Skip to main content
Top
Published in: BMC Public Health 1/2024

Open Access 01-12-2024 | Research

Social participation, subjective well-being, and cognitive function as serial mediators between tooth loss and functional limitations in older Chinese adults.

Authors: Weibo Ma, Pengchen Liang, Bei Wu, Ying Yu, Qiusi Shi, Renyao Zhong

Published in: BMC Public Health | Issue 1/2024

Login to get access

Abstract

Background

Although tooth loss appears to be related to functional limitations, the mechanisms that underpin this relationship are unknown. We sought to address this knowledge gap by examining a multiple mediation hypothesis whereby tooth loss is predicted to indirectly affect functional limitations through social participation, subjective well-being, and cognitive function.

Methods

This study included 7,629 Chinese adults from the 2017/2018 Chinese Longitudinal Healthy Longevity Survey wave. The serial mediation effects were examined using Model 6 in the Hayes’ PROCESS macro for SPSS.

Results

Tooth loss was significantly related to functional limitations. There was a direct (β = − 0.0308; 95% CI, − 0.0131 to − 0.0036) and indirect (β = − 0.0068; 95% CI, − 0.0096 to − 0.0041) association between tooth loss and instrumental activities of daily living (IADL) limitations, but only an indirect correlation with activities of daily living (ADL) limitations (β = − 0.0188; 95% CI, − 0.0259 to − 0.0121). Social participation, subjective well-being, and cognitive function serially mediated the relationship between tooth loss and ADL/IADL limitations.

