The public health implications of maternal care trade-offs

The socioeconomic and ethnic characteristics of parents are some of the most important correlates of adverse health outcomes in childhood. However, the relationships between ethnic, economic, and behavioral factors and the health outcomes responsible for this pervasive finding have not been specified in child health epidemiology. The general objective of this paper is to propose a theoretical approach to the study of maternal behaviors and child health in diverse ethnic and socioeconomic environments. The specific aims are: (a) to describe a causal pathway between the utility that women obtain through work outside the home and through child care and disease hazard rates in childhood using an optimization model; (b) to specify the influence of ethnic and socioeconomic factors on model constraints; (c) to use the model as a tool to learn about how different combinations of maternal wage labor and child care time might influence child health outcomes in diverse social contexts; (d) to identify parameters that will require measurement in future research; (e) to discuss research strategies that will enable us to obtain these measurements; and (f) to discuss the implications of the model for biostatistical modeling and public health intervention. Optimization models are powerful heuristic tools for understanding how ethnic, environmental, family, and personal characteristics can place important constraints on both the quality and quantity of care that women can provide to their children. They provide a quantitative appreciation for the difficult trade-offs that most women face between working in order to purchase basic goods that children cannot do without (e.g., food, clothing, shelter, health insurance), and increasing offspring well-being through child care (e.g., training in social skills, affection, protection from environmental hazards, help with homework). The research was funded by a Faculty Scholars Award from the William T. Grant Foundation to A. Magdalena Hurtado. A. Magdalena Hurtado, Ph.D., is an associate professor in the Department of Anthropology, University of New Mexico. Her research interests include the origins of the sexual division of labor, epidemiology of indigenous peoples, disease susceptibility, the development and intergenerational transmission of antigens and immune defense, immune function and allergic sensitization, and trauma. She also works on public health interventions, biological capital and poverty, and land tenure and human rights in native communities of South America. Carol Lambourne, M.Sc., is a doctoral candidate in the Department of Anthropology, University of New Mexico. Her research interests are evolutionary models of child and adolescent development, life history theory, family composition and investment patterns, pubertal timing and psychosexual maturation, juvenile stress, and infanticide. Kim Hill, Ph.D., is a professor in the Department of Anthropology, University of New Mexico. His research interests are modern hunter-gatherers, including extensive fieldwork in lowland South America. Current topics of interest include human evolution, economic strategies, life history theory, the evolution of cooperation, and the emergence of social norms enforced by punishment. He is also involved in economic development, health and education projects with lowland South American native populations. Karen Kessler received her M.S. in Anthropology from the University of New Mexico in 1996. Her research interests are the application of mathematical modeling to the prevention of diabetes and other causes of morbidity and mortality in historical populations.     

Integration of mental health into primary care and community health working in Kenya: context, rationale, coverage and sustainability

Integration of mental health into primary care is essential to meet population needs yet faces many challenges if such projects are to achieve impact and be sustainable in low income countries alongside other competing priorities. This paper describes the rationale and progress of a collaborative project in Kenya to train primary care and community health workers about mental health and integrate mental health into their routine work, Within a health systems strengthening approach. So far 1877 health workers have been trained. The paper describes the multiple challenges faced by the project, and reviews the mechanisms deployed which have strengthened its impact and sustainability to date.     

Rural health care looks to the future. Issues in the institutionalization and management of rural health care: making technology appropriate

Experimental projects have demonstrated the technical feasibility of systems of accessible, affordable health care. These projects have relied extensively on non-professional community health workers. However, large-scale implementation of these schemes will require new management procedures that are both responsive to rural health needs and congruent with national institutions. This paper identifies the need to establish institutional mechanisms to mobilize essential inputs, promote acceptance by beneficiaries, maintain quality standards, recruit and retain field staff, and achieve accountability for resources. It then outlines methods for developing these institutions. It stresses the need for both formal, bureaucratic organizations and informal organizations of clients. It also identifies the need to consider administrative and institutional resources in determining the appropriateness of a health care technology.     

