Epidemiology and Health

Original Articles

Associations of regional-level perceived stress and depression with health-related quality of life in Korean adults: a multilevel analysis of 2017 Korea Community Health Survey data: Eunsu Kim, Min-Ho Shin, Jung-Ho Yang, Soon-Ki Ahn, Baeg-Ju Na, Hae-Sung Nam; Epidemiol Health. 2021;43:e2021062. Published online September 8, 2021; DOI: https://doi.org/10.4178/epih.e2021062

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Abstract

OBJECTIVES
We examined the associations of individual and regional-level perceived stress and depression with health-related quality of life (HRQOL) in Korean adults.

METHODS

We used data from the 2017 Korea Community Health Survey, which included 216,713 adults living within 254 municipal districts. As individual-level independent variables, perceived stress (higher vs. lower) and depression (Patient Health Questionnaire-9 ≥10) were defined. Regional-level age-adjusted rates of perceived stress (%) and depression (%) were created for 254 municipal districts and categorized into quartiles to generate regional levels of stress and depression. HRQOL was defined as the individual-level EuroQol 5-dimensional index×100. A multilevel analysis was performed to identify the relationship between individual or regional-level independent variables and individual HRQOL.

RESULTS

In the null model, the proportions of individual variation in the HRQOL explained by region were 1.7% and 2.7% for men and women, respectively. When adjusted with all individual-level variables, regional stress and depression, as well as individual-level perceived stress and depression, were significantly related to HRQOL for both genders. In the full model including all variables, the decrease in HRQOL from the first to the fourth quartile group of regional stress was greater in women (-1.09; 95% confidence interval [CI], -1.87 to -0.31) than in men (-0.65; 95% CI, -1.04 to -0.26).

CONCLUSIONS

Our results suggest that regional-level perceived stress and depression, as well as individual-level perceived stress and depression, are inversely associated with individual HRQOL.

Summary

Korean summary
시군구 단위 스트레스 인지율과 우울 유병률이 개인 단위 건강관련 삶의 질 수준과 연관성을 갖는지 파악하고자 지역사회건강조사 자료를 이용하여 다수준 분석을 수행하였다. 개인 수준에서 인지된 스트레스와 우울은 건강관련 삶의 질 감소와 관련이 있었다. 스트레스와 우울 수준이 높은 시군구일수록 개인의 건강관련 삶의 질은 낮아지는 관계를 보였는데, 이는 남성보다는 여성에서 더 저명하였다.

Key Message
This study examined the associations of regional-level perceived stress and depression with individual HRQOL measured in terms of the EQ-5D using a multilevel model. Individual-level perceived stress and depression were significantly related to individual HRQOL. Regional stress and depression were also significant factors and both had greater negative impacts on HRQOL among women than among men.

Citations

Citations to this article as recorded by

Association between seafood intake and depression in Korean adults: analysis of data from the 2014–2020 Korea National Health and Nutrition Examination Survey
Hyemin Shin, Won Jang, Yangha Kim
Journal of Nutrition and Health.2023; 56(6): 702. CrossRef
Depression before and during-COVID-19 by Gender in the Korean Population
Won-Tae Cha, Hye-Jin Joo, Yu-Shin Park, Eun-Cheol Park, Soo-Young Kim
International Journal of Environmental Research and Public Health.2022; 19(6): 3477. CrossRef
Association Between Regional Levels of Particulate Matter and Recurrent Falls in Korea
Jung-Ho Yang, Ji-An Jeong, Sun-Seog Kweon, Min-Ho Shin
Journal of Korean Medical Science.2022;[Epub] CrossRef

Effect of tobacco outlet density on quit attempts in Korea: a multi-level analysis of the 2015 Korean Community Health Survey: Jaehyung Kong, Sung-il Cho; Epidemiol Health. 2021;43:e2021048. Published online August 3, 2021; DOI: https://doi.org/10.4178/epih.e2021048

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Abstract Summary PDF

Abstract

OBJECTIVES
This study aimed to examine whether the regional density of tobacco outlets in Korea was associated with the likelihood of attempting to quit among smokers

METHODS

This study was designed as a secondary data analysis of a cross-sectional study. Data from the 2015 Korean Community Health Survey and tobacco outlet registrations in 17 metropolitan cities and provinces with 254 communities in Korea were used for the analysis. In total, 41,013 current smokers (≥19 years of age) were included. Multi-level logistic regression analysis was conducted to investigate regional differences associated with smokers’ attempts to quit and to evaluate the effects of individual and regional characteristics on quit attempts.