Conclusion

The association between tooth loss and functional limitations is serially mediated by social participation, subjective well-being, and cognitive function. Our findings underscore the necessity of considering psychological and social factors as integrated healthcare approaches for the functional health of older adults.
Appendix
Available only for authorised users
Literature
1.
go back to reference Yip W, Hsiao WC. The Chinese health system at a crossroads. HEALTH AFFAIR. 2008;27(2):460–8.CrossRef Yip W, Hsiao WC. The Chinese health system at a crossroads. HEALTH AFFAIR. 2008;27(2):460–8.CrossRef
2.
go back to reference Chen X, Giles J, Yao Y, Yip W, Meng Q, Berkman L, Chen H, Chen X, Feng J, Feng Z, Glinskaya E, Gong J, Hu P, Kan H, Lei X, Liu X, Steptoe A, Wang G, Wang H, Wang H, Wang X, Wang Y, Yang L, Zhang L, Zhang Q, Wu J, Wu Z, Strauss J, Smith J, Zhao Y. The path to healthy ageing in China: a Peking University-Lancet Commission. LANCET. 2022, 400(10367): 1967–2006. Chen X, Giles J, Yao Y, Yip W, Meng Q, Berkman L, Chen H, Chen X, Feng J, Feng Z, Glinskaya E, Gong J, Hu P, Kan H, Lei X, Liu X, Steptoe A, Wang G, Wang H, Wang H, Wang X, Wang Y, Yang L, Zhang L, Zhang Q, Wu J, Wu Z, Strauss J, Smith J, Zhao Y. The path to healthy ageing in China: a Peking University-Lancet Commission. LANCET. 2022, 400(10367): 1967–2006.
3.
go back to reference Ansah JP, Chiu CT, Wei-Yan AC, Min T, Matchar DB. Trends in functional disability and cognitive impairment among the older adult in China up to 2060: estimates from a dynamic multi-state population model. BMC GERIATR. 2021;21(1):380.CrossRefPubMedPubMedCentral Ansah JP, Chiu CT, Wei-Yan AC, Min T, Matchar DB. Trends in functional disability and cognitive impairment among the older adult in China up to 2060: estimates from a dynamic multi-state population model. BMC GERIATR. 2021;21(1):380.CrossRefPubMedPubMedCentral
4.
go back to reference Kotronia E, Wannamethee SG, Papacosta AO, Whincup PH, Lennon LT, Visser M, Weyant RJ, Harris TB, Ramsay SE. Oral health, disability and physical function: results from studies of older people in the United Kingdom and United States of America. J AM MED DIR ASSOC. 2019;20(12):1651–4.CrossRef Kotronia E, Wannamethee SG, Papacosta AO, Whincup PH, Lennon LT, Visser M, Weyant RJ, Harris TB, Ramsay SE. Oral health, disability and physical function: results from studies of older people in the United Kingdom and United States of America. J AM MED DIR ASSOC. 2019;20(12):1651–4.CrossRef
5.
go back to reference Kotronia E, Brown H, Papacosta O, Lennon LT, Weyant RJ, Whincup PH, Wannamethee SG, Ramsay SE. Oral health problems and risk of incident disability in two studies of older adults in the United Kingdom and the United States. J AM GERIATR SOC. 2022;70(7):2080–92.CrossRefPubMedPubMedCentral Kotronia E, Brown H, Papacosta O, Lennon LT, Weyant RJ, Whincup PH, Wannamethee SG, Ramsay SE. Oral health problems and risk of incident disability in two studies of older adults in the United Kingdom and the United States. J AM GERIATR SOC. 2022;70(7):2080–92.CrossRefPubMedPubMedCentral
6.
go back to reference Huang G, Cao G. Tooth Loss Trajectories and their association with functional disability among older Chinese adults: results from the Chinese longitudinal healthy longevity survey. J EVID-BASED DENT PR. 2022;22(4):101771.CrossRef Huang G, Cao G. Tooth Loss Trajectories and their association with functional disability among older Chinese adults: results from the Chinese longitudinal healthy longevity survey. J EVID-BASED DENT PR. 2022;22(4):101771.CrossRef
7.
go back to reference Wannamethee SG, Whincup PH, Lennon L, Papacosta O, Lowe GD. Associations between fibrin D-dimer, markers of inflammation, incident self-reported mobility limitation, and all-cause mortality in older men. J AM GERIATR SOC. 2014;62(12):2357–62.CrossRefPubMedPubMedCentral Wannamethee SG, Whincup PH, Lennon L, Papacosta O, Lowe GD. Associations between fibrin D-dimer, markers of inflammation, incident self-reported mobility limitation, and all-cause mortality in older men. J AM GERIATR SOC. 2014;62(12):2357–62.CrossRefPubMedPubMedCentral
