Ethics and public health

Note: see later edition of this work at http://eprints.qut.edu.au/47632/ This chapter introduces you to the basic ethical principles that underpin public health practice. The themes to be considered in this chapter include: the characteristics of ‘ethics’, the justification for reflecting on ethics and values, the foundations of public health ethics, whether and how we can incorporate ethics and values into our practice and the nature of some of the potential ethical complications of public health practice.

The impact of globalisation on health

After reading this chapter, you should be able to: • understand the concept of globalisation and appreciate its complexity • identify the significant impacts of globalisation on population health, particularly the incidence of communicable and non-communicable diseases • understand the distribution of the global burden of disease in high-, middle- and low-income countries • critically evaluate the factors contributing to the major causes of death in low-income countries • understand some of the achievements of the global public health community and appreciate the challenges it faces.

Anxiety among high school students in India : comparisons across gender, school type, social strata, and perceptions of quality time with parents

The broad objective of the study was to better understand anxiety among adolescents in Kolkata city, India. Specifically, the study compared anxiety across gender, school type, socio-economic background and mothers’ employment status. The study also examined adolescents’ perceptions of quality time with their parents. A group of 460 adolescents (220 boys and 240 girls), aged 13-17 years were recruited to participate in the study via a multi-stage sampling technique. The data were collected using a self-report semi-structured questionnaire and a standardized psychological test, the State-Trait Anxiety Inventory. Results show that anxiety was prevalent in the sample with 20.1% of boys and 17.9% of girls found to be suffering from high anxiety. More boys were anxious than girls (p<0.01). Adolescents from Bengali medium schools were more anxious than adolescents from English medium schools (p<0.01). Adolescents belonging to the middle class (middle socio-economic group) suffered more anxiety than those from both high and low socio-economic groups (p<0.01). Adolescents with working mothers were found to be more anxious (p<0.01). Results also show that a substantial proportion of the adolescents perceived they did not receive quality time from fathers (32.1%) and mothers (21.3%). A large number of them also did not feel comfortable to share their personal issues with their parents (60.0% for fathers and 40.0% for mothers).

Rethinking health planning : a framework for organising information to underpin collaborative health planning

The field of collaborative health planning faces significant challenges created by the narrow focus of the available information, the absence of a framework to organise that information and the lack of systems to make information accessible and guide decision-making. These challenges have been magnified by the rise of the ‘healthy communities movement’, as a result of which, there have been more frequent calls for localised, collaborative and evidence-driven health related decision-making. This paper discusses the role of decision support systems as a mechanism to facilitate collaborative health decision-making. The paper presents a potential information management framework to underpin a health decision support system and describes the participatory process that is currently being used to create an online tool for health planners using geographic information systems. The need for a comprehensive information management framework to guide the process of planning for healthy communities has been emphasised. The paper also underlines the critical importance of the proposed framework not only in forcing planners to engage with the entire range of health determinants, but also in providing sufficient flexibility to allow exploration of the local setting-based determinants of health.

Health law : scope, sources and forces

• For the purposes of this chapter, “health law” encapsulates regulation of the medical and health professions, the administration of health services and the maintenance of public health to the extent that it is connected to the provision of health services. • There are diverging views as to whether health law can be regarded as a discrete “area of law”. • Health law draws on other areas of law such as tort law, criminal law and family law. It is also draws upon other disciplines, most notably medical and health ethics. • Social and economic forces have influenced the development and direction of health law, and these forces may become even more influential as the century develops. • The increasingly globalised world has implications for Australia’s health systems and raises questions and creates commitments in respect of the international community. • Technological developments, including in respect of treatment, diagnosis and information management, create ongoing challenges for health law. • Patient rights, human rights and consumerism are increasingly key drivers in the development of health law. • Health law is significant to contemporary Australian society because of the gravity of the topics that fall within its ambit, its social relevance to so many aspects of human existence and endeavour, the important role it plays in protecting the vulnerable, and the extent to which it engages with fundamental principles of justice.

The legal framework of the Australian health system

This chapter is about the role of law in the creation and operation of Australian health systems. Accordingly, this chapter discusses how law regulates the way in which health services in Australia are funded, organised, regulated, managed, operated and governed. (The question of how health professionals are regulated is discussed in Chapter 15.) Although the focus of much of health law is on legal mechanisms for the resolution of disputes or disagreements between the state, health providers, professionals, patients and families and friends, and through dispute resolutions processes setting standards for practice, these are only some of the “jobs” that health law performs. In health systems where the state undertakes a significant role in regulating, funding, managing and providing health services, health law also performs an important constitutive function. Health law declares the values upon which the health system is based, shapes social processes to achieve public ends and provides a structure for the complex interactions that occur within a modern health system. Health law regulates decision-makers in health systems by establishing who has the power to participate in decisions and in what circumstances, establishing processes through which decisions are made and creating mechanisms for decision-makers to be held publicly accountable. It is this broader constitutive function of health law that is a primary focus of much of this chapter — how and why governments use their legislative powers to structure and shape the health system.