RESULTS

Higher tobacco outlet density was associated with lower odds of attempting to quit. Smokers who resided in districts with the highest tobacco outlet density were 18% less likely to attempt quitting (odds ratio, 0.82; 95% confidence interval, 0.70 to 0.98) than smokers who resided in the regions with the lowest tobacco outlet density (intraclass correlation coefficient, 0.030).

CONCLUSIONS

This study showed that quit attempts were related to community-level factors, such as tobacco outlet density, as well as other individual factors. These findings support the implementation of national policies restricting the number of tobacco outlets within communities or zones and limiting tobacco marketing in tobacco outlets.

Summary

Korean summary
본 연구는 2015년 지역사회건강조사에 응답한 19세 이상 현재 흡연자 41,013명을 대상으로 금연 시도와 관련된 개인 수준의 요인과 지역 수준의 요인을 파악하기 위하여 다수준 분석을 실시하였다. 분석결과, 개인 수준의 요인뿐만 아니라 거주하는 지역의 담배소매점 밀집도가 흡연자의 금연 시도와 유의한 관계가 있는 것으로 확인되었다. 흡연조장환경 개선을 위한 담배 공급 감소 노력의 일환으로 지역사회 수준의 담배소매점 관리 정책이 필요하다.

Key Message
This study aimed to investigate whether the environment related to tobacco retailers impacts adult smokers’ attempts to quit smoking, for the first time in South Korea, using nationwide data on tobacco retailers and current smokers. Smokers who resided in districts with the highest tobacco outlet density were 18% less likely to attempt quitting (odds ratio, 0.82; 95% confidence interval, 0.70-0.98) than smokers who resided in the regions with the lowest tobacco outlet density. These findings support the implementation of national policies restricting the number of tobacco outlets within communities or zones and limiting tobacco marketing in tobacco outlets.

Citations

Citations to this article as recorded by

Association between area deprivation index and concerns to COVID-19: A multi-level analysis of individual and area factors
Doo Woong Lee, Jieun Jang, Jaeyong Shin
SSM - Population Health.2024; 25: 101580. CrossRef
Use of geographically weighted regression models to inform retail endgame strategies in South Korea: application to cigarette and ENDS prevalence
Heewon Kang, Eunsil Cheon, Jaeyoung Ha, Sung-il Cho
Tobacco Control.2023; : tc-2023-058117. CrossRef

Deprived areas and community water fluoridation in Brazil: a multilevel approach for refocusing public policy: Franklin Barbosa da Silva, José Leopoldo Ferreira Antunes, Paulo Frazão; Epidemiol Health. 2021;43:e2021031. Published online May 1, 2021; DOI: https://doi.org/10.4178/epih.e2021031

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Abstract Summary PDF: Abstract
OBJECTIVES
The aim of this study was to determine whether geographic location, socioeconomic status, infant mortality, and mortality from diarrheal disease in health regions are associated with the provision of community water fluoridation (CWF) in Brazilian municipalities.
METHODS
A multilevel ecological study was conducted based on data from the National Survey of Basic Sanitation and Human Development Atlas. A multilevel analysis was carried out considering Brazilian municipalities as the first level and health regions as the second level, comprising sanitation, demographic, socioeconomic, and health characteristics.
RESULTS
The observation units comprised 5,565 municipalities clustered in 438 health regions in Brazil. The lack of CWF provision was positively associated with the following municipal characteristics: a below-median proportion of inhabitants covered by the sewage network, medium to very low human development index, below-median per capita gross domestic product, and an above-median percentage of expenditures on sanitation. In relation to the health regions, the likelihood of a lack of CWF provision was greater in the municipalities belonging to the health regions located in the Northern and Northeastern areas of Brazil and in those where child mortality due to acute diarrheal disease and the proportion of people with low income were higher when adjusted by municipal indicators.
CONCLUSIONS
Information on the characteristics associated with CWF provision constitutes important input for refocusing public policy to reduce inequalities among Brazilian municipalities and health regions. These findings may help policy-makers to understand the challenges facing CWF expansion in low-, middle-, and high-income countries.; Summary

Key Message
Just as the challenges for CWF's expansion in Brazil's most vulnerable areas require firm leadership for refocusing public policy, expansion in low- and middle-income countries demands a continued global collaborative effort.

