Assessment of national health systems performance in the WHO African region

There is growing peer and donor pressure on African countries to utilize available resources more efficiently in a bid to support the ongoing efforts to expand coverage of health interventions with a view to achieving the health-related Millennium Development Goals. The purpose of this study was to estimate the technical and scale efficiency of national health systems in African continent. Methods The study applied the Data Envelopment Analysis approach to estimate the technical efficiency and scale efficiency among the 53 countries of the African Continent. Results Out of the 38 low-income African countries, 12 countries national health systems manifested a constant returns to scale technical efficiency (CRSTE) score of 100%; 15 countries had a VRSTE score of 100%; and 12 countries had a SE score of one. The average variable returns to scale technical efficiency (VRSTE) score was 95% and the mean scale efficiency (SE) score was 59%; meaning that while on average the degree of inefficiency was only 5%, the magnitude of scale inefficiency was 41%. Of the 15 middle-income countries, 5 countries, 9 countries and 5 countries had CRSTE, VRSTE and SE scores of 100%. Ten countries, six countries and 10 countries had CRSTE, VRSTE and SE scores of less than 100%; and thus, they were deemed inefficient. The average VRSTE (i.e. pure efficiency) score was 97.6%. The average SE score was 49.9%. Conclusion There are large unmet need for health and health-related services among countries of the African Continent. Thus, it would not be advisable for health policy-makers address NHS inefficiencies through reduction in excess human resources for health. Instead, it would be more prudent for them to leverage health promotion approaches and universal access prepaid (tax-based, insurance-based or mixtures) health financing systems to create demand for under utilised health services/interventions with a view to increasing ultimate health outputs to efficient target levels.

Norm-based comparison of SF -12 physical and mental health scale scores for a sample of employees of Broward County

In the new health paradigm, the connotation of health has extended beyond the measures of morbidity and mortality to include wellness and quality of life. Comprehensive assessments of health go beyond traditional biological indicators to include measures of physical and mental health status, social role-functioning, and general health perceptions. To meet these challenges, tools for assessment and outcome evaluation are being designed to collect information about functioning and well-being from the individual's point of view.^ The purpose of this study was to profile the physical and mental health status of a sample of county government employees against U.S. population norms. A second purpose of the study was to determine if significant relationships existed between respondent characteristics and personal health practices, lifestyle and other health how the tools and methods used in this investigation can be used to guide program development and facilitate monitoring of health promotion initiatives.^ The SF-12 Health Survey (Ware, Kosinski, & Keller, 1995), a validated measure of health status, was administered to a convenience sample of 450 employees attending one of nine health fairs at an urban worksite. The instrument has been utilized nationally which enabled a comparative analysis of findings of this study with national results.^ Results from this study demonstrated that several respondent characteristics and personal health practices were associated with a greater percentage of physical and/or mental scale scores that were significantly "worse" or significantly "better" than the general population. Respondent characteristics that were significantly related to the SF-12 physical and/or mental health scale scores were gender, age, education, ethnicity, and income status. Personal health practices that were significantly related to SF-12 physical and/or mental scale scores were frequency of vigorous exercise, presence of chronic illness, being at one's prescribed height and weight, eating breakfast, smoking and drinking status. This study provides an illustration of the methods used to analyze and interpret SF-12 Health Survey data, using norm-based interpretation guidelines which are useful for purposes of program development and collecting information on health at the community level. ^

Diabetes Self-management Behaviors, Medical Care, Glycemic Control, and Self-rated Health in US Men by Race/Ethnicity

Men, particularly minorities, have higher rates of diabetes as compared with their counterparts. Ongoing diabetes self-management education and support by specialists are essential components to prevent the risk of complications such as kidney disease, cardiovascular diseases, and neurological impairments. Diabetes self-management behaviors, in particular, as diet and physical activity, have been associated with glycemic control in the literature. Recommended medical care for diabetes may differ by race/ethnicity. This study examined data from the National Health and Nutrition Examination Surveys, 2007 to 2010 for men with diabetes (N = 646) from four racial/ethnic groups: Mexican Americans, other Hispanics, non-Hispanic Blacks, and non-Hispanic Whites. Men with adequate dietary fiber intake had higher odds of glycemic control (odds ratio = 4.31, confidence interval [1.82, 10.20]), independent of race/ethnicity. There were racial/ethnic differences in reporting seeing a diabetes specialist. Non-Hispanic Blacks had the highest odds of reporting ever seeing a diabetes specialist (84.9%) followed by White non-Hispanics (74.7%), whereas Hispanics reported the lowest proportions (55.2% Mexican Americans and 62.1% other Hispanics). Men seeing a diabetes specialist had the lowest odds of glycemic control (odds ratio = 0.54, confidence interval [0.30, 0.96]). The results of this study suggest that diabetes education counseling may be selectively given to patients who are not in glycemic control. These findings indicate the need for examining referral systems and quality of diabetes care. Future studies should assess the effectiveness of patient-centered medical care provided by a diabetes specialist with consideration of sociodemographics, in particular, race/ethnicity and gender.

