Examining Australia's heaviest drinkers

Objective : This study examined the distribution of alcohol consumption in Australia, identifying the heaviest drinking 10% of the population and examining their sociodemographic characteristics and their alcohol consumption and purchasing practices. Methods : Data came from the 2016 National Drug Strategy Household Survey and the 2013 International Alcohol Control Study. The heaviest drinking 10% of the population identified based on estimates of annual alcohol consumption. Logistic regression was then used to assess the factors that distinguished these heaviest drinkers from the rest of the drinking population. Results : The heaviest drinking 10% of the population consumed 54.4% of all alcohol consumed. These heavy drinkers were more likely to be men and to live in regional and remote areas. They were more likely to drink cask wine and full‐strength beer and to purchase cheaper alcohol than other drinkers. Conclusions : Australian alcohol consumption is heavily skewed. Alcohol consumption practices appear to differentiate the heaviest drinkers from others more clearly than sociodemographic factors. Implications for public health : Public health interventions that reduce drinking among the heaviest 10% of drinkers in Australia have the potential to markedly reduce per‐capita consumption and reduce alcohol‐related harm. Interventions focused on cheap alcohol may be effective with these drinkers.     

Alcohol consumption and burden of disease in the Americas: implications for alcohol policy.

OBJECTIVES: To describe patterns of alcohol consumption in the Americas, to estimate the burden of disease attributable to alcohol in the year 2000, and to suggest implications for policies to reduce alcohol-related disease burden. METHODS: Two dimensions of alcohol exposure were included in this secondary data analysis: average volume of alcohol consumption and patterns of drinking. There were two main outcome measures: mortality (number of deaths) and disability-adjusted life years (DALYs) lost (number of years of life lost due to premature mortality and disability). Separate estimates were obtained for different sexes, age groups and WHO regions. RESULTS: Despite regional variations, alcohol consumption in the Americas averaged more than 50% higher than worldwide consumption. Patterns of irregular heavy drinking prevailed. Alcohol consumption caused a considerable disease burden: 4.8% of all the deaths and 9.7% of all DALYs lost in the year 2000 were attributable to drinking, with most of the burden occurring outside North America. Intentional and unintentional injuries accounted for 59.8% of all alcohol-related deaths and 38.4% of the alcohol-related disease burden. Of all risk factors compared here, alcohol accounted for the greatest proportion of risk, followed by smoking. CONCLUSIONS: Interventions should be implemented to reduce the high burden of alcohol-related disease in the Americas. Given the epidemiological structure of this burden, injury prevention including, but not restricted to, prevention of traffic injuries, as well as appropriate treatment options, should play an important role in comprehensive plans to reduce the alcohol-related public health burden.     

Use of Alcohol in Long Term Care Settings: A Comparative Analysis of Personal Choice,Public Health Advice and the Law

Alcohol is one of the most widely available psychoactive substances globally. Many accept the risks associated with alcohol consumption for reasons such as social engagement and feelings of pleasure. Alcohol consumption in a nursing home (NH) setting highlights the moral and logistical challenges of balancing the need for a safe living and working environment with the dignity of risk (DoR) and personal autonomy of residents.This analysis explores public health, human rights, and legal frameworks in their approach to a NH resident's choice to drink alcohol. Key issues under the public health framework include the medical risks associated with alcohol consumption, whether residents with impaired cognitive functioning have the capacity to make a decision about alcohol consumption, and the practical and ethical implications of supplying alcohol to residents. Under a legal framework, NHs must consider the legal imperative to respect residents' rights, the possibility of liability in negligence, duties owed to employees, the existence of substitute decision-makers, and liquor licensing laws. Fundamental considerations under the human rights framework include the damaging psychological effects of risk-avoidance and the importance of inclusive risk assessment processes.Alcohol policies should incorporate elements from all 3 frameworks. There is limited data publicly available about alcohol policies in NHs. Further research is needed to establish current practice and to evaluate the merits and disadvantages of different policies. Establishing inclusive and thorough decision-making processes is key to achieving better consumer-directed care.     