Individual and regional factors associated with suicidal ideation among Korean elderly: a multilevel analysis of the Korea Community Health Survey: Sang Hee Jeong, Byung Chul Chun; Epidemiol Health. 2019;41:e2019022. Published online May 26, 2019; DOI: https://doi.org/10.4178/epih.e2019022

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
This study aimed to identify the individual and regional characteristics that influence suicidal ideation among the Korean elderly population.

METHODS

Using data collected from the 2013 Korea Community Health Survey, a multilevel analysis was performed to establish an understanding of individual behavioral patterns and regional influences on suicidal ideation.

RESULTS

Among the 77,407 individuals sampled, 11,236 (14.5%) elderly people over 60 years of age experienced suicidal ideation. Among individual factors, age, frequency of communication with friends, religious activity, social activity, leisure activity, trust in neighbors, subjective stress level, depressive symptoms, and subjective health status were significantly associated with suicidal ideation. The results showed that the lower the regional deprivation level, the higher the suicidal ideation odds ratio. In terms of regional size, the most significant effects were found in rural areas.

CONCLUSIONS

This study suggested that suicidal ideation in the elderly is associated with community factors, such as the regional deprivation index, as well as personal factors.

Summary

Korean summary
본 연구는 60세 이상 연령의 개인 요인에 따른 자살 생각에 영향을 미치는 요인과 지역 요인을 모두 반영하여 자살 생각에 영향을 미치는 요인을 파악하는 것으로 지역사회건강조사에 응답한 60대 이상 노인 77,407명 중 11,236(14.5%)명을 표본대상으로 선정하여 노인의 자살생각 가능성과 관련된 개인의 행태와 지역 또는 집단에서 영향력을 파악하기 위한 다수준 분석을 실시하였다. 결과적으로 본 연구는 60세이상의 노인에서 자살 생각에 개인적 요인 뿐 아니라 지역박탈지수와 같은 지역 요인이 관여한다는 점을 시사한다.

Citations

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A systematic review of psychosocial protective factors against suicide and suicidality among older adults
Myung Ki, Sylvie Lapierre, Boeun Gim, Minji Hwang, Minku Kang, Luc Dargis, Myoungjee Jung, Emily Jiali Koh, Brian Mishara
International Psychogeriatrics.2024; 36(5): 346. CrossRef
Effects of health-related quality of life and long-term care insurance infrastructure on suicidal ideation among older Korean adults
Changsook Lee, Sun-Young Heo
Asia Pacific Journal of Social Work and Development.2023; 33(2): 101. CrossRef
Influencing factors of psychological pain among older people in China: A cross-sectional study
Han Zhou, Dong Han, Haisen Zhou, Xinfeng Ke, Dongdong Jiang
Heliyon.2023; 9(10): e21141. CrossRef
Socioeconomic factors associated with suicidal behaviors in South Korea: systematic review on the current state of evidence
Nicolas Raschke, Amir Mohsenpour, Leona Aschentrup, Florian Fischer, Kamil J. Wrona
BMC Public Health.2022;[Epub] CrossRef
Evaluation of the accessibility and its equity of the national public-private mix (PPM) program for tuberculosis in South Korea: a multilevel analysis
Hyunjin Son, Changhoon Kim
Epidemiology and Health.2022; : e2023002. CrossRef
Body mass index, subjective body shape, and suicidal ideation among community-dwelling Korean adults
Chae Eun Yong, Young Bum Kim, Jiyoung Lyu
Archives of Public Health.2021;[Epub] CrossRef
Depression and quality of life in Brazilian and Portuguese older people communities
Bruno Araújo da Silva Dantas, Anna Carolyna Vieira Cavalcante, Jéssica Maria Arouca de Miranda, Gislani Acásia da Silva Toscano, Thaiza Teixeira Xavier Nobre, Felismina Rosa Parreira Mendes, Francisco Arnoldo Nunes de Miranda, Eulália Maria Chaves Maia, G
Medicine.2021; 100(46): e27830. CrossRef
Do Older Adults with Parent(s) Alive Experience Higher Psychological Pain and Suicidal Ideation? A Cross-Sectional Study in China
Ying Yang, Shizhen Wang, Borui Hu, Jinwei Hao, Runhu Hu, Yinling Zhou, Zongfu Mao
International Journal of Environmental Research and Public Health.2020; 17(17): 6399. CrossRef