Accounting for residential and non-residential environments to measure contextual effects on health behavior : the case of recreational walking behavior

Thèse réalisée en cotutelle entre l'Université de Montréal et l'Université Pierre et Marie Curie, Paris 06, Sorbonne Universités.

Participatory Methods for Climate Change and Mental Health Research: Photovoice in Nepal

Background: The relationship between mental health and climate change are poorly understood. Participatory methods represent ethical, feasible, and culturally-appropriate approaches to engage community members for mental health promotion in the context of climate change. Aim: Photovoice, a community-based participatory research methodology uses images as a tool to deconstruct problems by posing meaningful questions in a community to find actionable solutions. This community-enhancing technique was used to elicit experiences of climate change among women in rural Nepal and the association of climate change with mental health. Subjects and methods: Mixed-methods, including in-depth interviews and self-report questionnaires, were used to evaluate the experience of 10 women participating in photovoice. Quantitative tools included Nepali versions of Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) and a resilience scale. Results: In qualitative interviews after photovoice, women reported climate change adaptation and behavior change strategies including environmental knowledge-sharing, group mobilization, and increased hygiene practices. Women also reported beneficial effects for mental health. The mean BDI score prior to photovoice was 23.20 (SD=9.00) and two weeks after completion of photovoice, the mean BDI score was 7.40 (SD=7.93), paired t-test = 8.02, p<.001, n=10. Conclusion: Photovoice, as a participatory method, has potential to inform resources, adaptive strategies and potential interventions to for climate change and mental health.

Communities of practice as professional and organizational development strategy in local public health organizations in Québec, Canada : an evaluation model

Communities of practice (CoPs) are among the professional development strategies most widely used in such fields as management and education. Though the approach has elicited keen interest, knowledge pertaining to its conceptual underpinnings is still limited, thus hindering proper assessment of CoPs' effects and the processes generating the latter. To address this shortcoming, this paper presents a conceptual model that was developed to evaluate an initiative based on a CoP strategy: Health Promotion Laboratories are a professional development intervention that was implemented in local public health organizations in Montreal (Quebec, Canada). The model is based on latest theories on work-group effectiveness and organizational learning and can be usefully adopted by evaluators who are increasingly called upon to illuminate decision-making about CoPs. Ultimately, validation of this conceptual model will help advance knowledge and practice pertaining to CoPs as well as professional and organizational development strategies in public health.

Health equity in all policies

Public Health England (PHE) worked with the Association of Directors of Public Health (ADPH) and the Local Government Association (LGA) to develop a masterclass to understand what PHE could do to support directors and consultants of public health to embed health and health equity in all policies at a local level. These documents provide a full report and executive summary of 2 pilot masterclasses held on: 25 February 2015 in London 17 March 2015 in Manchester The masterclasses aimed to: frame public health challenges and use appropriate language within the context of overarching local authority priorities effectively position health and wellbeing in the context of competing (and sometimes conflicting) policy agendas engage wider service and policy areas in the pursuit of health and health equity within current economic and funding contexts

Medical journals and Wikipedia: a global health matter

Approximately 7000 stillbirths occur daily worldwide, and the vast majority of them (98%) Approximately 7000 stillbirths occur daily worldwide, and the vast majority of them (98%) take place in low-income and middle-income countries (LMICs). Despite this enormous burden, progress to reduce the death toll is slow and insufficient. WHO released its Making every baby count guide in 2016, which includes strategies aimed at addressing the challenge of stillbirths. Given the flurry of activity and attention on stillbirths from the Lancet Stillbirth Epidemiology investigator group and WHO, we expect that the wealth of information about stillbirths that is generated will filter down in a timely manner to where it is needed most: the general public.