A national framework for disaster health education in Australia

INTRODUCTION: Recent events have heightened awareness of disaster health issues and the need to prepare the health workforce to plan for and respond to major incidents. This has been reinforced at an international level by the World Association for Disaster and Emergency Medicine, which has proposed an international educational framework. ----------- OBJECTIVE: The aim of this paper is to outline the development of a national educational framework for disaster health in Australia. ----------- METHODS: The framework was developed on the basis of the literature and the previous experience of members of a National Collaborative for Disaster Health Education and Research. The Collaborative was brought together in a series of workshops and teleconferences, utilizing a modified Delphi technique to finalize the content at each level of the framework and to assign a value to the inclusion of that content at the various levels. ----------- FRAMEWORK: The framework identifies seven educational levels along with educational outcomes for each level. The framework also identifies the recommended contents at each level and assigns a rating of depth for each component. The framework is not intended as a detailed curriculum, but rather as a guide for educationalists to develop specific programs at each level. ----------- CONCLUSIONS: This educational framework will provide an infrastructure around which future educational programs in Disaster Health in Australia may be designed and delivered. It will permit improved articulation for students between the various levels and greater consistency between programs so that operational responders may have a consistent language and operational approach to the management of major events.

Assessing the vulnerability of eco-environmental health to climate change

There is an urgent need to assess the vulnerability of eco-environmental health to climate change. This paper aims to provide an overview of current research, to identify knowledge gaps, and to propose future research needs in this challenging area. Evidence shows that climate change is affecting and will, in the future, have more (mostly adverse) impacts on ecosystems. Ecosystem degradation, particularly the decline of the life support systems, will undoubtedly affect human health and wellbeing. Therefore, it is important to develop a framework to assess the vulnerability of eco-environmental health to climate change, and to identify appropriate adaptation strategies to minimize the impact of climate change.

Health impacts of floods

Introduction: Floods are the most common hazard to cause disasters and have led to extensive morbidity and mortality throughout the world. The impact of floods on the human community is related directly to the location and topography of the area, as well as human demographics and characteristics of the built environment. Objectives: The aim of this study is to identify the health impacts of disasters and the underlying causes of health impacts associated with floods. A conceptual framework is developed that may assist with the development of a rational and comprehensive approach to prevention, mitigation, and management. Methods: This study involved an extensive literature review that located >500 references, which were analyzed to identify common themes, findings, and expert views. The findings then were distilled into common themes. Results: The health impacts of floods are wide ranging, and depend on a number of factors. However, the health impacts of a particular flood are specific to the particular context. The immediate health impacts of floods include drowning, injuries, hypothermia, and animal bites. Health risks also are associated with the evacuation of patients, loss of health workers, and loss of health infrastructure including essential drugs and supplies. In the mediumterm, infected wounds, complications of injury, poisoning, poor mental health, communicable diseases, and starvation are indirect effects of flooding. In the long-term, chronic disease, disability, poor mental health, and poverty-related diseases including malnutrition are the potential legacy. Conclusions: This article proposes a structured approach to the classification of the health impacts of floods and a conceptual framework that demonstrates the relationships between floods and the direct and indirect health consequences.

National health and hospital network for Australia's future : Implications for emergency medicine

The proposals arising from the agreement reached between the Rudd government and the States and Territories (except Western Australia) in April 2010 represent the most fundamental realignment of health responsibilities since the creation of Medicare in 1984. They will change the health system, and the structures that will craft its future direction and design. These proposals will have a significant impact on Emergency Medicine; an impact from not only the system-wide effects of the proposals but also those that derive from the specific recommendations to create an activity-based funding mechanism for EDs, to implement the four hour rule and to develop a performance indicator framework for EDs. The present paper will examine the potential impact of the proposals on Emergency Medicine to inform those who work within the system and to help guide further developments. More work is required to better evaluate the proposals and to guide the design and development of specific reform instruments. Any such efforts should be based upon a proper analysis of the available evidence, and a structured approach to research and development so as to deliver on improved services to the community, and on improved quality and safety of emergency medical care.

