Public health at the crossroads: which way forward?

Charity Misconduct on Public Health Issues Impairs Willingness to Offer Help

Charity organizations positively impact our societies but charity misconduct impairs people’s willingness to contribute to charity and functional health systems on public health issues. This study investigates the impact of charity misconduct on people’s willingness to offer help on public health issues and possible ways of reducing the negative impact brought by charity misconduct news through four studies (N_total = 1269). Results showed that charity misconduct on public health issues significantly reduced individuals’ willingness to offer help via both the charity involved with the misconduct and any charity they prefer (Study 1 and 2). Furthermore, news on charity misconduct reduced people’s general willingness to help in contexts that did not involve charity (Study 3). Finally, presenting charity nonmisconduct news after charity misconduct news increases individuals’ willingness to offer help via the nonmisconduct charity (Study 4), suggesting a potential way to nudge people to provide help in the fight against the negative impact brought by charity misconduct news. The findings show the backfire of reporting charity misconduct news and have important implications for potential ways to facilitate people to offer help.

Big Data for Sound Policies: Toward Evidence-Informed Hearing Health Policies

PURPOSE

The scarcity of health care resources calls for their rational allocation, including within hearing health care. Policies define the course of action to reach specific goals such as optimal hearing health. The process of policy making can be divided into 4 steps: (a) problem identification and issue recognition, (b) policy formulation, (c) policy implementation, and (d) policy evaluation. Data and evidence, especially Big Data, can inform each of the steps of this process. Big Data can inform the macrolevel (policies that determine the general goals and actions), mesolevel (specific services and guidelines in organizations), and microlevel (clinical care) of hearing health care services. The research project EVOTION applies Big Data collection and analysis to form an evidence base for future hearing health care policies.

METHOD

The EVOTION research project collects heterogeneous data both from retrospective and prospective cohorts (clinical validation) of people with hearing impairment. Retrospective data from clinical repositories in the United Kingdom and Denmark will be combined. As part of a clinical validation, over 1,000 people with hearing impairment will receive smart EVOTION hearing aids and a mobile phone application from clinics located in the United Kingdom and Greece. These clients will also complete a battery of assessments, and a subsample will also receive a smartwatch including biosensors. Big Data analytics will identify associations between client characteristics, context, and hearing aid outcomes.

RESULTS

The evidence EVOTION will generate is relevant especially for the first 2 steps of the policy-making process, namely, problem identification and issue recognition, as well as policy formulation. EVOTION will inform microlevel, mesolevel, and macrolevel of hearing health care services through evidence-informed policies, clinical guidelines, and clinical care.

CONCLUSION

In the future, Big Data can inform all steps of the hearing health policy-making process and all levels of hearing health care services.

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

Health is created largely outside the health sector. Engagement in health governance, policy, and intervention development and implementation by sectors other than health is therefore important. Recent calls for building and implementing Health in All Policies, and continued arguments for intersectoral action, may strengthen the potential that other sectors have for health. This review clarifies the conceptual foundations for integral health governance, policy, and action, delineates the different sectors and their possible engagement, and provides an overview of a continuum of methods of engagement with other sectors to secure integration. This continuum ranges from institutional (re)design to value-based narratives. Depending on the lens applied, different elements can be identified within the continuum. This review is built on insights from political science, leadership studies, public health, empirical Health in All Policy research, knowledge and evidence nexus approaches, and community perspectives. Successful integration of health governance, policy, and action depends on integration of the elements on the continuum.

Integration of the Ecological Approach in Tobacco Programs for Youth: A Survey of Canadian Public Health Organizations

This study assessed the level of integration of the ecological approach in Canadian public health organizations’ tobacco control programs for youth. The study used a model that identified intervention settings, targets, and strategies as key dimensions of an ecological approach to programs. An inventory of the tobacco youth programs implemented by regional public health organizations identified 148 organizations conducting such programs, 129 of which agreed to participate. Program descriptions were obtained through telephone interviews. The mean number of settings in which programs were implemented was 3 (SD = 1.3), with schools and communities being the most often-used settings. The mean number of different intervention strategies was 3.6 (SD = 1.7). Most frequently, programs directly targeted youths themselves, followed by interpersonal and organizational environment. Overall, the level of integration of the ecological approach was deemed high. Canadian public health organizations’ tobacco control programs aimed at youth are evolving toward a more comprehensive agenda.