The use of motivational interviews by nurses to promote health behaviors in adolescents: a scoping review protocol

Adolescents - defined as young people between 10 and 19 years of age1 - are, in general, a relatively healthy segment of the population.2 However, the developmental changes that take place during adolescence may affect their subsequent risk for diseases and for a variety of health-related behaviors. In fact, early onset of preventable health problems (e.g. obesity, malnutrition, STDs) and the engagement in health risk behaviors (e.g., sedentary life style, excessive alcohol consumption, unprotected sex) during adolescence, are likely to put them at greater risk for physical and mental health problems at a later stage in life. Moreover, health related problems and health risk behaviors may disrupt adolescents' physical and cognitive development and therefore may affect their ability to think and act in relation to decisions about their health in the future.1 In summary, health-related behaviors in adolescence, apart from their influence on the continuum of "health-disease", they also have the potential to influence future behaviors. In fact, several studies have shown that past behaviors are good predictors of future behaviors .3,4 Thus, promoting healthy practices during adolescence and taking measures to better protect young people from health risks are essential for the prevention of health problems in adulthood.5 According to the World Health Organization, the main problems affecting young people include mental health problems (such as behavioral disorders, eating disorders, suicide, anxiety or depression), the use of substances (illegal substances, alcohol and tobacco), interpersonal violence, nutrition (a proper nutrition consists of healthy eating habits and physical exercise), unintentional injuries (which are a leading cause of death and disability among young people, with road traffic injuries accounting for about 700 deaths per day), sexual and reproductive health (for example, risky sexual behaviors, early pregnancy and childbirth) and HIV (resulting from sexual transmission and drug injection).5,6 On the other hand, the number of children and youth with chronic health conditions has increased dramatically in the past four decades7 as larger numbers of chronically ill children survive beyond the age of 10.8 Despite the lack of data on adolescents' health making it difficult to determine the prevalence of chronic illnesses in this age group9, it is known that one in ten adolescents suffers from a chronic condition worldwide.10 In fact, national population based studies from Western countries show that 20-30% of teenagers have a chronic illness, defined as one that lasts longer than six months.8 The most prevalent chronic illness among adolescents is asthma and the one with the highest incidence is diabetes mellitus, particularly type II.9 Traditionally, healthcare professionals have been mainly investing in health education activities, through the transmission of knowledge with a view to creating habits, customs and behaviors, and promoting healthy lifestyles. However, empowering people does not only consist of giving them the right information11 , i.e. good information is not enough to cause people to make changes.12 The motivation or desire to change unhealthy behaviors and habits depends on many factors, namely intrinsic motivation, control over personal decisions, self-confidence and perception of effectiveness, personal ambivalence, and individualized assistance.12 Many professionals assume that supplying knowledge is sufficient for behavioral changes; however, even very good advice often fails to generate behavioral change. After all, people continue to engage in unhealthy behaviors despite clearly knowing what they should do and how to change. "What is lacking is the motivation to apply that knowledge".13, p.1233 In fact, behavioral change is a complex phenomenon with multiple determinants that also includes motivational variables. It is associated with ambivalent processes expressed in the dilemma between keeping the current status and moving on to new ways of acting. For example, telling adolescents that if they keep on engaging in a certain behavior, they are increasing the risk of developing a long-term condition such as cardiovascular disease, stroke or diabetes is rarely enough to trigger the desired behavioral change; people are more likely to change when they believe that the change is really effective and that they are able to implement it.12 Therefore, it is essential to provide specific training for "healthcare professionals to master motivational techniques, avoid confrontation with the users, and facilitate behavioral changes".14 In this context, motivating patients to make behavioral changes is also an important nursing task where change in lifestyle is a major element of patients' treatment and preventive interventions.15 One of the nurse's goals is to help improve a patient's health or help them to manage existing health conditions. Once nurses are in a position where they have to focus on accomplishing tasks and telling patients what needs to be accomplished16, the role of the nurse is expanding even more into the use of motivational strategies.17 MI is bringing nurses back to therapeutic communication and moving them closer to successful health promotion and disease management, by promoting behavior change and empowering their patients. As the nursing profession evolves, MI is seen as a challenge and the basis of nurse's interactions with individuals, families and communities.16, 17 In the same way, MI may be taken as an essential tool in the provision of nursing care to