people typically don’t yet feel sick.

“That so few linked to care following HBCT is a call for innovative and creative strategies to work alongside HBCT to support the mostly healthy, asymptomatic newly diagnosed to engage with care in a way that is meaningful for them,” Genberg said.

In an editorial in the journal, Rashida Ferrand of the London School of Hygiene and Tropical Medicine said the study sounds a warning that home-based testing must be paired with effective ways to convince newly diagnosed patients to seek help.

“Unless paired with interventions targeted at hard-to-reach populations, the diagnosing of undiagnosed individuals in many settings will not be cost-effective and will have little effect on individual and population viral suppression,” she and colleagues wrote.

Genberg, who has been in Kenya this winter, said she is working with Kenyan collaborators on developing the needed interventions: “Right now we are working on a variety of studies, all designed to understand the barriers facing the newly diagnosed, and to implement and evaluate strategies to increase their engagement and retention in HIV care over time.”

In addition to Genberg the study’s authors are Joseph Hogan and Corey Duefield of Brown; Violet Naanyu, Juddy Wachira, and Samson Ndege of Moi University in Kenya; Edwin Sang, Monicah Nyambura, and Michael Odawa of AMPATH; and corresponding author Paula Braitstein of the University of Toronto.

The President’s Emergency Plan for AIDS Relief funded the study though USAID (grant AID-623-A-12-0001). Additional support came from the National Institutes of Health (K01MH099966) and the Bill and Melinda Gates Foundation.

Source: Brown University

WHO contemplates reforms after admitting missteps on Ebola

World Health Organization (WHO) Director-General Margaret Chan addresses the media during a special meeting on Ebola in Geneva on Jan. 25, 2015. Photo by Pierre Albouy/REUTERS.

In a special session on Sunday, the World Health Organization debated how to reform itself after acknowledging the organization had botched its response to the 2014 Ebola emergency. 

“The Ebola outbreak revealed some inadequacies and shortcomings in this organization’s administrative, managerial, and technical infrastructures,” WHO Director-General Margaret Chan said. At its headquarters in Geneva, Chan presented a series of proposals aimed at ending the current outbreak, as well as reinforcing preparedness globally and guaranteeing the WHO’s ability to address future large-scale outbreaks. 

She stressed the need to streamline recruitment for emergencies, as the current process is “too slow” and emphasized the need for a “one WHO” approach that employs universal operating procedures and tools for responding to emergencies. According to Chan, the current rules for reporting outbreaks – International Health Regulations (IHR) – created to prevent national health emergencies from becoming global crises, are too thin. But the largest lesson she and others at WHO learned during the outbreak fight was that well-trained, and appropriately paid health care workers, are essential to stemming the spread of disease. 

To date there have been more than 21,000 Ebola cases and over 8,400 deaths. “The volatile microbial world will always deliver surprises, Chan said. “Never again should the world be caught by surprise, unprepared.”

Source: WHO

Switching to vehicles powered by electricity from renewables could save lives

Driving vehicles that use electricity from renewable energy instead of gasoline could reduce the resulting deaths due to air pollution by 70 percent. Credit: © Dmitry Vereshchagin / Fotolia

Driving vehicles that use electricity from renewable energy instead of gasoline could reduce the resulting deaths due to air pollution by 70 percent. This finding comes from a new life cycle analysis of conventional and alternative vehicles and their air pollution-related public health impacts, published Monday, Dec. 15, 2014, in the Proceedings of the National Academy of Sciences.

The study also shows that switching to vehicles powered by electricity made using natural gas yields large health benefits. Conversely, vehicles running on corn ethanol or vehicles powered by coal-based or "grid average" electricity are worse for health; switching from gasoline to those fuels would increase the number of resulting deaths due to air pollution by 80 percent or more.

"These findings demonstrate the importance of clean electricity, such as from natural gas or renewables, in substantially reducing the negative health impacts of transportation," said Chris Tessum, co-author on the study and a researcher in the Department of Civil, Environmental, and Geo- Engineering in the University of Minnesota's College of Science and Engineering.

The University of Minnesota team estimated how concentrations of two important pollutants -- particulate matter and ground-level ozone -- change as a result of using various options for powering vehicles. Air pollution is the largest environmental health hazard in the U.S., in total killing more than 100,000 people per year. Air pollution increases rates of heart attack, stroke, and respiratory disease.