8.
go back to reference Alphantoniadou M, Varzakas T. Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly. CRIT REV FOOD SCI. 2021;61(19):3233–55.CrossRef Alphantoniadou M, Varzakas T. Breaking the vicious circle of diet, malnutrition and oral health for the independent elderly. CRIT REV FOOD SCI. 2021;61(19):3233–55.CrossRef
9.
go back to reference Cooray U, Tsakos G, Heilmann A, Watt RG, Takeuchi K, Kondo K, Osaka K, Aida J. Impact of Teeth on Social Participation: Modified Treatment Policy Approach. J DENT RES. 2023;102(8):887–94.CrossRefPubMed Cooray U, Tsakos G, Heilmann A, Watt RG, Takeuchi K, Kondo K, Osaka K, Aida J. Impact of Teeth on Social Participation: Modified Treatment Policy Approach. J DENT RES. 2023;102(8):887–94.CrossRefPubMed
10.
go back to reference Bernabe E, de Oliveira C, de Oliveira DY, Bof DAF, Sabbah W. Social participation and tooth loss, vision, and hearing impairments among older Brazilian adults. J AM GERIATR SOC; 2023. Bernabe E, de Oliveira C, de Oliveira DY, Bof DAF, Sabbah W. Social participation and tooth loss, vision, and hearing impairments among older Brazilian adults. J AM GERIATR SOC; 2023.
11.
go back to reference Igarashi A, Aida J, Yamamoto T, Hiratsuka Y, Kondo K, Osaka K. Associations between vision, hearing and tooth loss and social interactions: the JAGES cross-sectional study. J EPIDEMIOL COMMUN H. 2021;75(2):171–6. Igarashi A, Aida J, Yamamoto T, Hiratsuka Y, Kondo K, Osaka K. Associations between vision, hearing and tooth loss and social interactions: the JAGES cross-sectional study. J EPIDEMIOL COMMUN H. 2021;75(2):171–6.
12.
go back to reference He X, Shek D, Du W, Pan Y, Ma Y. The relationship between Social Participation and Subjective Well-being among older people in the Chinese Culture Context: the mediating effect of reciprocity beliefs. INT J ENV RES PUB HE 2022, 19(23). He X, Shek D, Du W, Pan Y, Ma Y. The relationship between Social Participation and Subjective Well-being among older people in the Chinese Culture Context: the mediating effect of reciprocity beliefs. INT J ENV RES PUB HE 2022, 19(23).
13.
go back to reference Dury S, Stas L, Switsers L, Duppen D, Domenech-Abella J, Dierckx E, Donder L. Gender-related differences in the relationship between social and activity participation and health and subjective well-being in later life. SOC SCI MED. 2021;270:113668.CrossRefPubMed Dury S, Stas L, Switsers L, Duppen D, Domenech-Abella J, Dierckx E, Donder L. Gender-related differences in the relationship between social and activity participation and health and subjective well-being in later life. SOC SCI MED. 2021;270:113668.CrossRefPubMed
14.
go back to reference Abbas H, Aida J, Kondo K, Osaka K. Association among the number of teeth, dental prosthesis use, and subjective happiness: a cross-sectional study from the Japan gerontological evaluation study (JAGES). J PROSTHET DENT; 2022. Abbas H, Aida J, Kondo K, Osaka K. Association among the number of teeth, dental prosthesis use, and subjective happiness: a cross-sectional study from the Japan gerontological evaluation study (JAGES). J PROSTHET DENT; 2022.
15.
go back to reference Muhammad T, Srivastava S. Tooth loss and associated self-rated health and psychological and subjective wellbeing among community-dwelling older adults: a cross-sectional study in India. BMC Public Health. 2022;22(1):7.CrossRefPubMedPubMedCentral Muhammad T, Srivastava S. Tooth loss and associated self-rated health and psychological and subjective wellbeing among community-dwelling older adults: a cross-sectional study in India. BMC Public Health. 2022;22(1):7.CrossRefPubMedPubMedCentral
16.
go back to reference Qi X, Zhu Z, Plassman BL, Wu B. Dose-response Meta-analysis on tooth loss with the risk of cognitive impairment and dementia. J AM MED DIR ASSOC. 2021;22(10):2039–45.CrossRefPubMedPubMedCentral Qi X, Zhu Z, Plassman BL, Wu B. Dose-response Meta-analysis on tooth loss with the risk of cognitive impairment and dementia. J AM MED DIR ASSOC. 2021;22(10):2039–45.CrossRefPubMedPubMedCentral