River Enhancement in the Upper Mississippi River Basin: Approaches Based on River Uses, Alterations, and Management Agencies

The Upper Mississippi River is characterized by a series of locks and dams, shallow impoundments, and thousands of river channelization structures that facilitate commercial navigation between Minneapolis, Minnesota, and Cairo, Illinois. Agriculture and urban development over the past 200 years have degraded water quality and increased the rate of sediment and nutrient delivery to surface waters. River enhancement has become an important management tool employed to address causes and effects of surface water degradation and river modification in the Upper Mississippi River Basin. We report information on individual river enhancement projects and contrast project densities, goals, activities, monitoring, and cost between commercially non‐navigated and navigated rivers (Non‐navigated and Navigated Rivers, respectively). The total number of river enhancement projects collected during this effort was 62,108. Cost of all projects reporting spending between 1972 and 2006 was about US$1.6 billion. Water quality management was the most cited project goal within the basin. Other important goals in Navigated Rivers included in‐stream habitat improvement and flow modification. Most projects collected for Non‐navigated Rivers and their watersheds originated from the U.S. Department of Agriculture (USDA). The U.S. Army Corps of Engineers and the USDA were important sources for projects in Navigated Rivers. Collaborative efforts between agencies that implement projects in Non‐navigated and Navigated Rivers may be needed to more effectively address river impairment. However, the current state of data sources tracking river enhancement projects deters efficient and broad‐scale integration.     

The 1000 Genomes Project: data management and community access

The 1000 Genomes Project was launched as one of the largest distributed data collection and analysis projects ever undertaken in biology. In addition to the primary scientific goals of creating both a deep catalog of human genetic variation and extensive methods to accurately discover and characterize variation using new sequencing technologies, the project makes all of its data publicly available. Members of the project data coordination center have developed and deployed several tools to enable widespread data access.     

Urban and rural river restoration in France: a typology

River restoration (RR) is widely practiced in both rural and urban contexts by combining various goals and measures. The theoretical discourse on RR not yet adequately reflects this breadth of restoration practice. In this study, we investigated 110 French RR projects implemented between 1980 and 2015. We analyzed projects considering eight key design features, main project motivation, restoration goals, project dates, costs, size, funding, river annual discharge, and implemented evaluation procedures. The study (1) provides a detailed account of the French RR effort, (2) compares restoration efforts in urban and rural contexts, and (3) establishes a RR project typology. The results also show that urban RR comprises a wider range of goals and measures than its rural counterpart, includes restoration of riparian habitats, and integrates ecological and social goals. A hierarchical multiple factor analysis yielded five types of projects, Fish RR (14% of the urban and 53% of the rural projects), Blue RR (4%, 7%), Water Framework Directive RR (36%, 40%), Flood protection RR (14%, 0%), and Human RR (32%, 0%). We suggest that the restoration community needs databases that use a project typology as developed in this study. This approach would take into account the multiple facets of RR projects, enabling more transparency into their communication and allow more suitable project comparisons.     

Genetics in public health: Rarely explored

The availability and the integration of genetic information into our understanding of normal and abnormal growth and development are driving important changes in health care. These changes have fostered the hope that the availability of genetic information will promote a better understanding of disease etiology and permit early, even pre-symptomatic diagnosis and preventive intervention to avoid disease onset. Hence, our aim was to review and provide the insight into the role of genetics in public health and its scope as well as barriers. The use of genetics along with their goals and essential public health functions are discussed. From the era of eugenics to the present era, this area has seen many turns in which geneticists have put through their effort to tie together the strings of both molecular genetics and public health. Though still the dark clouds of eugenics, the predictive power of genes, genetic reductionism, non-modifiable risk factors, individuals or populations, resource allocation, commercial imperative, discrimination and understanding and education are hanging above. The technological and scientific advances that have fundamentally changed our perception of human diseases fuel the expectations for this proactive health.     