adolescents, being itself a workspace with possible therapeutic effects regarding problems, clarification of doubts, and development of skills.18 In fact, MI may be particularly applicable in work with adolescents because of their specific developmental stage. Adolescents attempt to establish their own autonomy and identity while struggling with social interactions and moral issues, which leads to ambivalence.19 Consistent with the developmental challenges during adolescence, "MI explicitly honors autonomy, people's right and irrevocable ability to decide about their own behavior"20 while allowing the person to explore possibilities for change of risky or maladaptive behaviours.19 MI can be defined as a directive, client-centred counselling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style of interpersonal relationship.21 It is a set of strategies and techniques widely used in clinical practice based on the transtheoretical model of change. The Stages of Change model describes five stages of readiness—precontemplation, contemplation, preparation, action, and maintenance—and provides a framework for understanding behavior change.22 The MI has been widely tested and applied in different areas, such as modification of addictive behaviors, interventions with offenders in the context of justice, eating disorders, promotion of therapeutic adherence among chronic patients, promotion of learning in school settings or intervention with adolescents at risk.18,23 In general, clinical practice has been adopting the perspective of motivation as something relatively immutable, i.e., the adolescent is either motivated for change/treatment and, in these conditions, the professional's role is to help him/her, or the adolescent is not motivated and then change/treatment is not feasible. Alternatively the theoretical model underlying the MI technique postulates that the individual's adherence to change/treatment depends on his/her motivation, which can change throughout the therapeutic intervention. As several studies found positive results for effects of MI24-26 and its use by health professionals is encouraged23,27 nurses may play an important role in patients' process of change. As nurses have a crucial role in clinical contexts, they can facilitate the process of ending risk behaviors and/or adopting positive health behaviors through some motivational techniques, namely with adolescents. A considerable number of systematic reviews about MI already exist pointing to some benefits of its use in the treatment of a broad range of behavioral problems and diseases.13,28,29 Some of the current reviews focus on examining the effectiveness of MI for adolescents with diverse health risks/problems 30-32. However, to date there are no reviews that present and assess the evidence for the use of nurse-led MI in adolescents. Therefore, we have little knowledge of what works for whom (which adolescent subpopulation) under what circumstances (in which setting, for what problem) in relation to motivational interviewing by nurses. There is a clear need for scoping or mapping the use of MI by nurses with adolescents to identify evidence gaps and to inform opportunities for future development in nursing practice. On the other hand, information regarding nurse-led implemented and evaluated interventions, techniques and/or strategies used, contexts of application and adolescents subpopulation groups is dispersed in the literature33-36 which impedes the formulation of precise questions about the effectiveness of those interventions conducted by nurses and therefore the realization of a systematic review. In other words, it is known that different kind of motivational interventions have been implemented in different contexts by nurses, however does not exist a map about all the motivational techniques and/or strategies used. Furthermore the literature does not clarify which is the role of nurses at cross professional motivational intervention implemented programs and finally the outcomes and evaluation of interventions are unclear. Thus, the practical implication of this mapping will be clarifying all these aspects. Without this clarification is not possible to proceed to the realization of a systematic review about the effectiveness of the use of motivational interviews by nurses to promote health behaviors in adolescents, in a particular context and/or health risk behavior; or regarding the effectiveness of certain technique and/or strategy of MI. Consequently, there are important questions about the nature of the evidence in this area that need to be answered before formulating a precise question of effectiveness. This scoping review aims to respond to these questions. An initial search of the JBI Database of Systematic Reviews & Implementation Reports, Cochrane Database of Systematic Reviews, , Database of promoting health effectiveness reviews (DoPHER), The Campbell Library, Medline and CINAHL, has revealed that currently there is no Scoping Review (published or in progress) on the subject. In this context, this scoping review will examine and map the published and unpublished research around the use of MI by nurses implemented and evaluated to promote health behaviors in adolescents; to establish its current extent, range and nature and identify its feasibility, outcomes and gaps in the evidence defining research priorities in this field. This scoping review will be informed by the JBI methodology37 that suggests a five stage methodological framework for conducting scoping reviews which includes: identifying the research question, searching for relevant studies, selecting studies, charting data, collating, summarizing and reporting the results.

