Prioritizing population oral health through public policy in Australia: the Victorian experience

Dental caries, a non-communicable disease, is one of the most prevalent diseases globally and share common modifiable risk factors with obesity such as excess sugar intake. However, prioritization by governments to improve population oral health has been limited and is typically excluded from the discourse of public health policy development. Therefore, interventions that target dental caries can have other co-benefits including obesity prevention. In Victoria, Australia, local government authorities have a regulatory requirement to develop their Municipal Health and Wellbeing Plans. The aim of this paper is to identify whether prioritization for oral health by local government authorities in Victoria has changed through the subsequent renewal of the Victorian Public Health and Wellbeing Plans 2011-2015 and 2019-2023. Three desktop audits for all publicly available Municipal Health and Wellbeing Plans by local government authorities in Victoria were conducted between 2014 and 2022. Key terms related to oral health was searched within these policy documents and categorized into six indicators: (i) included oral health as a priority, (ii) linked healthy eating and oral health, (iii) supported the Achievement Program, (iv) included the Smiles 4 Miles program, (v) advocated for fluoridated drinking water, and (vi) included other strategies related to oral health. Overall, there was statistically significant reduction in five of the six indicators, with the exception for prioritization of other strategies related to oral health such as targeting excess sugar intake and smoking. A multi-sectoral approach, that includes oral health would be advantageous to address the growing burden of non-communicable diseases.

Support for and willingness to be involved in voluntary assisted dying: A multisite, cross-sectional survey study of clinicians in Victoria, Australia

CONTEXT

In the Australian state of Victoria, specialist doctors are central to the operation of Voluntary Assisted Dying (VAD). However, a broad range of clinicians may be involved in the care of patients requesting or using VAD.

OBJECTIVES

To conduct a multisite, cross-sectional survey of clinicians in seven Victorian hospitals, to describe levels of support for and willingness to be involved in VAD and consider factors associated with clinician support for the VAD legislation and physicians' willingness to provide VAD in practice.

METHODS

All clinicians were invited to complete an online survey measuring demographic characteristics, awareness of and support for the VAD legislation, willingness to participate in VAD related activities, and reasons for willingness or unwillingness to participate in VAD.

RESULTS

Of 5690 who opened the survey, 5159 (90.1%) were included in the final sample and 73% (n=3768) supported the VAD legislation. The strongest predictor of support for the VAD legislation was clinical role. Forty percent (n=238) of medical specialists indicated they would be willing to participate in either the VAD consulting or coordinating role. Doctors did not differ in willingness between high impact (44%) and low impact specialty (41%), however, doctors specializing in palliative care or geriatric medicine were significantly less willing to participate (27%).

CONCLUSION

Approximately 73% of surveyed staff supported Victoria's VAD legislation. However, only a minority of medical specialists reported willingness to participate in VAD, suggesting potential access issues for patients requesting VAD in accordance with the legal requirements in Victoria. This article is protected by copyright. All rights reserved.

Prolonged Viral Shedding in Patients with Mild to Moderate COVID-19 Disease: A Regional Perspective

BACKGROUND

The risk of transmission of Coronavirus Disease 2019 (COVID-19) is increasingly understood to be greatest early after symptom onset, however, factors associated with prolonged and increased risk of transmission remain unclear. In settings where COVID-19 prevalence is low, there may be a benefit of extending the period that patients are isolated to decrease the risk of transmission. This study explored the duration of viral shedding in such a location, in patients with mild-moderate COVID-19 disease in Ballarat, Australia.

METHODS

Patients diagnosed with COVID-19 disease using a real-time reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assay from oropharyngeal and bilateral deep nasopharyngeal sampling and managed through Ballarat Health Services between March 1 and May 1, 2020 were included. Patients were retested if they were afebrile for >72 hours, asymptomatic and >14 days since symptom onset. If positive on retesting, patients were tested every 3 to 7 days thereafter.

RESULTS

Patients underwent testing a median of 4 days (range 1-12) after initial symptom onset. Duration of symptoms ranged from 1 to 36 days. Positive tests were recorded up to a median of day 21 (range 6-38). Cycle thresholds were inversely correlated with time since symptom onset (P < .0001). Median time to the first negative test was 25 days (range 12-32). Two patients who had remained asymptomatic for >7 days after initial symptom onset had recrudescence of mild symptoms on day 13 and 14; both tested positive on follow-up tests at this time.

CONCLUSIONS

This study demonstrates prolonged shedding of COVID-19 in patients with mild-moderate disease. It suggests that some patients with mild disease may have recrudescence of symptoms a week or more after their initial symptoms resolved.