An oral health care guideline for institutionalised older people

Institutionalized older people are prone to oral health problems and their negative impact due to frailty, disabilities, multi-morbidity, and multiple medication use. Until recently, no evidence-based oral health care guideline for institutionalized older people has been available. For that reason, the Dutch Association of Nursing Home Physicians developed the Oral health care Guideline for Older people in Long-term care Institutions (OGOLI), meeting the requirements of the AGREE instrument for assessing a guideline's quality. This short report presents the keynotes and the content of the Oral health care Guideline. Most recommendations are based on expert opinions. Only 4 recommendations (education, pneumonia, use of an electric toothbrush, and fluoride rinsing in case of a sudden increase of oral plaque amount) are based on evidence level A2 conclusions. This emphasizes the need for further research on oral health of institutionalized older people.     

The Central San Joaquin Valley Area Health Education Center

With federal financial support, an area health education center was established in the central San Joaquin Valley of California. The center is a cooperative health sciences education and health care program organized by the University of California and some of the educational and health care institutions of the valley. The center''s goals include providing and improving primary health care education, and improving the distribution of health personnel. These goals are achieved through the cooperative development of a number of independent and interdependent activities. An extensive evaluation of the Area Health Education Center has shown that it is a highly effective program.     

Substance-related health problems during rave parties in The Netherlands (1997-2008)

The objective of this study was to describe a 12-year (1997-2008) observation of substance-related incidents occurring at rave parties in the Netherlands, including length of visits to first-aid stations, substances used, and severity of the incidents. During rave parties, specifically trained medical and paramedical personnel staffed first aid stations. Visitors were diagnosed and treated, and their data were recorded using standardized methods. During the 12-year period with 249 rave parties involving about 3,800,000 visitors, 27,897 people visited a first aid station, of whom 10,100 reported having a substance-related problem. The mean age of these people was 22.3+/-5.4 years; 52.4% of them were male. Most (66.7%) substance-related problems were associated with ecstasy or alcohol use or both. Among 10,100 substance-related cases, 515 required professional medical care, and 16 of these cases were life threatening. People with a substance-related problem stayed 20 min at the first aid station, which was significantly longer than the 5 min that those without a substance-related health problem stayed. These unique data from the Netherlands identify a variety of acute health problems related to the use of alcohol, amphetamines, cannabis, cocaine, ecstasy, and GHB. Although most problems were minor, people using GHB more often required professional medical care those using the other substances. We recommended adherence to harm and risk reduction policy, and the use of first aid stations with specially trained staff for both minor and serious incidents.     

Tackling inequalities in health: the Australian experience.

Federal and state governments in Australia have embarked on a series of national initiatives which show a firm commitment to tackling social inequalities in health. The development of national goals and targets for health, for example, covers social and environmental conditions and sets differential targets for specific social groups with very poor health status. In a complementary initiative, a wide ranging analysis of the health care system--the National Health Strategy--has as one of its main objectives to improve the equitable impact of the health system. Where problems of access to and quality of services have been exposed, policies have been devised to deal with them. The exceptionally poor health of the Aboriginal community has elicited cross party support for action. Resources have been allocated to implement the National Aboriginal Health Strategy: to improve living and working conditions, education, and employment opportunities. Britain can glean much from the Australian experience.     

Primary health care in London--changes since the Acheson report.

OBJECTIVE--To examine changes in primary care in London in the 11 years since the Acheson report on primary health care in inner London. DESIGN--Analysis of key data from the family health services authority performance indicators and from the Department of Health; study of trends since the time of the Acheson report; examination of the provision of primary care in 1990-1 and its relation to health and social factors. SETTING--Comparisons between the family health services authorities of inner London, outer London, and England as a whole, with a special study of Birmingham, Liverpool, and Manchester. SUBJECTS--The family health services authorities of England. RESULTS--There has been an improvement in the provision of primary care in inner London as judged by the criteria of the Acheson report, but these improvements have occurred only as part of an overall improvement in the provision of primary care in the country as a whole. None of the recommendations of the Acheson report specifically oriented to London have been implemented. There are some worrying trends in inner London, such as the increasing proportion of practices with more than 2500 patients. The problems faced by practitioners in inner London resemble those in other large inner city areas, but the primary care provision to deal with them is relatively poor.     

