X-Ray Survey Results and Costs—A Health Officer's Viewpoint,A Preliminary Report

The obvious results of a mass chest x-ray survey from a health officer''s viewpoint are:1. The early discovery of unknown cases of pathologic conditions of the chest—tuberculosis, neoplasms, heart abnormalities.2. Increase in the community''s awareness of its tuberculosis problem.3. Opportunity to work closely with the medical society and the individual private physicians.4. Stimulation of all agencies in a community, health and non-health, to work together on a health project for the good of all of the people.5. Increased cooperation between the local department of public health and other health agencies in a community.6. Opportunity to underline to a staff of a local department of public health the importance of thinking in terms of the department as a whole, rather than in terms of respective divisions or bureaus.7. Opportunity to focus the awareness of the community on its public health services.In relation to costs, there are three aspects from a health officer''s viewpoint:1. The planning, together with other agencies, of an adequate budget with full recognition of community resources.2. The planning for estimated expansion of tuberculosis control services both in terms of increased expense for maintenance and operation, and of assignment of personnel to survey staff with resulting curtailment or postponement of other programs.3. The planning for completion of the follow-up program of the x-ray survey and of future continued extension of the total tuberculosis control program as the result of increased community awareness of the tuberculosis problem.     

Leveraging bioterrorism preparedness for non-bioterrorism events: a public health example

When a local health department in Virginia learned that a deceased hospital-based nurse had worked for several months with undiagnosed and untreated active tuberculosis, it mounted an extraordinary effort to find, screen, test, and potentially treat numerous contacts. In responding to this challenge, it adapted plans, concepts, and equipment that had been recently developed or acquired for responding to acts of bioterrorism. The improved coordination and integration with community partners and participating agencies, fostered through bioterrorism preparedness planning, were keys to success. Using procedures developed and exercised to distribute prophylactic medication in the Strategic National Stockpile, the health department shifted philosophically from a program-specific response to a more integrated approach. Implementation of this mass tuberculosis-screening program was based on the principles of the Incident Command System (ICS). Owing to the efficiency of the operation, more than 2,500 people were quickly screened, and the rate of return for skin test readings was 91.6%, ranking it extremely high compared to the benchmarks. Overall, 5.9% of those tested were found to be infected with tuberculosis, and no cases of active tuberculosis were identified. This outcome demonstrated public health's improved ability to react, as a result of bioterrorism preparedness activities, to "traditional" public health mass events and non-bioterrorism emergencies.     

Climate change and local public health in the United States: preparedness, programs and perceptions of local public health department directors

While climate change is inherently a global problem, its public health impacts will be experienced most acutely at the local and regional level, with some jurisdictions likely to be more burdened than others. The public health infrastructure in the U.S. is organized largely as an interlocking set of public agencies at the federal, state and local level, with lead responsibility for each city or county often residing at the local level. To understand how directors of local public health departments view and are responding to climate change as a public health issue, we conducted a telephone survey with 133 randomly selected local health department directors, representing a 61% response rate. A majority of respondents perceived climate change to be a problem in their jurisdiction, a problem they viewed as likely to become more common or severe over the next 20 years. Only a small minority of respondents, however, had yet made climate change adaptation or prevention a top priority for their health department. This discrepancy between problem recognition and programmatic responses may be due, in part, to several factors: most respondents felt personnel in their health department--and other key stakeholders in their community--had a lack of knowledge about climate change; relatively few respondents felt their own health department, their state health department, or the Centers for Disease Control and Prevention had the necessary expertise to help them create an effective mitigation or adaptation plan for their jurisdiction; and most respondents felt that their health department needed additional funding, staff and staff training to respond effectively to climate change. These data make clear that climate change adaptation and prevention are not currently major activities at most health departments, and that most, if not all, local health departments will require assistance in making this transition. We conclude by making the case that, through their words and actions, local health departments and their staff can and should play a role in alerting members of their community about the prospect of public health impacts from climate change in their jurisdiction.     

Emergency Health Planning

This paper outlines the development of emergency health planning as a function of government. Ten provinces have the basic responsibility for the organization, preparation and operation of medical, nursing, hospital and public health services in an emergency. The Department of National Health and Welfare is responsible for the provision of advice and assistance to the provincial and municipal governments in such matters. Eight provinces have now hired full-time planning staffs to co-ordinate the health planning of the Provincial Departments of Health and Provincial Emergency Measures Organization.Four major programs have been established. The first program provides for the continuity of leadership and guidance by health authorities at the federal, provincial and municipal level. Essential records have been developed and emergency legislation prepared. This program, however, will be of little use unless health services are organized at the municipal level. In this organizational program, advice and assistance have been provided to existing hospitals and departments of health in the conduct of disaster planning. The efforts of these agencies are co-ordinated by municipal health authorities into a community disaster plan. The third program deals with information and education of the general public and the health workers. This program is designed to make the family unit self-sufficient for up to seven days and the health worker prepared to undertake his emergency role. The first three programs are directed to the organization and training of manpower; the fourth program provides the necessary supplies. From the national medical stockpile of $18,000,000, some $12,000,000 has been received, packaged for long-term storage and distributed to regional depots across the country. To ensure their ready availability in time of emergency an agreement has been reached with seven provinces for the release of hospital disaster kits.     