Towards public health ethics

Health is a value, both objective and subjective, yet it is not the only value that contributes to the well-being of persons. In public health, there are different connotations of the term “public” relevant from an ethical perspective: population, government action, and collective action of the community. Ethics seeks to provide a basis for and justify moral decisions and actions. Ethics asks, why should I do it?, and the reply consists of an argument. The type of ethics that underpins applied ethics in general, and bioethics in particular, is civic ethics, a philosophical reflection on the criteria that enable the peaceful coexistence of citizens with different morals. Progress means emancipation as well as an increase of autonomy. However, more is not always better, and now we know that no health intervention, including a public health intervention, is risk-free. The false belief that undergoing a prevention intervention is always better than doing nothing explains, at least in part, that in contrast to bioethics, only recently have the ethical implications in public health practice been given the attention they deserve. Positive externalities in third parties, such as in vaccination programmes or policies to prevent harm to passive smokers, can occasionally justify the potential risks of a public health intervention. It is in such situations where a conflict might arise between the goal of improving the health of the population and the respect for the rights and freedoms of the individual that characterizes the dilemmas in public health ethics. In conclusion, it is necessary to have a public health ethics framework and a professional code of ethics applied to public health. The training of public health professionals in ethics is essential to ensure that they feel more confident when it comes to addressing the sheer range of ethical conflicts that they frequently face in the performance of their duties.

Modern epidemiology and its discontents

The goal of this article is to present a snapshot of an ongoing debate within epidemiology, pitching opposing sides in the struggle to define the path it should follow in the years to come. The debate among epidemiologists in the mid-90s pitted those who defended the idea that epidemiology should necessarily deal with a wide context against those who believed that science and public health are better served by focusing on the individual level. Ian Hacking’s concept of styles of reasoning was used as a theoretical tool. The literature was reviewed using a core set of articles as an entry point, seeking articles that cited them, and then back-tracking the citations of the resulting set in the Scopus database. The main arguments are presented according to levels (ontological, epistemological, axiological and pragmatic), in order to show an even deeper disagreement, in the very conception of science and its relation to social issues and public policy.

Effectiveness and reach of a directed-population approach to improving dental health and reducing inequalities: a cross sectional study

Background

Childsmile School adopts a directed-population approach to target fluoride varnish applications to 20% of the primary one (P1) population in priority schools selected on the basis of the proportion of enrolled children considered to be at increased-risk of developing dental caries. The study sought to compare the effectiveness of four different methods for identifying individuals most in need when a directed-population approach is taken.

Methods

The 2008 Basic National Dental Inspection Programme (BNDIP) cross-sectional P1 Scottish epidemiological survey dataset was used to model four methods and test three definitions of increased-risk. Effectiveness was determined by the positive predictive value (PPV) and explored in relation to 1-sensitivity and 1-specificity.

Results

Complete data was available on 43470 children (87% of the survey). At the Scotland level, at least half (50%) of the children targeted were at increased-risk irrespective of the method used to target or the definition of increased-risk. There was no one method across all definitions of increased-risk that maximised PPV. Instead, PPV was highest when the targeting method complimented the definition of increased-risk. There was a higher percentage of children at increased-risk who were not targeted (1-sensitivity) when caries experience (rather than deprivation) was used to define increased-risk, irrespective of the method used for targeting. Over all three definitions of increased-risk, there was no one method that minimised (1-sensitivity) although this was lowest when the method and definition of increased-risk were complimentary. The false positive rate (1-specificity) for all methods and all definitions of increased-risk was consistently low (<20%), again being lowest when the method and definition of increased-risk were complimentary.

Conclusion

Developing a method to reach all (or even the vast majority) of individuals at increased-risk defined by either caries experience or deprivation is difficult using a directed-population approach at a group level. There is a need for a wider debate between politicians and public health experts to decide how best to reach those most at need of intervention to improve health and reduce inequalities.

Public health understandings of policy and power: lessons from INSITE

Drug addiction is a major public health problem, one that is most acutely felt in major cities around the globe. Harm reduction and safe injection sites are an attempt to address this problem and are at the cutting edge of public health policy and practice. One of the most studied safe injection sites is INSITE located in Vancouver, British Columbia. Using INSITE as a case study, this paper argues that knowledge translation offers a limited framework for understanding the development of public health policy. This paper also argues that the experience of INSITE suggests that science and social justice, the meta-ideas that lie at the core of the public health enterprise, are an inadequate basis for a theory of public health policy making. However, on a more positive note, INSITE also shows the value of concepts drawn from the ways in which political science analyzes the policy process.