Identifying health inequalities in individuals with major mental illness (MMI) using routine data

Abstract and Summary of Thesis: Background: Individuals with Major Mental Illness (such as schizophrenia and bipolar disorder) experience increased rates of physical health comorbidity compared to the general population. They also experience inequalities in access to certain aspects of healthcare. This ultimately leads to premature mortality. Studies detailing patterns of physical health comorbidity are limited by their definitions of comorbidity, single disease approach to comorbidity and by the study of heterogeneous groups. To date the investigation of possible sources of healthcare inequalities experienced by individuals with Major Mental Illness (MMI) is relatively limited. Moreover studies detailing the extent of premature mortality experienced by individuals with MMI vary both in terms of the measure of premature mortality reported and age of the cohort investigated, limiting their generalisability to the wider population. Therefore local and national data can be used to describe patterns of physical health comorbidity, investigate possible reasons for health inequalities and describe mortality rates. These findings will extend existing work in this area. Aims and Objectives: To review the relevant literature regarding: patterns of physical health comorbidity, evidence for inequalities in physical healthcare and evidence for premature mortality for individuals with MMI. To examine the rates of physical health comorbidity in a large primary care database and to assess for evidence for inequalities in access to healthcare using both routine primary care prescribing data and incentivised national Quality and Outcome Framework (QOF) data. Finally to examine the rates of premature mortality in a local context with a particular focus on cause of death across the lifespan and effect of International Classification of Disease Version 10 (ICD 10) diagnosis and socioeconomic status on rates and cause of death. Methods: A narrative review of the literature surrounding patterns of physical health comorbidity, the evidence for inequalities in physical healthcare and premature mortality in MMI was undertaken. Rates of physical health comorbidity and multimorbidity in schizophrenia and bipolar disorder were examined using a large primary care dataset (Scottish Programme for Improving Clinical Effectiveness in Primary Care (SPICE)). Possible inequalities in access to healthcare were investigated by comparing patterns of prescribing in individuals with MMI and comorbid physical health conditions with prescribing rates in individuals with physical health conditions without MMI using SPICE data. Potential inequalities in access to health promotion advice (in the form of smoking cessation) and prescribing of Nicotine Replacement Therapy (NRT) were also investigated using SPICE data. Possible inequalities in access to incentivised primary healthcare were investigated using National Quality and Outcome Framework (QOF) data. Finally a pre-existing case register (Glasgow Psychosis Clinical Information System (PsyCIS)) was linked to Scottish Mortality data (available from the Scottish Government Website) to investigate rates and primary cause of death in individuals with MMI. Rate and primary cause of death were compared to the local population and impact of age, socioeconomic status and ICD 10 diagnosis (schizophrenia vs. bipolar disorder) were investigated. Results: Analysis of the SPICE data found that sixteen out of the thirty two common physical comorbidities assessed, occurred significantly more frequently in individuals with schizophrenia. In individuals with bipolar disorder fourteen occurred more frequently. The most prevalent chronic physical health conditions in individuals with schizophrenia and bipolar disorder were: viral hepatitis (Odds Ratios (OR) 3.99 95% Confidence Interval (CI) 2.82-5.64 and OR 5.90 95% CI 3.16-11.03 respectively), constipation (OR 3.24 95% CI 3.01-3.49 and OR 2.84 95% CI 2.47-3.26 respectively) and Parkinson’s disease (OR 3.07 95% CI 2.43-3.89 and OR 2.52 95% CI 1.60-3.97 respectively). Both groups had significantly increased rates of multimorbidity compared to controls: in the schizophrenia group OR for two comorbidities was 1.37 95% CI 1.29-1.45 and in the bipolar disorder group OR was 1.34 95% CI 1.20-1.49. In the studies investigating inequalities in access to healthcare there was evidence of: under-recording of cardiovascular-related conditions for example in individuals with schizophrenia: OR for Atrial Fibrillation (AF) was 0.62 95% CI 0.52 - 0.73, for hypertension 0.71 95% CI 0.67 - 0.76, for Coronary Heart