INTENSIVE X-RAY SURVEY FOR TUBERCULOSIS IN A RURAL COUNTY

In an intensive fast-tempo tuberculosis case-finding survey in a rural county 34,345 residents (73 per cent of all persons 15 years of age or over) had miniature x-ray films of the chest taken. In 256 instances, x-ray findings were consistent with pulmonary tuberculosis. Sixty-eight persons were ultimately reported as having active tuberculosis (one case of active tuberculosis for every 505 persons covered by the survey). Within one year, 57 of them had been hospitalized for treatment. Only four of the 68 cases had been known to the health department before the survey.The cost of the survey (80 cents per person surveyed and $444.58 per case of active tuberculosis) compares favorably with that of other surveys.     

Creating community agency placements for undergraduate medical education: a program description

PROGRAM OBJECTIVE: To provide first- and second-year medical students with stimulating learning experiences in the community. SETTING: Three hundred placements representing a broad array of urban community agencies providing both general and specialized health care services. PARTICIPANTS: All first- and second-year medical students at the University of Toronto (n = 354). Other participants include staff of community agencies and tutors from the Faculty of Medicine and from the community. PROGRAM: The Health, illness and the Community course is mandatory and consists of 3 components. The first, in the first semester of first year, emphasizes the provision of health care in the community for individuals and populations. The second, in the second semester of first year, introduces a health promotion paradigm. The third component, throughout second year, allows students to engage in an in-depth study of the interconnection between a health problem and a social issue in a community agency setting. OUTCOMES: Students have expressed high levels of satisfaction with the community agency placements. The feedback from agencies has also been enthusiastic. Patients in the home care program have reported that visits by medical students are a positive experience. CONCLUSION: It is possible to recruit and maintain large numbers of urban community agencies as learning sites for medical students. It is hoped that this approach will help to produce socially responsive medical practitioners.     

Review of evolution of clinical,training and educational services and research program for autism spectrum disorders in Hong Kong

The evolution of a local fragmented model of services for children with autism in Hong Kong emerged gradually over the past three decades with lack of government funding or support. This had been due to increasing number of children with autism being detected and referred for earlier assessment. With increasing pressure from parents due to long waiting time for assessment and training services and the increasing polarization by mass media there had been a gradual increasing public awareness over the past five years. Though still highly fragmented in the availability of services, there is a growing "business model" available in the community due to increasing need and lack of public funding for support. There is a lack of strategic planning for medical diagnostic and management issues in Hong Kong. Our University of Hong Kong based Autism Research Program was pioneered in 1985 based on the increasing load of autism cases referred for assessment for other developmental problems and diagnosed as Autism in the Duchess of Kent Children's Hospital. As the first author has been the staff of the University of Hong Kong, this program flourished as a research based program. The benefits of early identification and intervention of autism spectrum disorder(ASD) had been increasingly recognized, and with the increased public awareness and increasing trend of earlier diagnosis, there has been a continuously high demand from parents for earlier assessment and training for children suspected to have ASD. This model had not received extra funding for this integrated program for research, teaching and training in autism. We had to apply for various donations and grants to support the development of this pioneer program. The research output and organization of forums for public education and awareness are reviewed. The latter part of the paper reports the summary of clinical profile of autism cases(N=1441) assessed from 1985 to 2010 June under the University of Hong Kong. As the waiting time for initial developmental assessment for any children in Hong Kong is 12?24 months, we also report our preliminary experience with a newly launched triaging service provision for children suspected to be ASD since 2009, including multi-disciplinary assessment and parallel interim training in our university affiliated child assessment centre in Hong(N=89).     

Preventable diseases; the scope of public health

The purpose of a department of public health is to put into effect for the benefit of all the people of a community the practical lessons of preventive medicine. The scope of public health work is chiefly determined by our knowledge of the causes of the preventable diseases. We do not know how to prevent all diseases. We do, however, know effective ways to prevent or to reduce the occurrence of at least a dozen varieties of disease. Every health department ought to provide for a program and services which will prevent so far as possible the preventable diseases and the preventable hazards to health. To concentrate on prevention is to avoid diversion by specious arguments into the fields of medical care of the sick.     