Socioeconomic position, gender, health behaviours and biomarkers of cardiovascular disease and diabetes

Socio-economic gradients in cardiovascular disease (CVD) and diabetes have been found throughout the developed world and there is some evidence to suggest that these gradients may be steeper for women. Research on social gradients in biological risk factors for CVD and diabetes has received less attention and we do not know the extent to which gradients in biomarkers vary for men and women. We examined the associations between two indicators of socio-economic position (education and household income) and biomarkers of diabetes and cardiovascular disease (CVD) for men and women in a national, population-based study of 11,247 Australian adults. Multi-level linear regression was used to assess associations between education and income and glucose tolerance, dyslipidaemia, blood pressure (BP) and waist circumference before and after adjustment for behaviours (diet, smoking, physical activity, TV viewing time, and alcohol use). Measures of glucose tolerance included fasting plasma glucose and insulin and the results of a glucose tolerance test (2 h glucose) with higher levels of each indicating poorer glucose tolerance. Triglycerides and High Density Lipoprotein (HDL) Cholesterol were used as measures of dyslipidaemia with higher levels of the former and lower levels of the later being associated with CVD risk. Lower education and low income were associated with higher levels of fasting insulin, triglycerides and waist circumference in women. Women with low education had higher systolic and diastolic BP and low income women had higher 2 h glucose and lower HDL cholesterol. With only one exception (low income and systolic BP), all of these estimates were reduced by more than 20% when behavioural risk factors were included. Men with lower education had higher fasting plasma glucose, 2 h glucose, waist circumference and systolic BP and, with the exception of waist circumference, all of these estimates were reduced when health behaviours were included in the models. While low income was associated with higher levels of 2-h glucose and triglycerides it was also associated with better biomarker profiles including lower insulin, waist circumference and diastolic BP. We conclude that low socio-economic position is more consistently associated with a worse profile of biomarkers for CVD and diabetes for women.

Determinants of infant and young child feeding practices in Bangladesh: Secondary data analysis of Demographic and Health Survey 2004

BACKGROUND: In Bangladesh, poor infant and young child feeding practices are contributing to the burden of infectious diseases and malnutrition. Objective. To estimate the determinants of selected feeding practices and key indicators of breastfeeding and complementary feeding in Bangladesh. METHODS: The sample included 2482 children aged 0 to 23 months from the Bangladesh Demographic and Health Survey of 2004. The World Health Organization (WHO)-recommended infant and young child feeding indicators were estimated, and selected feeding indicators were examined against a set of individual-, household-, and community-level variables using univariate and multivariate analyses. RESULTS: Only 27.5% of mothers initiated breastfeeding within the first hour after birth, 99.9% had ever breastfed their infants, 97.3% were currently breastfeeding, and 22.4% were currently bottle-feeding. Among infants under 6 months of age, 42.5% were exclusively breastfed, and among those aged 6 to 9 months, 62.3% received complementary foods in addition to breastmilk. Among the risk factors for an infant not being exclusively breastfed were higher socioeconomic status, higher maternal education, and living in the Dhaka region. Higher birth order and female sex were associated with increased rates of exclusive breastfeeding of infants under 6 months of age. The risk factors for bottle-feeding were similar and included having a partner with a higher educational level (OR = 2.17), older maternal age (OR for age > or = 35 years = 2.32), and being in the upper wealth quintiles (OR for the richest = 3.43). Urban mothers were at higher risk for not initiating breastfeeding within the first hour after birth (OR = 1.61). Those who made three to six visits to the antenatal clinic were at lower risk for not initiating breastfeeding within the first hour (OR = 0.61). The rate of initiating breastfeeding within the first hour was higher in mothers from richer households (OR = 0.37). CONCLUSIONS: Most breastfeeding indicators in Bangladesh were below acceptable levels. Breastfeeding promotion programs in Bangladesh need nationwide application because of the low rates of appropriate infant feeding indicators, but they should also target women who have the main risk factors, i.e., working mothers living in urban areas (particularly in Dhaka).

Determinants of infant and young child feeding practices in Sri Lanka : secondary data analysis of demographic and health survey 2000