National survey data can be used to measure trends in population alcohol consumption in Australia

Objectives : To assess the accuracy of the National Drug Strategy Household Survey (NDSHS) at capturing trends in alcohol consumption at the population level, using apparent per capita alcohol consumption as a benchmark. Methods : Data was from five waves of the NDSHS (2001–2013), with estimates of per capita alcohol consumption derived from the detailed graduated frequency alcohol questions. Trends are compared with per capita measures, and trends in both series compared. Further analyses explore whether recent trends in consumption are consistent across age groups. Results : The NDSHS survey estimates still track apparent consumption well, which increases between 2001 and 2007 and then declines to 2013. Since 2007, survey estimates show a 10.5% decline in per capita alcohol consumption, compared with 8.9% in ABS data. Two‐thirds of the decline came from reductions in drinking among respondents under 30. Conclusions : NDSHS data provide reasonably accurate estimates of trends in Australian population alcohol consumption. Survey data are critical to understanding the composition of overarching trends, with these analyses demonstrating substantial variation by age. Implications : Survey data are a crucial tool in monitoring Australian alcohol consumption, despite their inherent limitations.     

WHO Expert Committee on Problems Related to Alcohol Consumption. Second report

The disease burden attributable to alcohol consumption is significant and, in many countries, public health problems caused by harmful use of alcohol represent a substantial health, social and economic burden. Reduction of the alcohol-attributable burden is becoming a priority area for international public health. Alcohol-related harm can be reduced through the implementation of proven alcohol strategies, including at a global level. This report of a WHO Expert Committee reviews the health and social consequences of alcohol consumption and disease burden attributable to alcohol in the context of alcohol-related harm and recent trends in alcohol consumption worldwide. Based on the reviews of available evidence, including the latest data on the contribution of alcohol consumption to the global disease burden, the Committee makes several recommendations emphasizing WHO's role in coordinating a global response, and the need for global action to reduce alcohol-related harm through effective mechanisms of international action and country support. The Committee recommends a range of strategies and policy options that have a sound evidence base and global relevance for reducing alcohol-related harm, emphasizing that their adaptation and implementation at the national and sub-national levels should take into account specific cultural and legal contexts and the local configuration of alcohol problems. The Committee also recommends that WHO should support governments, particularly in low- and middle-income countries, in developing, implementing and evaluating national and sub-national evidence-based policies, action plans and programmes. The Committee's conclusions and recommendations have significant implications for future developments in this area.     

Mini-symposium — Public Health Observatories: Assessing and communicating the health and judicial impact of alcohol use

BACKGROUND: Alcohol consumption places an increasing burden on health services, criminal justice agencies and private industry throughout the UK. Despite a national strategy to tackle alcohol-related harm, there remains a lack of epidemiology on alcohol use and related harms at local levels. Utilising national data sources and existing research studies, Regional Public Health Observatories are appropriately placed to calculate such measures and examine their relationship with deprivation. METHODS: For the North West of England, borough and health locality data were extracted from national sources. Alcohol consumption utilised lifestyle survey data and estimates of related harm were calculated by applying existing alcohol attributable fractions to deaths, hospital episodes and crime data. Contribution of alcohol to reduction in life expectancy was also calculated and all measures were correlated with deprivation. RESULTS: For the North West, the annual burden of alcohol was estimated at over 3700 deaths, 56,700 hospital episodes and 71,000 crimes. Annual alcohol-related death rates for men varied from 0.43 to 1.17 per 1000 between Local Authorities and there was a six-fold variation in alcohol-related crime rate between areas. For males, alcohol reduced life expectancy by more than five months in the area worst affected. For both sexes, more deprived areas had significantly higher levels of alcohol-related hospital episodes, crime, and contribution to reduced life expectancy. CONCLUSIONS: Alcohol-related harm requires urgent, multi-agency attention at local levels throughout the UK. Applying appropriate research methods to national data sources provides limited but valuable local measures of alcohol use and its impact on health and crime. Regional Public Health Observatories can facilitate partnership working through such provision of national intelligence tailored to support local and regional action. Application of these techniques also helps identify additional requirements for better local intelligence on health-related behaviours and the necessity for consistency across local health and behaviour surveys.     