Factors affecting screening for diabetic complications in the community: a multilevel analysis: Jin A Han, Soo Jeong Kim, Gawon Kim, Eun Ji Kim, Soon Young Lee; Epidemiol Health. 2016;38:e2016017. Published online May 3, 2016; DOI: https://doi.org/10.4178/epih.e2016017

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
The objective of the present study was to identify the factors that affect screening for diabetic complications by sex in the community.

METHODS

This study used individual-level data from the 2013 Community Health Survey (CHS) for 20,806 (male, 9,958; female, 10,848) adults aged 30 years or older who were diagnosed with diabetes. Community-level data for 253 communities were derived from either CHS or national statistics. A chi-square test and multilevel logistic regression analysis was performed.

RESULTS

There were significant differences in the rate of screening for diabetic complications according to individual-level and community-level variables. In the multilevel analysis, the community-level variance ratio of the null model was 7.4% and 9.2% for males and females, respectively. With regard to community-level variables, males were affected by the city type, number of physicians, and their living environment, while females were affected by number of physicians, natural and living environments, and public transportation.

CONCLUSIONS

The factors that influenced individual willingness to undergo screening for diabetic complications differed slightly by sex; however, both males and females were more likely to undergo screening when they recognized their health status as poor or when they actively sought to manage their health conditions. Moreover, in terms of community-level variables, both males and females were affected by the number of physicians. It is essential to provide sufficient and ongoing opportunities for education on diabetes and its management through collaboration with local communities and primary care medical centers.

Summary

Korean summary
본 연구는 지역사회의 당뇨병 환자들의 성별에 따른 합병증검사 수진율을 파악하고 개인의 특성과 지역사회의 특성이 합병증 검사 수진여부에 어떻게 영향을 미치는지 다수준 분석을 통해 살펴보고자 하였다. 당뇨병 치료자 중 약 1/3만이 합병증검사를 받았다. 성별에 따라 개인의 당뇨병 합병증 검사 수진행위에 영향을 미치는 요인이 다르긴 하지만 남성과 여성 모두 본인의 건강상태가 좋지 않다고 인지하거나 질병관리에 적극적인 행동을 취하는 경우, 그리고 지역변수로는 내과전문의 수에 영향을 받았다. 이는 지역사회와 1차 의료기관의 협업을 통해 당뇨병과 당뇨병 관리에 대한 충분하고 지속적인 학습기회의 제공이 중요하다고 할 수 있다.

Citations

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Factors Influencing the Utilization of Diabetes Complication Tests Under the COVID-19 Pandemic: Machine Learning Approach
Haewon Byeon
Frontiers in Endocrinology.2022;[Epub] CrossRef
Effects of Diabetes Quality Assessment on Diabetes Management Behaviors Based on a Nationwide Survey
Chang Kyun Choi, Jungho Yang, Ji-An Jeong, Min-Ho Shin
International Journal of Environmental Research and Public Health.2022; 19(23): 15781. CrossRef

Validity analysis on merged and averaged data using within and between analysis: focus on effect of qualitative social capital on self-rated health: Sang soo Shin, Young-jeon Shin; Epidemiol Health. 2016;38:e2016012. Published online April 8, 2016; DOI: https://doi.org/10.4178/epih.e2016012

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
With an increasing number of studies highlighting regional social capital (SC) as a determinant of health, many studies are using multi-level analysis with merged and averaged scores of community residents’ survey responses calculated from community SC data. Sufficient examination is required to validate if the merged and averaged data can represent the community. Therefore, this study analyzes the validity of the selected indicators and their applicability in multi-level analysis.

METHODS

Within and between analysis (WABA) was performed after creating community variables using merged and averaged data of community residents’ responses from the 2013 Community Health Survey in Korea, using subjective self-rated health assessment as a dependent variable. Further analysis was performed following the model suggested by WABA result.