17.
go back to reference Alvarenga M, Ferreira RO, Magno MB, Fagundes N, Maia LC, Lima RR. Masticatory dysfunction by extensive tooth loss as a risk factor for cognitive deficit: a systematic review and Meta-analysis. FRONT PHYSIOL. 2019;10:832.CrossRefPubMedPubMedCentral Alvarenga M, Ferreira RO, Magno MB, Fagundes N, Maia LC, Lima RR. Masticatory dysfunction by extensive tooth loss as a risk factor for cognitive deficit: a systematic review and Meta-analysis. FRONT PHYSIOL. 2019;10:832.CrossRefPubMedPubMedCentral
18.
go back to reference Galindo-Moreno P, Lopez-Chaichio L, Padial-Molina M, Avila-Ortiz G, O’Valle F, Ravida A, Catena A. The impact of tooth loss on cognitive function. CLIN ORAL INVEST. 2022;26(4):3493–500.CrossRef Galindo-Moreno P, Lopez-Chaichio L, Padial-Molina M, Avila-Ortiz G, O’Valle F, Ravida A, Catena A. The impact of tooth loss on cognitive function. CLIN ORAL INVEST. 2022;26(4):3493–500.CrossRef
19.
go back to reference Yin Z, Yang J, Huang C, Sun H, Wu Y. Eating and communication difficulties as mediators of the relationship between tooth loss and functional disability in middle-aged and older adults. J DENT. 2020;96:103331.CrossRefPubMed Yin Z, Yang J, Huang C, Sun H, Wu Y. Eating and communication difficulties as mediators of the relationship between tooth loss and functional disability in middle-aged and older adults. J DENT. 2020;96:103331.CrossRefPubMed
21.
go back to reference Lemon BW, Bengtson VL, Peterson JA. An exploration of the activity theory of aging: activity types and life satisfaction among in-movers to a retirement community. J Gerontol. 1972;27(4):511–23.CrossRefPubMed Lemon BW, Bengtson VL, Peterson JA. An exploration of the activity theory of aging: activity types and life satisfaction among in-movers to a retirement community. J Gerontol. 1972;27(4):511–23.CrossRefPubMed
22.
go back to reference Ma W, Wu B, Gao X, Zhong R. Association between frailty and cognitive function in older Chinese people: a moderated mediation of social relationships and depressive symptoms. J AFFECT DISORDERS. 2022;316:223–32.CrossRefPubMed Ma W, Wu B, Gao X, Zhong R. Association between frailty and cognitive function in older Chinese people: a moderated mediation of social relationships and depressive symptoms. J AFFECT DISORDERS. 2022;316:223–32.CrossRefPubMed
23.
go back to reference Zhu X, Luchetti M, Aschwanden D, Sesker AA, Stephan Y, Sutin AR, Terracciano A. Multidimensional Assessment of Subjective Well-Being and Risk of Dementia: findings from the UK Biobank Study. J HAPPINESS STUD. 2023;24(2):629–50.CrossRefPubMed Zhu X, Luchetti M, Aschwanden D, Sesker AA, Stephan Y, Sutin AR, Terracciano A. Multidimensional Assessment of Subjective Well-Being and Risk of Dementia: findings from the UK Biobank Study. J HAPPINESS STUD. 2023;24(2):629–50.CrossRefPubMed
24.
go back to reference Sone T, Nakaya N, Sugawara Y, Matsuyama S, Tsuji I. Effect of social participation on the association between frailty and disability. ARCH GERONTOL GERIAT. 2023;110:104989.CrossRef Sone T, Nakaya N, Sugawara Y, Matsuyama S, Tsuji I. Effect of social participation on the association between frailty and disability. ARCH GERONTOL GERIAT. 2023;110:104989.CrossRef
25.
26.
go back to reference Wang J, Zhu WH, Li YF, Zhu WW. Temporal precedence of cognitive function and functional abilities: a latent difference score model of the Chinese community-dwelling elders. INT J GERIATR PSYCH. 2019;34(12):1892–9.CrossRef Wang J, Zhu WH, Li YF, Zhu WW. Temporal precedence of cognitive function and functional abilities: a latent difference score model of the Chinese community-dwelling elders. INT J GERIATR PSYCH. 2019;34(12):1892–9.CrossRef
27.
go back to reference Amanzio M, Palermo S, Zucca M, Rosato R, Rubino E, Leotta D, Bartoli M, Rainero I. Neuropsychological correlates of instrumental activities of daily living in neurocognitive disorders: a possible role for executive dysfunction and mood changes. INT PSYCHOGERIATR. 2018;30(12):1871–81.CrossRefPubMed Amanzio M, Palermo S, Zucca M, Rosato R, Rubino E, Leotta D, Bartoli M, Rainero I. Neuropsychological correlates of instrumental activities of daily living in neurocognitive disorders: a possible role for executive dysfunction and mood changes. INT PSYCHOGERIATR. 2018;30(12):1871–81.CrossRefPubMed