The role of race/ethnicity in alcohol-attributable injury in the United States

A substantial proportion of injuries worldwide are attributable to alcohol consumption, and US estimates indicate that the drinking patterns of racial/ethnic groups vary considerably. The authors reviewed evidence from 19 publications regarding racial/ethnic differences in overall alcohol-attributable injury as well as percent blood alcohol content positivity for injury deaths in the United States. They found that Native Americans evidence higher rates of alcohol-attributable motor vehicle crash fatality, suicide, and falls compared with other racial/ethnic groups; conversely, Asians evidence lower rates of alcohol-attributable injury than other racial/ethnic groups. The rate of alcohol positivity and intoxication among Hispanics is disproportionately high relative to estimates of alcohol use. Black subgroups also evidence higher rates of alcohol positivity than would be expected given estimates of alcohol use, including for alcohol positivity among drivers of fatally injured black children and homicide. These findings highlight the continued need for public health focus on Native American populations with respect to alcohol consumption and injury. Further, the disparity in alcohol-attributable injury mortality among black and Hispanic groups relative to their reported rates of alcohol consumption is an overlooked area of research. The authors review potential social determinants of racial/ethnic disparities in alcohol-attributable injuries and identify directions for further research on these patterns.     

Alcohol accounts for a high proportion of premature mortality in central and eastern Europe

BACKGROUND: There is a west-east mortality gradient in Europe, more pronounced in men. The objective of this article was to quantify the contribution of alcohol use to the gap in premature adult mortality between three old (France, Sweden and United Kingdom) and four new (Czech Republic, Hungary, Lithuania and Poland) European Union (EU) member states for the year 2002. Russia was added as an external comparator. METHODS: Exposure data were taken from surveys and per capita consumption records from the World Health Organization (WHO) Global Alcohol Database. Mortality data were taken from the WHO databank. The risk relationships were taken from published meta-analyses and from the WHO Comparative Risk Assessment project. Alcohol exposure and relative risk information was combined to derive alcohol-attributable fractions for relevant causes of premature mortality. RESULTS: Alcohol consumption was responsible for 14.6% of all premature adult mortality in the eight countries, 17.3% in men and 8.0% in women. This proportion was clearly higher in the new EU member states and Russia compared with the comparison countries from the old EU. For men, Russia with 29.0 alcohol-attributable premature deaths per 10,000 population had a more than 10-fold higher rate compared with Sweden (2.7 deaths/10,000). For women, the ratio between Hungary (5.0 alcohol-attributable deaths/10,000) and Russia (4.7 deaths/10,000) compared with Sweden (0.5 deaths/10,000) was almost as high, but the rates were much lower. The Czech Republic and Poland showed proportionally less alcohol-attributable premature mortality than the other new EU member states or Russia for both genders, which, however, was still higher than in any of the old EU member states. CONCLUSIONS: Alcohol is a strong contributor to the health gap between western and central and eastern Europe, with both average volume of consumption and patterns of drinking contributing to burden of disease and injury. Alcohol also contributes substantially to male-female differences in mortality and life expectancy. However, there are feasible and cost-effective measures to reduce alcohol-related burden that should be implemented in central and eastern Europe.     