Field Epidemiology and Laboratory Training Programs in sub-Saharan Africa from 2004 to 2010: need, the process, and prospects

As of 2010 sub-Saharan Africa had approximately 865 million inhabitants living with numerous public health challenges. Several public health initiatives [e.g., the United States (US) President's Emergency Plan for AIDS Relief and the US President's Malaria Initiative] have been very successful at reducing mortality from priority diseases. A competently trained public health workforce that can operate multi-disease surveillance and response systems is necessary to build upon and sustain these successes and to address other public health problems. Sub-Saharan Africa appears to have weathered the recent global economic downturn remarkably well and its increasing middle class may soon demand stronger public health systems to protect communities. The Epidemic Intelligence Service (EIS) program of the US Centers for Disease Control and Prevention (CDC) has been the backbone of public health surveillance and response in the US during its 60 years of existence. EIS has been adapted internationally to create the Field Epidemiology Training Program (FETP) in several countries. In the 1990s CDC and the Rockefeller Foundation collaborated with the Uganda and Zimbabwe ministries of health and local universities to create 2-year Public Health Schools Without Walls (PHSWOWs) which were based on the FETP model. In 2004 the FETP model was further adapted to create the Field Epidemiology and Laboratory Training Program (FELTP) in Kenya to conduct joint competency-based training for field epidemiologists and public health laboratory scientists providing a master's degree to participants upon completion. The FELTP model has been implemented in several additional countries in sub-Saharan Africa. By the end of 2010 these 10 FELTPs and two PHSWOWs covered 613 million of the 865 million people in sub-Saharan Africa and had enrolled 743 public health professionals. We describe the process that we used to develop 10 FELTPs covering 15 countries in sub-Saharan Africa from 2004 to 2010 as a strategy to develop a locally trained public health workforce that can operate multi-disease surveillance and response systems.

Global public health: a scorecard

Global health is attracting an unprecedented level of interest. In this paper, we summarise recent trends and identify the unfinished and new agendas in global public health. We propose a global public health scorecard as a simple way to assess progress and suggest actions by public health practitioners and their organisations for improving the effectiveness of public health. Although we find many recent positive developments in global health, the potential for global cooperation and progress is still largely untapped. Compared with other components of development, health improvement should easily foster global cooperation; strong advocacy and political will are keys to continuing progress. We view global public health as a barometer of more general development. Our responses to the current health challenges are at the forefront of the global struggle for survival.

From victim blaming to upstream action: tackling the social determinants of oral health inequalities

The persistent and universal nature of oral health inequalities presents a significant challenge to oral health policy makers. Inequalities in oral health mirror those in general health. The universal social gradient in both general and oral health highlights the underlying influence of psychosocial, economic, environmental and political determinants. The dominant preventive approach in dentistry, i.e. narrowly focusing on changing the behaviours of high-risk individuals, has failed to effectively reduce oral health inequalities, and may indeed have increased the oral health equity gap. A conceptual shift is needed away from this biomedical/behavioural 'downstream' approach, to one addressing the 'upstream' underlying social determinants of population oral health. Failure to change our preventive approach is a dereliction of ethical and scientific integrity. A range of complementary public health actions may be implemented at local, national and international levels to promote sustainable oral health improvements and reduce inequalities. The aim of this article is to stimulate discussion and debate on the future development of oral health improvement strategies.

The global burden of non-conflict related firearm mortality

OBJECTIVE

Understanding global firearm mortality is hindered by data availability, quality, and comparability. This study assesses the adequacy of publicly available data, examines populations for whom firearm mortality data are not publicly available, and estimates the global burden of non-conflict related firearm mortality.

DESIGN

The design is a secondary analysis of existing data. A dataset of countries, populations, economic development, and geographic regions was created, using United Nations 2000 world population data and World Bank classifications of economic development and global regions. Firearm mortality data were obtained from governmental vital statistics reported by the World Health Organization and published survey data. A qualitative review of literature informed estimates for the 15 most populous countries without firearm death data. For countries without data, estimates of firearm deaths were made using quartiles of observed rates and peer reviewed literature.

MAIN OUTCOME MEASURES

Non-conflict related firearm deaths.

RESULTS

Global non-conflict related firearm deaths were estimated to fall between 196,000 and 229,000, adjusted to the year 2000. 162,800 firearm deaths adjusted for the year 2000 came from countries reporting data and represent 35% of the world's 186 countries. Public data are not available for 122 of these 186 countries, representing more than three billion (54%) of the world's population, predominately in lower and lower middle income countries. Estimates of firearm death for those countries without data range from 33,200 to 66,200.

CONCLUSIONS

This study provides evidence that the burden of firearm related mortality poses a substantial threat to local and global health.

From Miasma to Fractals: The Epidemiology Revolution and Public Health Nursing

If public health nursing is truly a synthesis of public health science and nursing science, then nurses must keep track of current developments in public health science. Unfortunately, the public health nursing literature has not kept pace with revolutionary developments in epidemiology, one of the sciences that informs population-focused nursing practice. Most epidemiology chapters in community health nursing texts do not reflect the intellectual development that has taken place in epidemiology over the past two decades. The purpose of this article therefore is to facilitate an updated synthesis by (a) reviewing the development of epidemiology and the focus of public health nursing practice through three historical eras, (b) discussing current controversies and tensions within epidemiology, (c) introducing an emerging paradigm in epidemiology based on an ecosocial perspective, and (d) discussing the congruence of this perspective with the evolving theory and practice of public health nursing.