Newcastle: making strides.

In the past year those involved in implementing community care in Newcastle have been on a massive learning curve, starting to understand purchasing services, moving towards all kinds of domiciliary services. Provision of services by the independent sector is still developing, leaving the social services department to consolidate its own home care services; voluntary agencies are being contracted to supply others. A new assessment system is evolving. Joint planning is moving forward slowly.     

PREVENTABLE DISEASES: THE SCOPE OF PUBLIC HEALTH

The purpose of a department of public health is to put into effect for the benefit of all the people of a community the practical lessons of preventive medicine. The scope of public health work is chiefly determined by our knowledge of the causes of the preventable diseases. We do not know how to prevent all diseases. We do, however, know effective ways to prevent or to reduce the occurrence of at least a dozen varieties of disease.Every health department ought to provide for a program and services which will prevent so far as possible the preventable diseases and the preventable hazards to health. To concentrate on prevention is to avoid diversion by specious arguments into the fields of medical care of the sick.     

Access to Tuberculosis Services for Individuals with Disability in Rural Malawi,a Qualitative Study

Tuberculosis occurs in all populations, but with higher prevalence in poor contexts. Vulnerable groups, including individuals with disability, run a particular risk due to poorer access to information and health services. Studying access to tuberculosis services for vulnerable groups in poor contexts may provide useful insight into the quality of such services in low-income contexts. This article aims to present a contextual understanding of access to tuberculosis services for people with disabilities in one district in southern Malawi. A qualitative method with semi-structured interviews and site observations was applied. In all, 89 participants were interviewed: 47 persons with disability, 11 parents/guardians of youths with disability, and the remaining 31 comprising eight health workers, four community rehabilitation assistants and volunteers, and 19 leaders in the community.Our main findings are that lack of information and knowledge, and considerable confusion related to tuberculosis, its cause and how to protect oneself, are major barrier to accessing services. Disease awareness and personal risk perception are key factors in this regard. Further findings concerns the pathways to tuberculosis related health services, in particular having a test and completing the treatment. The combination of lack of knowledge and barriers in accessing tests implies substantial availability and access problems.It is of importance to understand the combined impact of individual, social, contextual, and systems barriers to fully address the complexity of accessing tuberculosis services for vulnerable groups in poor populations. Lack of disability specific strategies in the local health services may be part of the reason why individuals with disability to not access such services.     

深圳市社区公共卫生服务包运行的成本结构分析

目的 了解深圳市社区公共卫生服务包运行成本的总体情况及财政投入的参考标准。方法 在人力成本、基本支持与保障成本测算的基础上,结合社康中心普查资料与统计年鉴,分析服务包运行中各要素成本及其占财政支出的比例。结果 完成服务包基本项目时,按每万服务人口计,服务包运行成本为64.67万元,其中人力成本占70%,此时服务包成本占同年财政一般性的比例约为1%。结论 深圳市有实力也有必要进一步加大对社区卫生服务的投入,特别是保证人员经费的投入。     

Narratives of ethnic identity among practitioners in community settings in the northeast of England

The increasing ethnic diversity of the UK has been mirrored by growing public awareness of multicultural issues, alongside developments in academic and government thinking. This paper explores the contested meanings around ethnic identity/ies in community settings, drawing on semi-structured interviews with staff from Children's Centres and allied agencies conducted for a research project that examined the relationship between identity and the participation of parents/carers in services in northeast England. The research found that respondents were unclear about, especially, white ethnic identities, and commonly referred to other social categorizations, such as age, nationality, and circumstances such as mobility, when discussing service users. While in some cases this may have reflected legitimate attempts to resist over-ethnicizing non-ethnic phenomena, such constructions coexisted with assumptions about ethnic difference and how it might translate into service needs. These findings raise important considerations for policy and practice.     

The Physician and Industry

Many employers are interested in helping their employees improve and maintain health through a program of preventive medicine designed to supplement health services which already exist in the community. The objectives of such a health program can be attained only through team work between physicians, both within and outside industry. Such specific objectives as the development of measures for the maintenance and improvement of health and the prevention of disease; the provision of readily available diagnostic, treatment and counselling services; the rehabilitation of disabled employees; and the effective administration of sick-benefit plans require the closest communication and co-operation among the occupational health service, the private physician, and other health and welfare agencies. Only by such liaison can the maximum benefits of both preventive and curative medicine be extended to the employee—in his best interest as well as that of the community and the employer.     