The authors looked at liquid biofuels, diesel, compressed natural gas, and electricity from a range of conventional and renewable sources. Their analysis included not only the pollution from vehicles, but also emissions generated during production of the fuels or electricity that power them. With ethanol, for example, air pollution is released from tractors on farms, from soils after fertilizers are applied, and to supply the energy for fermenting and distilling corn into ethanol.

"Our work highlights the importance of looking at the full life cycle of energy production and use, not just at what comes out of tailpipes," said Bioproducts and Biosystems Engineering Assistant Professor Jason Hill, co-author of the study. "We greatly underestimate transportation's impacts on air quality if we ignore the upstream emissions from producing fuels or electricity."

The researchers also point out that whereas recent studies on life cycle environmental impacts of transportation have focused mainly on greenhouse gas emissions, it is also important to consider air pollution and health. Their study provides a unique look at where life cycle emissions occur, how they move in the environment, and where people breathe that pollution. Their results provide unprecedented detail on the air quality-related health impacts of transportation fuel production and use.

"Air pollution has enormous health impacts, including increasing death rates across the U.S.," said Civil, Environmental and Geo- Engineering Associate Professor Julian Marshall, co-author on this study. "This study provides valuable new information on how some transportation options would improve or worsen those health impacts."

Source: University of Minnesota

Computational model: Ebola could infect more than 1.4 million people by end of January 2015

The Network Dynamics and Simulation Science Laboratory at the Virginia Bioinformatics Institute modeled the rate of infections and how interventions would affect the rate.
Credit: Source: CDC / Image courtesy of Virginia Tech

The Ebola epidemic could claim hundreds of thousands of lives and infect more than 1.4 million people by the end of January, according to a statistical forecast released this week by the U.S. Centers for Disease Control and Prevention.

The CDC forecast supports the drastically higher projections released earlier by a group of scientists, including epidemiologists with the Virginia Bioinformatics Institute, who modeled the Ebola spread as part of a National Institutes of Health-sponsored project called Midas, short for Models of Infectious Disease Agent Study.

The effort is also supported by the federal Defense Threat Reduction Agency.

Before the scientists released results, the outbreak in West Africa was expected to be under control in nine months with only about 20,000 total cases. But modeling showed 20,000 people could be infected in just a single month.

The predictions could change dramatically if public health efforts become effective, but based on the virus's current uncontrolled spread, numbers of people infected could skyrocket.

"If the disease keeps spreading as it has been we estimate there could be hundreds of thousands of cases by the end of the year in Liberia alone," said Bryan Lewis, a computational epidemiologist with the Network Dynamics and Simulation Science Laboratory at the Virginia Bioinformatics Institute.

Lewis and his fellow researchers use a combination of models to predict outcomes of the epidemic.

The agent-based models are adaptive, evolving as more information is fed into them to provide an accurate forecast.

Pharmaceutical intervention, which is still on the horizon, is proving less effective in the models than supportive care and personal protection equipment for health care workers.

"The work with Ebola is not an isolated event," said Christopher Barrett, the executive director of the institute. "This research is part of a decades-long effort largely funded by the Defense Threat Reduction Agency to build a global synthetic population that will allow us to ask questions about our world and ourselves that we have never been able to ask before, and to use those answers to prevent or quickly intervene during a crisis."

Barrett and other institute leaders updated U.S. Sen. Tim Kaine and Virginia Tech President Timothy Sands about the Network Dynamics and Simulation Science Lab's role in analyzing the Ebola outbreak at the Virginia Tech Research Center in Arlington on Tuesday morning. That afternoon in Blacksburg they briefed staff members from U.S. Sen. Mark Warner's office.

A university-level Research Institute of Virginia Tech, the Virginia Bioinformatics Institute was established in 2000 with an emphasis on informatics of complex interacting systems scaling the microbiome to the entire globe. It helps solve challenges posed to human health, security, and sustainability. Headquartered at the Blacksburg campus, the institute occupies 154,600 square feet in research facilities, including state-of-the-art core laboratory and high-performance computing facilities, as well as research offices in the Virginia Tech Research Center in Arlington, Virginia.

Source: Virginia Tech

Credit score can also describe health status

It appears the same behaviors that ruin credit ruin health too. Credit: © Ivelin Radkov / Fotolia

A credit score doesn't just reduce a person's entire financial history down to a single number and somehow predict their credit-worthiness.