Ethical issues in implementation research: a discussion of the problems in achieving informed consent

Background

Implementation of research into practice in health care systems is a challenging and often unsuccessful endeavor. The United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) research teams include formative evaluations (FE) in their action-oriented VA implementation projects to identify critical information about the processes of implementation that can guide adjustments to project activities, in order to better meet project goals. This article describes the development and use of FE in an action-oriented implementation research project.

Methods

This two-year action-oriented implementation research project was conducted at 23 VA Spinal Cord Injury (SCI) Centers, and targeted patients, staff and the system of care, such as administration and information technology. Data for FE were collected by electronic and paper surveys, semi-structured and open-ended interviews, notes during conference calls, and exchange of e-mail messages. Specific questions were developed for each intervention (designed to improve vaccination rates for influenza in veterans with spinal cord injury and disorder); informants were selected for their knowledge of interventions and their use in SCI Centers.

Results

Data from FE were compiled separately for each intervention to describe barriers to progress and guide adjustments to implementation activities. These data addressed the processes of implementing the interventions, problem-solving activities and the status of interventions at SCI Centers.

Conclusion

Formative evaluations provided the project team with a broad view of the processes of implementing multi-targeted interventions as well as the evolving status of the related best practice. Using FE was useful, although the challenges of conducting FE for non-field researchers should be addressed. Work is needed to develop methods for conducting FE across multiple sites, as well as acknowledging variations in local contexts that affect implementation of interventions.     

Oral health practices and beliefs among caregivers of the dependent elderly

doi: 10.1111/j.1741‐2358.2011.00553.x Oral health practices and beliefs among caregivers of the dependent elderly Background: Caregivers deal with oral health care of the dependent elderly; however, this has a low priority among them, and their education in daily oral care is deficient. Therefore, studying the oral care practices as well as their oral health beliefs is important as these affect the quality of the oral care they perform. Objective: To compare formal and informal caregivers’ oral care practices and oral health beliefs when taking care of severely dependent elderly. Material and methods: A cross‐sectional study was conducted on a convenience sample of 21 formal caregivers from a long‐term residence and 18 informal caregivers from a local primary health care domiciliary programme. Caregivers were surveyed using a questionnaire designed to elicit oral care practices and oral health beliefs. The nursing Dental Coping Beliefs Scale questionnaire was translated and validated in Chile. Results: Significant differences were observed between formal and informal caregivers’ performance of some oral health care practices. There were no significant differences between formal and informal caregivers’ oral health beliefs. Conclusions: Although there are some differences in formal and informal caregivers’ oral health care practices, we cannot state that one caregiver’s performance is better than the other, in fact, negative oral health beliefs were found in both groups.     

'Changing climate, changing health, changing stories' profile: using an EcoHealth approach to explore impacts of climate change on inuit health

Global climate change and its impact on public health exemplify the challenge of managing complexity and uncertainty in health research. The Canadian North is currently experiencing dramatic shifts in climate, resulting in environmental changes which impact Inuit livelihoods, cultural practices, and health. For researchers investigating potential climate change impacts on Inuit health, it has become clear that comprehensive and meaningful research outcomes depend on taking a systemic and transdisciplinary approach that engages local citizens in project design, data collection, and analysis. While it is increasingly recognised that using approaches that embrace complexity is a necessity in public health, mobilizing such approaches from theory into practice can be challenging. In 2009, the Rigolet Inuit Community Government in Rigolet, Nunatsiavut, Canada partnered with a transdisciplinary team of researchers, health practitioners, and community storytelling facilitators to create the Changing Climate, Changing Health, Changing Stories project, aimed at developing a multi-media participatory, community-run methodological strategy to gather locally appropriate and meaningful data to explore climate-health relationships. The goal of this profile paper is to describe how an EcoHealth approach guided by principles of transdisciplinarity, community participation, and social equity was used to plan and implement this climate-health research project. An overview of the project, including project development, research methods, project outcomes to date, and challenges encountered, is presented. Though introduced in this one case study, the processes, methods, and lessons learned are broadly applicable to researchers and communities interested in implementing EcoHealth approaches in community-based research.     