Community perspectives of second-generation alcohol misuse and HIV risk in rural Kenya: A gendered syndemic lens

ABSTRACT

Sub-Saharan Africa is at the intersection of the HIV epidemic and the highest burden of alcohol-related disease and injury. Alcohol consumption is associated with an increased likelihood of HIV infection, high rates of intimate partner violence and is considered both a cause and a contributor of economic stress and poverty. Our study integrates the syndemic and socio-ecological system theoretical frameworks to qualitatively explore the effect of second-generation alcohol consumption on sexual risk behaviours, alcohol misuse, violence and economic stress (SAVE) factors and HIV infection risk. We recruited 80 people from rural Kenya to participate in 12 focus groups. Consistent with the literature, we found evidence of syndemic associations of second-generation alcohol consumption with SAVE factors, including HIV infection risk. Structural-level factors including availability of cheap second-generation alcohol and widespread unemployment are the biggest risk factors for alcohol misuse. Because of the psychological effect of women’s increasing economic independence on men, gendered syndemic programming – that includes both men and women – and addresses the complex web of risk factors for second-generation alcohol misuse can interrupt the vicious cycle of poverty, violence, sexual risk behaviours and mitigate HIV infection risk in rural Kenya.     

Measuring the population burden of fatal and nonfatal injury

The value of measuring the population burden of fatal and nonfatal injury is well established. Population health metrics are important for assessing health status and health-related quality of life after injury and for integrating mortality, disability, and quality-of-life consequences. A frequently used population health metric is the disability-adjusted life-year. This metric was launched in 1996 in the original Global Burden of Disease and Injury study and has been widely adopted by countries and health development agencies alike to identify the relative magnitude of different health problems. Apart from its obvious advantages and wide adherence, a number of challenges are encountered when the disability-adjusted life-year is applied to injuries. Validation of disability-adjusted life-year estimates for injury has been largely absent. This paper provides an overview of methods and existing knowledge regarding the population burden of injury measurement. The review of studies that measured burden of injury shows that estimates of the population burden remain uncertain because of a weak epidemiologic foundation; limited information on incidence, outcomes, and duration of disability; and a range of methodological problems, including definition and selection of incident and fatal cases, choices in selection of assessment instruments and timings of use for nonfatal injury outcomes, and the underlying concepts of valuation of disability. Recommendations are given for methodological refinements to improve the validity and comparability of future burden of injury studies.     

Statistical modeling of volume of alcohol exposure for epidemiological studies of population health: the US example

Background  

Alcohol consumption is a major risk factor in the global burden of disease, with overall volume of exposure as the principal underlying dimension. Two main sources of data on volume of alcohol exposure are available: surveys and per capita consumption derived from routine statistics such as taxation. As both sources have significant problems, this paper presents an approach that triangulates information from both sources into disaggregated estimates in line with the overall level of per capita consumption.     

Global burden of injuries attributable to alcohol consumption in 2004: a novel way of calculating the burden of injuries attributable to alcohol consumption

Background

Alcohol consumption is a major risk factor for injuries; however, international data on this burden are limited. This article presents new methods to quantify the burden of injuries attributable to alcohol consumption and quantifies the number of deaths, potential years of life lost (PYLL), and disability-adjusted life years (DALYs) lost from injuries attributable to alcohol consumption for 2004.

Methods

Data on drinking indicators were obtained from the Comparative Risk Assessment study. Data on mortality, PYLL, and DALYs for injuries were obtained from the World Health Organization. Alcohol-attributable fractions were calculated based on a new risk modeling methodology, which accounts for average and heavy drinking occasions. 95% confidence intervals (CIs) were calculated using a Monte Carlo simulation method.

Results

In 2004, 851,900 (95% CI: 419,400 to 1,282,500) deaths, 19,051,000 (95% CI: 9,767,000 to 28,243,000) PYLL, and 21,688,000 (95% CI: 11,097,000 to 32,385,000) DALYs for people 15?years and older were due to injuries attributable to alcohol consumption. With respect to the total number of deaths, harms to others were responsible for 15.1% of alcohol-attributable injury deaths, 14.5% of alcohol-attributable injury PYLL, and 11.35% of alcohol-attributable injury DALYs. The overall burden of injuries attributable to alcohol consumption corresponds to 17.3% of all injury deaths, 16.7% of all PYLL, and 13.6% of all DALYs caused by injuries, or 1.4% of all deaths, 2.0% of all PYLL, and 1.4% of all DALYs in 2004.