It might also be saying something about a person's health status, too, according to a new analysis from a long-term study of the physical and mental health of more than 1,000 New Zealanders who have been monitored continuously from birth to age 38.

The latest paper from the study, appearing this week in the Proceedings of the National Academy of Sciences, has found a strong relationship between low credit scores and poor cardiovascular health.

This doesn't mean that poor financial management hurts your health, post-doctoral researcher Salomon Israel of Duke University is quick to point out. It's that the sort of personal attributes that can lead to a poor credit score can also contribute to poor health.

This and other studies from the Dunedin Multidisciplinary Health and Development Study in New Zealand have found that self-control, planning ahead and perseverance are attributes that predict both better financial status and better health.

"What it comes down to is that people who don't take care of their money don't take care of their health," said study leader Terrie Moffitt, who is the Nannerl O. Keohane university professor of psychology and neuroscience at Duke. She said this study confirms what the insurance and financial industries may already understand.

Backtracking into the data on these study participants, the researchers found that about 20% of the relationship between credit scores and heart health was accounted for by the attitudes, behaviors and competencies displayed by the study members when they were younger than age 10.

"We're showing that these things take root early in life," Israel said.

Harvard economist David Laibson, who was not involved in the research, said the study "fundamentally transforms our understanding of the psychological factors that connect our health and wealth."

Lamar Pierce, an associate professor of organization & strategy at Washington University in St. Louis, agreed. "This study is important because it identifies common cognitive foundations long before financial and physical health problems emerge," said Pierce, who was not involved in this study. "It provides hope that early life intervention can impede the development of life-long patterns of illness and financial struggle."

Using a standard measure called the Framingham cardiovascular risk score, the Duke researchers estimated the "heart age" of their participants, based on blood pressure, cholesterol levels, blood sugar and smoking habits. At age 38, the participants' Framingham "heart ages" ranged from 22 to 85 years. Participants with higher credit scores had younger "heart ages." The components of the Dunedin study's human capital measure -- educational attainment, cognitive ability and self-control -- each predicted higher credit scores and younger heart age.

The idea of checking credit scores against the detailed personal data in the Dunedin study came from a conversation Moffitt had with her seatmate on a plane about a decade ago. When she told her travelling companion from the life insurance industry that she studied self-control and life outcomes, he said, "We do that too, but we use credit scores."

"The thing that's so compelling about credit scores is that they're both predictive and retrospective," said co-author Avshalom Caspi, the Edward M. Arnett professor of psychology and neuroscience, psychiatry & behavioral sciences at Duke. "They offer a window on the future, but also a window on the past."

In recent years, credit scores have been used for pre-employment screening and many other functions beyond their original intent, Israel said. This study seems to bear out their usefulness as a proxy for a person's reliability and steadfastness, and in turn how healthy they may be.

"Our findings suggest that life insurance companies that acquire an applicant's credit score are also indirectly acquiring information about that applicant's educational attainment, intelligence and personality, right back to childhood," the authors wrote.

The link might work the other way as well. In less developed countries where credit scores aren't available, a Harvard team has been experimenting with using a 40-minute personality quiz to assess candidates' credit-worthiness for microloans.

This research was supported by the New Zealand Health Research Council, US National Institute on Aging (AG032282, T32-AG000029), the UK Medical Research Council (MR/K00381X) the Jacobs Foundation and the Yad Hanadiv Rothschild Foundation.

Source: Duke University

Switching to vehicles powered by electricity from renewables could save lives

Driving vehicles that use electricity from renewable energy instead of gasoline could reduce the resulting deaths due to air pollution by 70 percent. Credit: © Dmitry Vereshchagin / Fotolia

Driving vehicles that use electricity from renewable energy instead of gasoline could reduce the resulting deaths due to air pollution by 70 percent. This finding comes from a new life cycle analysis of conventional and alternative vehicles and their air pollution-related public health impacts, published Monday, Dec. 15, 2014, in the Proceedings of the National Academy of Sciences.

The study also shows that switching to vehicles powered by electricity made using natural gas yields large health benefits. Conversely, vehicles running on corn ethanol or vehicles powered by coal-based or "grid average" electricity are worse for health; switching from gasoline to those fuels would increase the number of resulting deaths due to air pollution by 80 percent or more.