RESULTS

Both E-test results (1) and WABA results (2) revealed that single-level analysis needs to be performed using qualitative SC variable with cluster mean centering. Through single-level multivariate regression analysis, qualitative SC with cluster mean centering showed positive effect on self-rated health (0.054, p<0.001), although there was no substantial difference in comparison to analysis using SC variables without cluster mean centering or multi-level analysis.

CONCLUSIONS

As modification in qualitative SC was larger within the community than between communities, we validate that relational analysis of individual self-rated health can be performed within the group, using cluster mean centering. Other tests besides the WABA can be performed in the future to confirm the validity of using community variables and their applicability in multi-level analysis.

Summary

Korean summary
이 연구는 개인의 주관적 건강감에 미치는 지역 사회 자본의 효과를 보기 위하여 개인 응답치의 합산 평균한 자료를 지역 변인으로 활용하는 것이 타당한지 WABA 를 수행하였다. 분석 결과 다수준 분석을 하는 것이 적절치 않았으며 개인 수준의 사회자본에서 지역 수준의 사회자본을 뺀 값을 단수준 분석에 활용할 것을 제안하였다.

Citations

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Social capital and physical health: An updated review of the literature for 2007–2018
Justin Rodgers, Anna V. Valuev, Yulin Hswen, S.V. Subramanian
Social Science & Medicine.2019; 236: 112360. CrossRef
Kennedy’s disease 1234 scale: Preliminary design and test
Ming Lu, Haixiao Guo, Dongsheng Fan
Journal of Clinical Neuroscience.2017; 40: 185. CrossRef

The influence of regional deprivation index on personal happiness using multilevel analysis: Kil Hun Kim, Jin-Ho Chun, Hae Sook Sohn; Epidemiol Health. 2015;37:e2015019. Published online April 16, 2015; DOI: https://doi.org/10.4178/epih/e2015019

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
The objective of the present study was to identify the factors that influence the happiness index of community residents, by considering personal and regional aspects, and to use as evidence of efforts for improvement of the happiness index.

METHODS

The study was conducted based on information from 16,270 participants who met the data requirement among those who participated in the 2011 South Gyeongsang Community Health Survey. Of the factors that can influence the happiness index, socioeconomic characteristics, health behavior, morbidity, and healthcare use, social contact, and participation in social activities were classified as personal factors; for regional factors, data from the 2010 census were used to extrapolate the regional deprivation indices at the submunicipal-level (eup, myeon, and dong) in South Gyeongsang Province. The happiness index for each characteristic was compared to that for others via t-test and ANOVA, and multilevel analysis was performed, using four models: a basic model for identification of only random effects, model 1 for identification of personal factors, model 2 for identification of regional factors, and model 3 for simultaneous consideration of both personal and regional factors.

RESULTS

The mean happiness index was 63.2 points (64.6 points in males and 62.0 points in females), while the mean deprivation index was -1.58 points. In the multilevel analysis, the regional-level variance ratio of the basic model was 10.8%, confirming interregional differences. At the personal level, higher happiness indices were seen in groups consisting of males with high educational level, high income, high degree of physical activity, sufficient sleep, active social contact, and participation in social activities; whereas lower happiness indices were seen in people who frequently skipped breakfast, had unmet healthcare needs, and had accompanying diseases, as well as those with higher deprivation index.

CONCLUSIONS

The study confirmed that the happiness index of community residents was influenced by not only personal aspects but also various regional characteristics. To increase the happiness index, interests at both personal and regional levels, as well as community emphasis on creating social rapport and engaging in selective efforts, are needed in vulnerable regions with relatively high deprivation index.

Summary

Korean summary
본 연구는 행복지수의 연구에 있어서 개인수준과 지역수준까지 고려한 연구이다. 지역수준의 영향력을 보다 정확하게 확인하기 위해 읍면동 단위까지 박탈지수를 산출하여 분석하였으며, 지역수준의 영향이 있음을 확인하였다.