Conclusions

The novel methodology described in this article to calculate the burden of injuries attributable to alcohol consumption improves on previous methodology by more accurately calculating the burden of injuries attributable to one??s own drinking, and for the first time, calculates the burden of injuries attributable to the alcohol consumption of others. The burden of injuries attributable to alcohol consumption is large and is entirely avoidable, and policies and strategies to reduce it are recommended.     

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.     

Alcohol and the Older Adult: A Comprehensive Review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of “boomers” who believe that alcohol intake improves health comes of age.     

Most recent risky drinking session with Australian teenagers

Objective : Despite declines in Australian alcohol consumption, youth alcohol related harms remain prevalent. These alcohol‐related consequences appear to be driven by a subset of risky drinkers who engage in ‘high intensity’ drinking episodes and are underrepresented in national health surveys. This project aims to investigate high risk drinking practices and alcohol‐related harms amongst young people not otherwise recorded in existing data. Methods : A community sample of the heaviest drinking 20–25% 16–19 year olds were surveyed across three Australian states (n=958; 80% metropolitan). We examined the context of their last risky drinking session through online and face‐to‐face surveys. Results : Males consumed a mean of 17 and females 14 standard drinks, and 86% experienced at least one alcohol‐related consequence during this session. More than a quarter of the face‐to‐face sample had Alcohol Use Disorders Identification Test (AUDIT) scores indicative of alcohol dependence. Indications of dependence were 2.3 times more likely among those who felt uncomfortable about seeking alcohol treatment, and less likely if harm reduction strategies were frequently used while drinking. Conclusions : It is clear this underrepresented population experiences substantial acute and potentially chronic consequences. Implications : Within the context of increasing alcohol‐related harms among young Australians, the understanding of this group's drinking habits should be prioritised.     

Review of estimates of the global burden of injury and illness due to occupational exposures

BACKGROUND: Over the last decade, there have been several attempts to estimate the global burden of ill health due to work activity. The most recent of these is the Comparative Risk Assessment (CRA) project of the World Health Organization. METHODS: Published estimates of global burden of injury and disease due to occupational factors were summarized, compared, and contrasted with the aim of putting the CRA estimates into context, identifying the most reliable and appropriate estimate for total burden due to occupational risks, and making recommendations regarding future work. RESULTS: The best estimate of global work-related deaths of workers is approximately two million per year, with disease responsible for the vast majority of these, but even this is likely to be a considerable underestimate of the true number of deaths because of shortcomings in the available data. CONCLUSIONS: The CRA estimates of burden due to individual risk factors appear appropriate for the limited number of exposures and conditions included, but are a major underestimate of the overall number of work-related deaths at a global level due to exclusion of risk factors because of data limitations. Improvements in global estimates are likely to come from the use of different methodologies and improvements in the availability and use of local data.     

Episodic heavy drinking,problem drinking and injuries – Results of the WHO/NIAAA collaborative emergency room study in South Korea