28.
go back to reference Li J, Xu H, Pan W, Wu B. Association between tooth loss and cognitive decline: a 13-year longitudinal study of Chinese older adults. PLoS ONE. 2017;12(2):e171404. Li J, Xu H, Pan W, Wu B. Association between tooth loss and cognitive decline: a 13-year longitudinal study of Chinese older adults. PLoS ONE. 2017;12(2):e171404.
29.
go back to reference KATZ S, FORD AB, MOSKOWITZ RW, JACKSON BA, JAFFE MW. STUDIES OF ILLNESS IN THE AGED. THE INDEX OF ADL. A STANDARDIZED MEASURE OF BIOLOGICAL AND PSYCHOSOCIAL FUNCTION. JAMA-J AM MED ASSOC. 1963;185:914–9.CrossRef KATZ S, FORD AB, MOSKOWITZ RW, JACKSON BA, JAFFE MW. STUDIES OF ILLNESS IN THE AGED. THE INDEX OF ADL. A STANDARDIZED MEASURE OF BIOLOGICAL AND PSYCHOSOCIAL FUNCTION. JAMA-J AM MED ASSOC. 1963;185:914–9.CrossRef
30.
go back to reference Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. GERONTOLOGIST. 1969;9(3):179–86.CrossRefPubMed Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. GERONTOLOGIST. 1969;9(3):179–86.CrossRefPubMed
31.
go back to reference Diener E. Subjective well-being. The science of happiness and a proposal for a national index. AM PSYCHOL. 2000;55(1):34–43.CrossRefPubMed Diener E. Subjective well-being. The science of happiness and a proposal for a national index. AM PSYCHOL. 2000;55(1):34–43.CrossRefPubMed
32.
go back to reference Cheng G, Yan Y. Sociodemographic, health-related, and social predictors of subjective well-being among Chinese oldest-old: a national community-based cohort study. BMC GERIATR. 2021;21(1):124.CrossRefPubMedPubMedCentral Cheng G, Yan Y. Sociodemographic, health-related, and social predictors of subjective well-being among Chinese oldest-old: a national community-based cohort study. BMC GERIATR. 2021;21(1):124.CrossRefPubMedPubMedCentral
33.
go back to reference Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. SOC SCI MED. 2000;51(6):843–57.CrossRefPubMed Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. SOC SCI MED. 2000;51(6):843–57.CrossRefPubMed
34.
go back to reference Fan Z, Lv X, Tu L, Zhang M, Yu X, Wang H. Reduced social activities and networks, but not social support, are associated with cognitive decline among older Chinese adults: a prospective study. SOC SCI MED. 2021;289:114423.CrossRefPubMed Fan Z, Lv X, Tu L, Zhang M, Yu X, Wang H. Reduced social activities and networks, but not social support, are associated with cognitive decline among older Chinese adults: a prospective study. SOC SCI MED. 2021;289:114423.CrossRefPubMed
35.
go back to reference Hayes A. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: The Guilford; 2013. Hayes A. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: The Guilford; 2013.
36.
go back to reference Jiao J, Jing W, Si Y, Feng X, Tai B, Hu D, Lin H, Wang B, Wang C, Zheng S, Liu X, Rong W, Wang W, Li W, Meng H, Wang X. The prevalence and severity of periodontal disease in Mainland China: data from the Fourth National oral health survey (2015–2016). J CLIN PERIODONTOL. 2021;48(2):168–79.CrossRefPubMed Jiao J, Jing W, Si Y, Feng X, Tai B, Hu D, Lin H, Wang B, Wang C, Zheng S, Liu X, Rong W, Wang W, Li W, Meng H, Wang X. The prevalence and severity of periodontal disease in Mainland China: data from the Fourth National oral health survey (2015–2016). J CLIN PERIODONTOL. 2021;48(2):168–79.CrossRefPubMed
38.
go back to reference Chapple IL, Bouchard P, Cagetti MG, Campus G, Carra MC, Cocco F, Nibali L, Hujoel P, Laine ML, Lingstrom P, Manton DJ, Montero E, Pitts N, Range H, Schlueter N, Teughels W, Twetman S, Van Loveren C, Van der Weijden F, Vieira AR, Schulte AG. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J CLIN PERIODONTOL. 2017;44(Suppl 18):39–S51. Chapple IL, Bouchard P, Cagetti MG, Campus G, Carra MC, Cocco F, Nibali L, Hujoel P, Laine ML, Lingstrom P, Manton DJ, Montero E, Pitts N, Range H, Schlueter N, Teughels W, Twetman S, Van Loveren C, Van der Weijden F, Vieira AR, Schulte AG. Interaction of lifestyle, behaviour or systemic diseases with dental caries and periodontal diseases: consensus report of group 2 of the joint EFP/ORCA workshop on the boundaries between caries and periodontal diseases. J CLIN PERIODONTOL. 2017;44(Suppl 18):39–S51.