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Social Connection and Lifestyle Factors Associated With Happiness in Urban Older Adults in China: A Cross-Sectional Study With a Community Sample
Jianghong Liu, Sini Li, Xuhan Yan, Junxin Li, Qiuzi Sun, Hua Mei, Hengyi Rao
Research in Gerontological Nursing.2023; 16(3): 147. CrossRef
Long-Term Trend in the Association Between Disaster Damage and Happiness Before and After the Great East Japan Earthquake
Masato Nagai, Hiroyuki Hikichi, Koichiro Shiba, Katsunori Kondo, Ichiro Kawachi, Jun Aida
International Journal of Public Health.2022;[Epub] CrossRef
Evaluation of the accessibility and its equity of the national public-private mix program for tuberculosis in Korea: a multilevel analysis
Hyunjin Son, Changhoon Kim
Epidemiology and Health.2022; 45: e2023002. CrossRef

The effects of community environmental factors on obesity among Korean adults: a multilevel analysis: Nan-He Yoon, Soonman Kwon; Epidemiol Health. 2014;36:e2014036. Published online December 24, 2014; DOI: https://doi.org/10.4178/epih/e2014036

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Abstract Summary PDF Supplementary Material

Abstract

OBJECTIVES
This study explored multidimensional factors related to obesity by dividing them into individual and environmental factors, and performed multilevel analysis to investigate community environmental effects.

METHODS

Data from the 2011 and 2012 Community Health Surveys were used for the analysis. Community-level variables, constructed from various regional statistics, were included in the model as environmental factors. Respondents with body mass index (BMI)≥25 were defined as obese, and a multilevel logistic regression analysis was conducted to analyze individual and environmental factors related to obesity. Moreover, a stratified analysis was conducted to compare factors related to obesity between men and women.

RESULTS

Of 337,136 samples, 82,887 (24.6%) were obese, with BMI≥25. Sociodemographic characteristics at the individual level were mostly significantly related to obesity; however, while there were more obese men subjects among those with high socioeconomic status, there were more obese women among those with low socioeconomic status. There were fewer obese respondents among those who regularly walked and more obese respondents among those who reported short sleep duration or were highly stressed. At the community level, people living in areas with high socioeconomic status, high satisfaction with safety and public transportation, and high accessibility to sports facilities in their community had lower obesity risks.

CONCLUSIONS

Community-level environmental factors affected obesity, especially perceived community environment, more significant than physical environment. Thus, it is necessary to develop effective obesity prevention and management strategies by considering potential community environmental factors that affect obesity.

Summary

Korean summary
다수준 분석을 통해 개인의 비만 발생에 영향을 미치는 다차원의 요인들을 탐색한 결과, 비만과 개인적 요인들의 관계는 성별에 따라 다르게 나타났고, 지역사회 환경에 대한 주관적 인식이 개인의 비만 발생과 유의한 관계가 있는 것으로 확인되었다. 보다 효과적인 비만 예방 및 관리를 위해 다양한 차원의 환경적 특성과 배경, 맥락을 반영한 전략의 개발이 필요하다.

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Obesity-Related Factors in Adult Women with Early Menarche
Hunha Cho, Jeong-Won Han
Healthcare.2023; 11(4): 557. CrossRef
Do the Self-Reported Changes in Physical Activity After the Emergence of the COVID-19 Pandemic Associate With Major Depression According to Moderate to Vigorous Physical Activity Status?
Jeong Hyun Ahn, Jin Young Nam
Journal of Physical Activity and Health.2022; : 1. CrossRef
Employment Status Transition Predicts Adult Obesity Trajectory
Young Joong Kang, Dong-wook Lee, Min Young Park, Mo-Yeol Kang
Journal of Occupational & Environmental Medicine.2021; 63(12): e861. CrossRef
Combined effects of disease management and food insecurity on physical and mental health in Korean adults
Hyun Ja Kim, Kirang Kim
Public Health Nutrition.2020; 23(1): 112. CrossRef
Generational Differences: A Comparison of Weight-Related Cognitions and Behaviors of Generation X and Millennial Mothers of Preschool Children
Ruiying Xiong, Kim Spaccarotella, Virginia Quick, Carol Byrd-Bredbenner
International Journal of Environmental Research and Public Health.2019; 16(13): 2431. CrossRef
Influence of Neighborhood Environment on Korean Adult Obesity Using a Bayesian Spatial Multilevel Model
Eun Young Lee, Sugie Lee, Bo Youl Choi, Jungsoon Choi
International Journal of Environmental Research and Public Health.2019; 16(20): 3991. CrossRef
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