Cultural safety in hospitals: validating an empirical measurement tool to capture the Aboriginal patient experience

Objective The aim of the present study was to develop a scale to measure cultural safety in hospitals from an Aboriginal patient perspective. Methods The Cultural Safety Survey was designed to measure five key characteristics of cultural safety that contribute to positive hospital experiences among Aboriginal hospital patients. Investigators developed a range of different methods to assess the validity and reliability of the scale using a sample of 316 participants who had attended a New South Wales hospital in the past 12 months. Targeted recruitment was conducted at two hospital sites. Opportunistic recruitment took place through a local health district, discharge follow-up service and online via social media. Results The Cultural Safety Survey Scale was a robust measurement tool that demonstrated a high level of content and construct validity. Conclusion The Cultural Safety Survey Scale could be a useful tool for measuring cultural safety in hospitals from the Aboriginal patient perspective. What is known about the topic? There are increasing calls by governments around the world for health institutions to enhance the cultural safety of their services as one way of removing access barriers and increasing health equity. However, currently there are no critical indicators or systematic methods of measuring cultural safety from the patient perspective. What does this paper add? The cultural safety scale, an Australian first, presents the first empirically validated tool that measures cultural safety from the Aboriginal patient perspective. What are the implications for practitioners? This measurement model will allow hospitals to measure the cultural safety of their services and ascertain whether current efforts aimed to improve cultural safety are resulting in Aboriginal patients reporting more culturally safe experiences. Over time it is hoped that the tool will be used to benchmark performance and eventually be adopted as a performance measure for hospitals across New South Wales.

Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology diagnoses

QUALITY PROBLEM OR ISSUE

In 2005 we were informed about the possibility of a systemic error in pathology diagnoses of ~7400 histological tests done between 4 and 6 years earlier.

INITIAL ASSESSMENT

We determined to undertake a lookback and apply principles of open disclosure to inform the affected community of ~200,000 people.

CHOICE OF SOLUTION

The lookback included subjecting all cases to independent pathology review. The public announcement of the review included an unreserved apology and took place before the results of the re-examination of the pathology specimens were known.

IMPLEMENTATION

The lookback involved the simultaneous implementation of five critical elements: leadership and governance, risk assessment and planning, implementation of the independent review, procedures for patient care and communication and open disclosure. Protocols were developed to care for those patients whose original test results were found to be incorrect.

EVALUATION

The original result for >200 patients was incorrect, and 38 had experienced clinical consequences. There was no public panic as a result of the wide open disclosure. Few related legal claims or complaints were made. The impact of the pathology diagnostic error has continued to 2011 for some patients.

LESSONS LEARNED

Openly disclosing a risk of widespread error meant the community could be supported with information and medical management as needed. Credentialing and peer-review processes for senior staff must be precise and collegiate. Sometimes action has to take place even when the risk is ill defined. There are five critical elements in planning and implementing a large-scale lookback.

Advance Australia Fair: Social democratic and conservative politicians’ discourses concerning Aboriginal and Torres Strait Islander Peoples and their health 1972–2001

This paper reports research undertaken as part of a larger project in which we examined whether and how values and beliefs communicated by Australian politicians have shaped decades of health policy and influenced health outcomes for Aboriginal and Torres Strait Islander Peoples of Australia. To first characterise those values and beliefs we analysed the public statements of the politicians responsible nationally for the health of Aboriginal and Torres Strait Islander Peoples 1972-2001, using critical discourse analysis. We found that four discourses, communicated through words, phrases, sentences and grammatical structures, dominated public statements over the study period. These four discourses focused on the competence and capacity of Aboriginal and Torres Strait Islander Peoples to "manage"; matters of control of and responsibility for the health of Aboriginal and Torres Strait Islander Peoples; Aboriginal and Torres Strait Islander Peoples as "Other"; and the nature of the "problem" concerning the health of Aboriginal and Torres Strait Islander Peoples. Analysis of the discursive elements contributing to shaping these four discourses is reported in this paper.

A case study on determining and responding to health managers' priorities for research to assist health service decision making

The Newcastle Institute of Public Health (NIPH) is a collaboration of health service and public health research groups in the Hunter Region of New South Wales, Australia which aims to promote the use of evidence in decision making. However, use of research evidence in decision making is a complex process, with many barriers and enablers described in the literature. Informed by strategies described in the literature around developing priority-driven research, NIPH researchers undertook to determine whether asking local health decision-makers about their needs for research information might lead to greater use of the resulting research evidence to inform health service management decisions. This paper describes a process used by NIPH to determine the research needs of 11 local senior health managers, our response to specific research questions, the communication of this research information, and the outcome.

Using socioeconomic evidence in clinical practice guidelines

The effects of socioeconomic position on health have been largely ignored in clinical guidelines. Australia's National Health and Medical Research Council has produced a framework to ensure that they are taken into account

Agenda-setting in health reform:the role of community

This paper presents a number of issues surrounding the setting of agendas for health care reform. We argue the needfor increased community involvement, as well as the necessity to wrest health-care decision-making from health careprofessionals, or at least to ensure that such decision-making is informed by community values.We attempt to answer a few questions: who sets the health reform agenda and who should set it, how is the agendaset and why is this critical, when and where is the agenda set, and how should the agenda be set in the future?