Alcohol is the 5th leading risk factor to the global disease burden and disability and about half of the global alcohol burden was attributable to injuries. Despite a large body of evidence documenting the associations between alcohol and injuries, data from Asian countries including South Korea are sparse. The aim of this study was to investigate the associations between episodic heavy past-year drinking, problem drinking symptomatic of alcohol dependence and alcohol-related and intentional injuries. Data from 1989 injured patients recruited for the WHO/NIAAA Collaborative Study on Alcohol and Injury in South Korea were analyzed with respect to the prevalence rates and associations between injuries and frequency of past-year episodic heavy drinking and problem drinking. In estimating the odds ratios (ORs) and the associated 95% confidence intervals between alcohol intake and injuries multivariable logistic models were employed to adjust for sociodemographic characteristics and selected drinking variables. All analyses were conducted using the SAS 9.2 software. Findings of this study were consistent with prior studies that the risk of alcohol-related or intentional injury was positively associated with the frequency of episodic heavy drinking. The magnitudes of the associations were larger with frequent consumption of 5+ drinks (OR = 4.0 approximately) than with frequent consumption of 12+ drinks (OR = 3.1). Strong associations were also noted between RAPS4-assessed alcohol dependence and alcohol-related and intentional injuries. Further, the prevalence of intentional injury and its association with alcohol increased sharply once the acute alcohol intake exceeded 90 ml. Our results were consistent with prior studies that episodic heavy consumption, acute intoxication and problem drinking are pervasive among emergency room patients. Results of our study also lent support for administering a single-item screener querying consumption of 5+ drinks at a sitting in the past 12 months as a triage tool in Korea.     

The burden of disease and injury in Australia.

An overview of the results of the Australian Burden of Disease (ABD) study is presented. The ABD study was the first to use methodology developed for the Global Burden of Disease study to measure the burden of disease and injury in a developed country. In 1996, mental disorders were the main causes of disability burden, responsible for nearly 30% of total years of life lost to disability (YLD), with depression accounting for 8% of the total YLD. Ischaemic heart disease and stroke were the main contributors to the disease burden disability-adjusted life years (DALYs), together causing nearly 18% of the total disease burden. Risk factors such as smoking, alcohol consumption, physical inactivity, hypertension, high blood cholesterol, obesity and inadequate fruit and vegetable consumption were responsible for much of the overall disease burden in Australia. The lessons learnt from the ABD study are discussed, together with methodological issues that require further attention.     

Comparing alcohol consumption in central and eastern Europe to other European countries

AIMS: To give an overview of the volume of alcohol consumption, beverage preference, and patterns of drinking among adults (people 15 years and older) in central and eastern Europe (Bulgaria, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, Slovakia, and Slovenia) and to compare it to southern and western Europe, Russia and Ukraine. METHODS: Secondary data analysis. Consumption and preferred beverage type data for the year 2002 were taken from the WHO Global Status Report on Alcohol and the WHO Global Alcohol Database. RESULTS: Average consumption in central and eastern Europe is high with a relatively large proportion of unrecorded consumption ranging from one litre in Czech Republic and Estonia to 10.5 l in Ukraine. The proportion of heavy alcohol consumption (more than 40 g of pure alcohol per day) among men was the lowest in Bulgaria (25.8%) and the highest in Czech Republic (59.4%). Among women, the lowest proportion of heavy alcohol consumption was registered in Estonia (4.0%) and the highest in Hungary (16.0%). Patterns of drinking are detrimental with a high proportion of binge drinking, especially in the group of countries traditionally drinking vodka. In most countries, beer is now the most prevalent alcoholic beverage. CONCLUSIONS: Other studies suggest that the population drinking levels found in central and eastern Europe are linked with higher levels of detrimental health outcomes. Known effective and cost-effective programs to reduce levels of risky drinking should, therefore, be implemented, which may, in turn, lead to a reduction of alcohol-attributable burden of disease.     

Integrating paid work and chronic illness in daily life: A space-time approach to understanding the challenges

The upward trend of chronic illness in working age populations calls for better understanding of the difficulties chronically ill people face with workforce participation. Existing research focuses primarily on physical limitations and employer attitudes about chronic illness. Here we use a space-time approach to illuminate the importance of negotiating logistical challenges and embodied rhythms when balancing work and chronic illness. We draw from time geography and rhythmanalysis in analysing interviews from a qualitative case study of 26 individuals living with chronic kidney disease in Australia. Difficulties with paid work arise from: (1) competition for space-time resources by employers and health services; (2) arrhythmias between the body, work and health services; and (3) the absence of workplace rhythms on which to ‘hook’ health activities. Implications for workplaces and health services design are discussed.