39.
go back to reference Yang L, Guo D, Zheng J, Guo Y, Li Z. Association between Social Participation and remaining Teeth and Urban-Rural difference among older adults in China. INT J ENV RES PUB HE 2023, 20(2). Yang L, Guo D, Zheng J, Guo Y, Li Z. Association between Social Participation and remaining Teeth and Urban-Rural difference among older adults in China. INT J ENV RES PUB HE 2023, 20(2).
40.
go back to reference Wettstein M, Spuling SM, Cengia A. Trajectories of functional health and its associations with information processing speed and subjective well-being: the role of age versus time to death. PSYCHOL AGING. 2020;35(2):190–203.CrossRefPubMed Wettstein M, Spuling SM, Cengia A. Trajectories of functional health and its associations with information processing speed and subjective well-being: the role of age versus time to death. PSYCHOL AGING. 2020;35(2):190–203.CrossRefPubMed
41.
go back to reference Werngren-Elgstrom M, Carlsson G, Iwarsson S. A 10-year follow-up study on subjective well-being and relationships to person-environment (P-E) fit and activity of daily living (ADL) dependence of older Swedish adults. ARCH GERONTOL GERIAT. 2009;49(1):e16–e22.CrossRef Werngren-Elgstrom M, Carlsson G, Iwarsson S. A 10-year follow-up study on subjective well-being and relationships to person-environment (P-E) fit and activity of daily living (ADL) dependence of older Swedish adults. ARCH GERONTOL GERIAT. 2009;49(1):e16–e22.CrossRef
42.
go back to reference Garatachea N, Molinero O, Martinez-Garcia R, Jimenez-Jimenez R, Gonzalez-Gallego J, Marquez S. Feelings of well being in elderly people: relationship to physical activity and physical function. ARCH GERONTOL GERIAT. 2009;48(3):306–12.CrossRef Garatachea N, Molinero O, Martinez-Garcia R, Jimenez-Jimenez R, Gonzalez-Gallego J, Marquez S. Feelings of well being in elderly people: relationship to physical activity and physical function. ARCH GERONTOL GERIAT. 2009;48(3):306–12.CrossRef
43.
go back to reference Tsakos G, Watt RG, Rouxel PL, de Oliveira C, Demakakos P. Tooth loss associated with physical and cognitive decline in older adults. J AM GERIATR SOC. 2015;63(1):91–9.CrossRefPubMed Tsakos G, Watt RG, Rouxel PL, de Oliveira C, Demakakos P. Tooth loss associated with physical and cognitive decline in older adults. J AM GERIATR SOC. 2015;63(1):91–9.CrossRefPubMed
44.
go back to reference Thomson WM, Barak Y. Tooth loss and dementia: a critical examination. J DENT RES. 2021;100(3):226–31.CrossRefPubMed Thomson WM, Barak Y. Tooth loss and dementia: a critical examination. J DENT RES. 2021;100(3):226–31.CrossRefPubMed
45.
go back to reference Johnson KJ, Mutchler JE. The emergence of a positive gerontology: from disengagement to social involvement. GERONTOLOGIST. 2014;54(1):93–100.CrossRefPubMed Johnson KJ, Mutchler JE. The emergence of a positive gerontology: from disengagement to social involvement. GERONTOLOGIST. 2014;54(1):93–100.CrossRefPubMed
46.
go back to reference Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ. Validation of self-reported oral health measures. J PUBLIC HEALTH DENT. 2002;62(2):122–8.CrossRefPubMed Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ. Validation of self-reported oral health measures. J PUBLIC HEALTH DENT. 2002;62(2):122–8.CrossRefPubMed
Metadata
Title
Social participation, subjective well-being, and cognitive function as serial mediators between tooth loss and functional limitations in older Chinese adults.
Authors
Weibo Ma
Pengchen Liang
Bei Wu
Ying Yu
Qiusi Shi
Renyao Zhong
Publication date
01-12-2024
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2024
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-024-18255-w

Other articles of this Issue 1/2024

BMC Public Health 1/2024 Go to the issue