Mechanism of capsid assembly for an icosahedral plant virus

Capsids of spherical viruses share a common architecture: an icosahedral arrangement of identical proteins. We suggest that there may be a limited number of common assembly mechanisms for such viruses. Previous assembly mechanisms were proposed on the basis of virion structure but were not rigorously tested. Here we apply a rigorous analysis of assembly to cowpea chlorotic mottle virus (CCMV), a typical, small, positive-strand RNA virus. The atomic resolution structure of CCMV revealed an interleaving of subunits around the quasi-sixfold vertices, which suggested that capsid assembly was initiated by a hexamer of dimers (Speir et al., 1995, Structure 3, 63-78). However, we find that the capsid protein readily forms pentamers of dimers in solution, based on polymerization kinetics observed by light scattering. Capsid assembly is nucleated by a pentamer, determined from analysis of the extent of assembly by size-exclusion chromatography. Subsequent assembly likely proceeds by the cooperative addition of dimers, leading to the T = 3 icosahedral capsid. At high protein concentrations, the concentration-dependent nucleation reaction causes an overabundance of five-dimer nuclei that can be identified by classical light scattering. In turn these associate to form incomplete capsids and pseudo-T = 2 capsids, assembled by oligomerization of 12 pentamers of dimers. The experimentally derived assembly mechanisms of T = 3 and pseudo-T = 2 CCMV capsids are directly relevant to interpreting the structure and assembly of other T = 3 viruses such as Norwalk virus and pseudo-T = 2 viruses such as the vp3 core of blue tongue virus.

Opportunistic blood lead testing in a paediatric inpatient population

We report a simple protocol which has potential to estimate community paediatric blood lead levels using opportunistic testing. Permission to use leftover blood for a lead assay was sought from parents or guardians of 397 children one month to 13 years of age who were admitted to general paediatric wards of John Hunter Hospital, Newcastle, between May and August 1993 and who had blood for a full blood count taken for any reason. Results were reviewed by a medical officer and returned to parents. Where a child's blood lead level was of concern according to National Health and Medical Research Council guidelines, the child was referred to a specialist paediatrician for clinical assessment. Written consent was received from the parents or guardians of 95.5 per cent of eligible children (n = 379); 93.4 per cent of responders (354 of 379) had blood suitable for testing, giving an overall result rate of 89.2 per cent (354 of 397). The mean blood lead level for the whole group was 5.3 micrograms/dL. The highest blood lead level for any age group was 6.4 micrograms/dL in the 36 to < 60 month age group. Stratification by geographical area showed a trend in increasing blood lead with increasing population density and areas where lead polluting industries exist. The approximate cost per result achieved was $40. This opportunistic survey method provides a promising technique for obtaining data on community blood lead levels. It may be a practical and resource-efficient alternative to large-scale community surveys. Further studies are under way to validate the method as a community surveillance tool.

All-terrain vehicle injuries in central Wisconsin: a continuing problem

All-terrain vehicles (ATVs) have become well recognized as associated with injuries. This recognition has resulted in attempts at education and regulation to reduce the number and severity of injuries and number of deaths. The Marshfield Clinic and St. Joseph's Hospital surveyed all-terrain vehicle accidents in the Emergency Department in 1985 and again in 1988 and followed these patients for at least 1 year after the injury. Between the two dates, extensive educational and legislative activity had taken place. The actual number of all-terrain vehicle accidents had increased. The characteristics of victims who were involved in all-terrain vehicle accidents did not change. The actual number of accidents associated with three-wheeled ATVs did not appreciably decrease but the number of accidents associated with four-wheeled ATVs did increase. To date, it is not clear that legislative and educational activities are effective in reducing the number of ATV accidents or in changing the pattern of the accidents.

The awareness of the risk of elevated cholesterol levels and knowledge about cholesterol-lowering action in Australia

We report on a survey of the frequency of the assessment of cholesterol levels and blood pressure in the Australian population. Attitudes to risk-factor modification for cardiovascular disease also were evaluated and emphasis was placed on the assessment of knowledge about dietary modification in relation to cardiovascular disease. Respondents in this survey more frequently reported that they had undergone a blood pressure assessment than that they had had their blood cholesterol levels measured (96% and 46% of respondents, respectively). The proportion (5%) of respondents who recalled a cholesterol assessment with elevated cholesterol levels was found to be substantially lower than was that for participants in the 1983 National Heart Foundation Risk Factor Prevalence Study (19% of men and 21% of women had cholesterol levels of more than 6.5 mmol/L). Very few (9%) respondents in this survey nominated that they would reduce their dietary fat intake in order to modify their risk of developing cardiovascular disease. However, a greater number of respondents answered appropriately when asked about their potential modification of specific food items. More than 80% of respondents reported that they would reduce their intake of fried foods, although fewer would minimize their intakes of dairy products and meat. Women and respondents with a higher level of education were found to be more likely to respond appropriately. In addition, of those respondents who recalled ever having had their blood cholesterol level measured, those who reported that they had an elevated cholesterol level were more likely to indicate appropriate dietary modifications compared with those who reported normal cholesterol levels. Cholesterol reduction continues to be an important public-health issue in Australia. The results of this survey indicate that there is a need for both increased identification of individuals with elevated cholesterol levels in the population and further educational programmes about the relationship among cholesterol, diet and cardiovascular disease.