"These findings demonstrate the importance of clean electricity, such as from natural gas or renewables, in substantially reducing the negative health impacts of transportation," said Chris Tessum, co-author on the study and a researcher in the Department of Civil, Environmental, and Geo- Engineering in the University of Minnesota's College of Science and Engineering.

The University of Minnesota team estimated how concentrations of two important pollutants -- particulate matter and ground-level ozone -- change as a result of using various options for powering vehicles. Air pollution is the largest environmental health hazard in the U.S., in total killing more than 100,000 people per year. Air pollution increases rates of heart attack, stroke, and respiratory disease.

The authors looked at liquid biofuels, diesel, compressed natural gas, and electricity from a range of conventional and renewable sources. Their analysis included not only the pollution from vehicles, but also emissions generated during production of the fuels or electricity that power them. With ethanol, for example, air pollution is released from tractors on farms, from soils after fertilizers are applied, and to supply the energy for fermenting and distilling corn into ethanol.

"Our work highlights the importance of looking at the full life cycle of energy production and use, not just at what comes out of tailpipes," said Bioproducts and Biosystems Engineering Assistant Professor Jason Hill, co-author of the study. "We greatly underestimate transportation's impacts on air quality if we ignore the upstream emissions from producing fuels or electricity."

The researchers also point out that whereas recent studies on life cycle environmental impacts of transportation have focused mainly on greenhouse gas emissions, it is also important to consider air pollution and health. Their study provides a unique look at where life cycle emissions occur, how they move in the environment, and where people breathe that pollution. Their results provide unprecedented detail on the air quality-related health impacts of transportation fuel production and use.

"Air pollution has enormous health impacts, including increasing death rates across the U.S.," said Civil, Environmental and Geo- Engineering Associate Professor Julian Marshall, co-author on this study. "This study provides valuable new information on how some transportation options would improve or worsen those health impacts."

Source: University of Minnesota

Many older adults still homebound after 2011 Great East Japan Earthquake

2011 Great East Japan Earthquake

A new study, published online in the journal Age and Ageing, shows that the homebound status of adults over the age of 65 in the aftermath of the 2011 Great East Japan Earthquake is still a serious public health concern. Of 2,327 older adults surveyed, approximately 20% were found to be homebound.

A team of researchers led by Naoki Kondo of the University of Tokyo's School of Public Health studied data from the city of Rikuzentakata, an area that was seriously damaged by the disaster. Of its total population of 23,302 before the events of 2011, 1,773 people died or are still missing. Of 7,730 houses, 3,368 (43.6%) were affected with 3,159 "completely destroyed." Much of the population had been concentrated in flat coastal areas, and since the community infrastructure was totally shattered, many people who lost their houses insisted on moving to areas in the mountains.

This study used home-visit interviews with 2,327 adults over 65 years old (1027 men; 1300 women), and was carried out between August 2012 and October 2013. Interviewers gathered information of current morbidity, socio-economic status, health behaviour (diet, smoking, and alcohol intake), frequency of going out, and social support. 19.6% of men and 23.2% of women were shown to be homebound, defined as only leaving the house every 4 or more days. Of those older adults who were classified as homebound, around 40% also had no contact with neighbours.

Information was also obtained on the locations of grocery stores, convenience stores, and shopping centres from the online community directory database in August 2012. Information on shopper bus stops and hawker sites was provided by a disaster support team, and the team also collated road network data. This geographical analysis indicated that distances to retail stores was associated with the risk of people being homebound.

Lead author Naoki Kondo says: "This study has important implications for public health, especially in the setting of post-disaster community reconstruction. First, community diagnoses in a post-disaster setting should cover the built environment, including access to shopping facilities. Second, to prevent older victims of a disaster such as the Great East Japan Earthquake being homebound, it is clearly essential to provide access to the facilities that fulfil their daily needs.

"Given the findings of this study, such access could be increased by the private sector, suggesting the importance of public-private partnerships for post-disaster reconstruction."

Key messages:

• The homebound status of older victims of the 2011 Great East Japan Earthquake is a matter of public health concern
• Geographical analysis indicated that distances to retail stores was associated with the risk of people being homebound
• Hawker and shopping bus services contributed to improved access, providing more opportunities for going out

Source: Oxford University Press (OUP)