MEDICAL CARE AND PUBLIC HEALTH SERVICES

Medical care applies to the individual, and public health to the community. One is the concentrated application of diagnosis and treatment for the life, the comfort of a patient, and includes guidance in health as for motherhood, infancy, childhood and old age.Public health services, provided by the community through its local government and the local department of health, are concerned with the prevention of diseases of all kinds. Some are controlled by sanitary authority, but the majority of preventable diseases are dealt with by public health education.It is not the function of the health department to treat the sick. The family physicians, the hospitals and dispensaries provide for medical care. Medical care of the sick and public health protection are two parallel activities to make use of medical science, one for treatment, the other for prevention of disease.     

Mass survey--Its future

Experience with a fast-tempo case finding survey in Seattle confirms the opinion expressed with regard to other areas, that the tools now are at hand to eradicate tuberculosis in Seattle in a 20-year period. The most important single factor in controlling tuberculosis is segregation and treatment of patients with active cases - sanatorium care that is sufficient in quantity and quality. Aggressive use of community-wide, mass x-ray program constitutes the second largest factor in controlling tuberculosis and has its greatest application in cities of over 100,000 population. The cost of such a mass survey program is trifling when compared with the cost of an adequate hospitalization program. The Seattle experience indicates that the cost of a mass survey program amortized over a five-year period is only 2 per cent of the cost of one year of hospital care.     

Mass Survey—Its Future

Experience with a fast-tempo case finding survey in Seattle confirms the opinion expressed with regard to other areas, that the tools now are at hand to eradicate tuberculosis in Seattle in a 20-year period.The most important single factor in controlling tuberculosis is segregation and treatment of patients with active cases — sanatorium care that is sufficient in quantity and quality.Aggressive use of community-wide, mass x-ray program constitutes the second largest factor in controlling tuberculosis and has its greatest application in cities of over 100,000 population.The cost of such a mass survey program is trifling when compared with the cost of an adequate hospitalization program. The Seattle experience indicates that the cost of a mass survey program amortized over a five-year period is only 2 per cent of the cost of one year of hospital care.     

Community mental health care worldwide: current status and further developments

This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low‐ and middle‐income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long‐term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.     

Mass surveys and selective case-finding; two tools for tuberculosis control

The productivity and effectiveness of the traditional mass x-ray survey method of tuberculosis case-finding were compared with those of a selective use of mobile miniature x-ray equipment. In Tulare County, California, two mobile miniature x-ray units were operated independently of each other. One unit conducted community-wide, pre-planned surveys, while the other unit operated a regular weekly schedule of mobile screening clinics in four cities in the county. THE MAIN FEATURES OF THE SELECTIVE SCREENING PROGRAM WERE: (1) Extensive use of the physician referral method; (2) utilization of the unit for contact contact investigation; (3) interpretation of the minifilm and mailing of film and report to the family physician one day after the screening clinic.RESULTS: Mass survey found one case of tuberculosis per 2,200 minifilms taken; cost per case found, $475. Selective screening program found one case per 292 minifilms taken; cost per case found, $111. Of all cases of tuberculosis reported in 1953, 8 per cent were found by mass survey and 18 per cent by selective screening.     

Managing Minor Ailments; The Public’s Preferences for Attributes of Community Pharmacies. A Discrete Choice Experiment

Background

Demand for health services continues to rise. Greater use of community pharmacy services instead of medical services for minor ailments could help relieve pressure on healthcare providers in high-cost settings. Community pharmacies are recognised sources of treatment and advice for people wishing to manage these ailments. However, increasing the public’s use of pharmacy services may depend on attributes of pharmacies and their staff. This study aimed to determine the general public’s relative preferences for community pharmacy attributes using a discrete choice experiment (DCE).

Method

A UK-wide DCE survey of the general public was conducted using face-to-face computer-assisted personal interviews. Attributes and levels for the DCE were informed by a literature review and a cohort study of community pharmacy customers. The context for the experiment was a minor ailment scenario describing flu-like symptoms. The DCE choice sets described two hypothetical community pharmacy services; respondents were asked to choose which (if either) of the two pharmacies they would prefer to help them manage symptoms. Data from 1,049 interviews were analysed using an error components logit model. Willingness to pay (WTP), a monetary measure of benefit, was estimated for the different attribute levels.

Results

When seeking help or treatment for flu-like symptoms, respondents most valued a pharmacy service that would improve their understanding and management of symptoms (WTP = £6.28), provided by staff who are trained (WTP (pharmacist) = £2.63: WTP(trained assistant) = £3.22), friendly and approachable (WTP = £3.38). Waiting time, pharmacy location and availability of parking also contributed to respondents’ preferences. WTP for a service comprising the best possible combination of attributes and levels was calculated as £55.43.

Conclusion

Attributes of a community pharmacy and its staff may influence people’s decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public’s preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.