Making youth tobacco control programs more ecological: organizational and professional profiles

PURPOSE

To identify the organizational and professional correlates of the integration of the ecological approach in Canadian public health organizations' tobacco control programs for youth.

DESIGN

Cross-sectional survey.

SETTING

Canadian public health organizations.

SUBJECTS

One hundred and ten tobacco control programs implemented in 90 organizations. The response rate for the organizations was 87%.

MEASURES

Descriptions of programs were obtained by telephone interviews. An analytical procedure was applied to the program data to identify intervention settings, targets and strategies for each program. Using this information, a summary score of the integration of the ecological approach was estimated for each program. Organizational and professional variables were assessed by self-administered questionnaires to managers and professionals involved in these programs.

RESULTS

The level of integration of the ecological approach in programs was related to organizational (frequency of contacts and collaborations with external partners, team composition) and extraorganizational factors (size of the city in which the public health unit is located). Cognitive attributes of the practitioners (knowledge and beliefs) also emerged as significant predictors. Finally, positive associations were observed between practitioners' personal characteristics (educational achievement, working status in health promotion [full vs. part-time], previous experience, gender, and disciplinary/professional background) and cognitive predictors.

CONCLUSIONS

Organizational environment and staff preparation play a critical role in the adoption of the ecological approach in tobacco control programs.

Global health assistance: a new perspective

Health care priorities for many emerging economies have undergone a dramatic transition in the recent past because of the rise in chronic illness, increased longevity, and lessened infant mortality. Two additional major societal forces, democratization and the information revolution, will alter the nature of global health assistance. Because of democratization, governments will feel increasing pressure to provide adequate health care. Because of the information revolution, all practitioners will know what is available. The convergence of these three forces will create an enormous financial burden for emerging economies. Adapting to these new realities will be the challenge to donor organizations. What is likely to emerge as a critical health care problem around the world is the need to balance priorities between acute care and prevention or modification of chronic disease. These efforts will be directed at different populations, one manifestly ill and one potentially so, and each will need to be recognized politically as having valid claims on governmental resources. External support will need to include demonstration within the recipient communities that data collection permits an accurate identification of disease burden, that risk factor modification ameliorates the impact of disease, that continuity of care is essential to long term outcomes, and that therapy of developed disease can be rationally carried out utilizing evidence based medicine to insure efficiency and appropriateness.

Nursing ethics in an era of globalization

We live in an era of globalization in which our essential interdependence is increasingly revealed. Transportation and communication technology plus worldwide health, environmental, and security risks and a world economy driven by transnational corporations are connecting us in a new kind of way. Incredible advances in biotechnology, the pressing demands of equity and justice in resource allocation, and the need for a universal perspective in health ethics are some of the issues challenging our moral imagination in significant ways. Nurses need to ask themselves: What changes for nursing ethics when the global-not the local-becomes the dominant frame of reference?

Advancing health promotion in Australian general practice

Health promotion activities, while having the potential to prevent disease and decrease the burden of ill health, often play a minor role in the health care offered by general practitioners. There are several identified barriers to the involvement of Australian general practitioners in health promotion. These include structural barriers and barriers within the practice setting, individual practitioner and patient factors, and difficulties in evaluating the outcomes of health promotion activities. This article explores the barriers to the engagement of Australian general practice with health promotion and reviews several recent initiatives that have the potential to increase the health promotion activities of general practitioners. These initiatives act at the level of the individual practitioner, the practice, and in the community. Despite the lack of a coordinated national approach, these strategies form an important development in general practice.

Managing the ecosystem to improve human health: integrated approaches to safe drinking water

The ecosystem approach to human health is a holistic concept of health for both humans and the environment in which they live. This approach requires a holistic management of all facets of the ecosystem, be they physical, biologic, or indeed human-such as culture, economy, and developmental needs. This paradigm may at first glance seem theoretical and difficult to put into practice in everyday field research. However, using basic human needs, such as water and sanitation, as entry points illustrates how ecosystem health can indeed prove a powerful tool for sustainable development, promoting both human well-being and sustainable ecosystems. The authors describe the efforts of international agencies, particularly the International Development Research Centre (IDRC), to promote household safe drinking water security in developing countries. Essential to the success of these endeavors are strong partnerships with communities, research institutions, and donor agencies. The roles of these players are delineated. An important feature of IDRC projects, which is critical to their success, is the establishment of a simple, community-based water-quality monitoring program that the people can maintain with the limited resources available to them. The process and outcomes of past IDRC projects are presented and ongoing efforts are described.