Integration of mental health into primary care in Kenya

Integration of mental health into primary care is essential in Kenya, where there are only 75 psychiatrists for 38 million population, of whom 21 are in the universities and 28 in private practice. A partnership between the Ministry of Health, the Kenya Psychiatric Association and the World Health Organization (WHO) Collaborating Centre, Institute of Psychiatry, Kings College London was funded by Nuffield Foundation to train 3,000 of the 5,000 primary health care staff in the public health system across Kenya, using a sustainable general health system approach. The content of training was closely aligned to the generic tasks of the health workers. The training delivery was integrated into the normal national training delivery system, and accompanied by capacity building courses for district and provincial level staff to encourage the inclusion of mental health in the district and provincial annual operational plans, and to promote the coordination and supervision of mental health services in primary care by district psychiatric nurses and district public health nurses. The project trained 41 trainers, who have so far trained 1671 primary care staff, achieving a mean change in knowledge score of 42% to 77%. Qualitative observations of subsequent clinical practice have demonstrated improvements in assessment, diagnosis, management, record keeping, medicine supply, intersectoral liaison and public education. Around 200 supervisors (psychiatrists, psychiatric nurses and district public health nurses) have also been trained. The project experience may be useful for other countries also wishing to conduct similar sustainable training and supervision programmes.     

Politics, Practical Logic, and Primary Health Care in Rural Haiti

During the 1980s, an ambitious project for health development restructured medical services throughout rural Haiti. The "Rural Health Delivery System" (RHDS) pursued several goals of primary health care, including dispensary-based maternal and child health services and the provision of low–cost drugs. Based on fieldwork in a single village, this article examines how local residents pushed the project in unpredictable and ironic directions. People did not regard dispensary services—which were planned and financed by international health agencies—as essentially foreign elements in the local health–care system. They rather engaged with the dispensary according to long–standing local strategies for prestige and economic advance. Despite the dramatically new shape of biomedicine introduced by the RHDS, the dispensary remained for most people a recognizable arena to gain access to state resources or to contest state control over their lives. The "success" of clinic services, and the "failure" of the project to distribute essential drugs arose more from people's practical routes to symbolic and material power than from the formal plans of health planners or state bureaucrats. This practice-based analysis provides another dimension to both the liberal and neo-Marxist critiques of international health development, [primary health care, community participation, planned development, Haiti]     

Electronic health records: the European scene.

Caring for patients'' health problems relies increasingly on sharing information between clinical departments and disciplines and with managers. The medical record of the future will need to provide a flexible and shareable framework for recording and analysing the consultation process. The advanced informatics in medicine (AIM) programme seeks to encourage research and development in telemedicine in areas that are beyond the scope of any one country. It includes many European projects attempting to define the best storage and transmission formats for such diverse data types as laboratory results, biosignals, x ray images, and photographs, and in clinical specialties varying from intensive care to medicine for elderly people. One example, the good European health record project, is developing a model architecture for computerised health records across Europe that is capable of operating on a wide variety of computer hardwares and will also be able to communicate with many different information systems. The ultimate European health record will be comprehensive and medicolegally acceptable across clinical domains, hold all data types, and be automatically translated between languages.     

John Black Grant: a 20th-century public health giant

John Black Grant (1890-1962) was instrumental in getting China, India, and Puerto Rico to develop health systems that integrated preventive and curative care and oriented medical education to be supportive of such systems. As these remain priority goals for all countries today, knowledge of his achievements remains of relevance. This article brings his accomplishments to the attention of the contemporary medical public.