Background: Poor feeding practices in early childhood contribute to the burden of childhood malnutrition and morbidity. Objective: To estimate the key indicators of breastfeeding and complementary feeding and the determinants of selected feeding practices in Sri Lanka. Methods: The sample consisted of 1,127 children aged 0 to 23 months from the Sri Lanka Demographic and Health Survey 2000. The key infant feeding indicators were estimated and selected indicators were examined against a set of individual-, household-, and community- level variables using univariate and multivariate analyses. Results: Breastfeeding was initiated within the first hour after birth in 56.3% of infants, 99.7% had ever been breastfed, 85.0% were currently being breastfed, and 27.2% were being bottle-fed. Of infants under 6 months of age, 60.6% were fully breastfed, and of those aged 6 to 9 months, 93.4% received complementary foods. The likelihood of not initiating breastfeeding within the first hour after birth was higher for mothers who underwent cesarean delivery (OR = 3.23) and those who were not visited by a Public Health Midwife at home during pregnancy (OR = 1.81). The rate of full breastfeeding was significantly lower among mothers who did not receive postnatal home visits by a Public Health Midwife. Bottlefeeding rates were higher among infants whose mothers had ever been employed (OR = 1.86), lived in a metropolitan area (OR = 3.99), or lived in the South-Central Hill country (OR = 3.11) and were lower among infants of mothers with secondary education (OR = 0.27). Infants from the urban (OR = 8.06) and tea estate (OR = 12.63) sectors were less likely to receive timely complementary feeding than rural infants. Conclusions: Antenatal and postnatal contacts with Public Health Midwives were associated with improved breastfeeding practices. Breastfeeding promotion strategies should specifically focus on the estate and urban or metropolitan communities.

Determinants of infant and young child feeding practices in Nepal : secondary data analysis of demographic and health survey 2006

Background: Childhood undernutrition and mortality are high in Nepal, and therefore interventions on infant and young child feeding practices deserve high priority. Objective. To estimate infant and young child feeding indicators and the determinants of selected feeding practices. Methods: The sample consisted of 1,906 children aged 0 to 23 months from the Demographic and Health Survey 2006. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Results. Breastfeeding was initiated within the first hour after birth in 35.4% of children, 99.5% were ever breastfed, 98.1% were currently breastfed, and 3.5% were bottle-fed. The rate of exclusive breastfeeding among infants under 6 months of age was 53.1%, and the rate of timely complementary feeding among those 6 to 9 months of age was 74.7%. Mothers who made antenatal clinic visits were at a higher risk for no exclusive breastfeeding than those who made no visits. Mothers who lived in the mountains were more likely to initiate breastfeeding within 1 hour after birth and to introduce complementary feeding at 6 to 9 months of age, but less likely to exclusively breastfeed. Cesarean deliveries were associated with delay in timely initiation of breastfeeding. Higher rates of complementary feeding at 6 to 9 months were also associated with mothers with better education and those above 35 years of age. Risk factors for bottle-feeding included living in urban areas and births attended by trained health personnel. Conclusions: Most breastfeeding indicators in Nepal are below the expected levels to achieve a substantial reduction in child mortality. Breastfeeding promotion strategies should specifically target mothers who have more contact with the health care delivery system, while programs targeting the entire community should be continued.

Infant and young child feeding indicators and determinants of poor feeding practices in India : secondary data analysis of National Family Health Survey 2005–06

Background: In India, poor feeding practices in early childhood contribute to the burden of malnutrition and infant and child mortality. Objective. To estimate infant and young child feeding indicators and determinants of selected feeding practices in India. Methods: The sample consisted of 20,108 children aged 0 to 23 months from the National Family Health Survey India 2005–06. Selected indicators were examined against a set of variables using univariate and multivariate analyses. Results: Only 23.5% of mothers initiated breastfeeding within the first hour after birth, 99.2% had ever breastfed their infant, 89.8% were currently breastfeeding, and 14.8% were currently bottle-feeding. Among infants under 6 months of age, 46.4% were exclusively breastfed, and 56.7% of those aged 6 to 9 months received complementary foods. The risk factors for not exclusively breastfeeding were higher household wealth index quintiles (OR for richest = 2.03), delivery in a health facility (OR = 1.35), and living in the Northern region. Higher numbers of antenatal care visits were associated with increased rates of exclusive breastfeeding (OR for ≥ 7 antenatal visits = 0.58). The rates of timely initiation of breastfeeding were higher among women who were better educated (OR for secondary education or above = 0.79), were working (OR = 0.79), made more antenatal clinic visits (OR for ≥ 7 antenatal visits = 0.48), and were exposed to the radio (OR = 0.76). The rates were lower in women who were delivered by cesarean section (OR = 2.52). The risk factors for bottle-feeding included cesarean delivery (OR = 1.44), higher household wealth index quintiles (OR = 3.06), working by the mother (OR=1.29), higher maternal education level (OR=1.32), urban residence (OR=1.46), and absence of postnatal examination (OR=1.24). The rates of timely complementary feeding were higher for mothers who had more antenatal visits (OR=0.57), and for those who watched television (OR=0.75). Conclusions: Revitalization of the Baby Friendly Hospital Initiative in health facilities is recommended. Targeted interventions may be necessary to improve infant feeding practices in mothers who reside in urban areas, are more educated, and are from wealthier households.