Disease (CHD) 0.76 95% CI 0.69 - 0.83 and for peripheral vascular disease (PVD) 0.83 95% CI 0.72 - 0.97. Similarly in individuals with bipolar disorder OR for AF was 0.56 95% CI 0.41-0.78, for hypertension 0.69 95% CI 0.62 - 0.77 and for CHD 0.77 95% CI 0.66 - 0.91. There was also evidence of less intensive prescribing for individuals with schizophrenia and bipolar disorder who had comorbid hypertension and CHD compared to individuals with hypertension and CHD who did not have schizophrenia or bipolar disorder. Rate of prescribing of statins for individuals with schizophrenia and CHD occurred significantly less frequently than in individuals with CHD without MMI (OR 0.67 95% CI 0.56-0.80). Rates of prescribing of 2 or more anti-hypertensives were lower in individuals with CHD and schizophrenia and CHD and bipolar disorder compared to individuals with CHD without MMI (OR 0.66 95% CI 0.56-0.78 and OR 0.55 95% CI 0.46-0.67, respectively). Smoking was more common in individuals with MMI compared to individuals without MMI (OR 2.53 95% CI 2.44-2.63) and was particularly increased in men (OR 2.83 95% CI 2.68-2.98). Rates of ex-smoking and non-smoking were lower in individuals with MMI (OR 0.79 95% CI 0.75-0.83 and OR 0.50 95% CI 0.48-0.52 respectively). However recorded rates of smoking cessation advice in smokers with MMI were significantly lower than the recorded rates of smoking cessation advice in smokers with diabetes (88.7% vs. 98.0%, p<0.001), smokers with CHD (88.9% vs. 98.7%, p<0.001) and smokers with hypertension (88.3% vs. 98.5%, p<0.001) without MMI. The odds ratio of NRT prescription was also significantly lower in smokers with MMI without diabetes compared to smokers with diabetes without MMI (OR 0.75 95% CI 0.69-0.81). Similar findings were found for smokers with MMI without CHD compared to smokers with CHD without MMI (OR 0.34 95% CI 0.31-0.38) and smokers with MMI without hypertension compared to smokers with hypertension without MMI (OR 0.71 95% CI 0.66-0.76). At a national level, payment and population achievement rates for the recording of body mass index (BMI) in MMI was significantly lower than the payment and population achievement rates for BMI recording in diabetes throughout the whole of the UK combined: payment rate 92.7% (Inter Quartile Range (IQR) 89.3-95.8 vs. 95.5% IQR 93.3-97.2, p<0.001 and population achievement rate 84.0% IQR 76.3-90.0 vs. 92.5% IQR 89.7-94.9, p<0.001 and for each country individually: for example in Scotland payment rate was 94.0% IQR 91.4-97.2 vs. 96.3% IQR 94.3-97.8, p<0.001. Exception rate was significantly higher for the recording of BMI in MMI than the exception rate for BMI recording in diabetes for the UK combined: 7.4% IQR 3.3-15.9 vs. 2.3% IQR 0.9-4.7, p<0.001 and for each country individually. For example in Scotland exception rate in MMI was 11.8% IQR 5.4-19.3 compared to 3.5% IQR 1.9-6.1 in diabetes. Similar findings were found for Blood Pressure (BP) recording: across the whole of the UK payment and population achievement rates for BP recording in MMI were also significantly reduced compared to payment and population achievement rates for the recording of BP in chronic kidney disease (CKD): payment rate: 94.1% IQR 90.9-97.1 vs.97.8% IQR 96.3-98.9 and p<0.001 and population achievement rate 87.0% IQR 81.3-91.7 vs. 97.1% IQR 95.5-98.4, p<0.001. Exception rates again were significantly higher for the recording of BP in MMI compared to CKD (6.4% IQR 3.0-13.1 vs. 0.3% IQR 0.0-1.0, p<0.001). There was also evidence of differences in rates of recording of BMI and BP in MMI across the UK. BMI and BP recording in MMI were significantly lower in Scotland compared to England (BMI:-1.5% 99% CI -2.7 to -0.3%, p<0.001 and BP: -1.8% 99% CI -2.7 to -0.9%, p<0.001). While rates of BMI and BP recording in diabetes and CKD were similar in Scotland compared to England (BMI: -0.5 99% CI -1.0 to 0.05, p=0.004 and BP: 0.02 99% CI -0.2 to 0.3, p=0.797). Data from the PsyCIS cohort showed an increase in Standardised Mortality Ratios (SMR) across the lifespan for individuals with MMI compared to the local Glasgow and wider Scottish populations (Glasgow SMR 1.8 95% CI 1.6-2.0 and Scotland SMR 2.7 95% CI 2.4-3.1). Increasing socioeconomic deprivation was associated with an increased overall rate of death in MMI (350.3 deaths/10,000 population/5 years in the least deprived quintile compared to 794.6 deaths/10,000 population/5 years in the most deprived quintile). No significant difference in rate of death for individuals with schizophrenia compared with bipolar disorder was reported (6.3% vs. 4.9%, p=0.086), but primary cause of death varied: with higher rates of suicide in individuals with bipolar disorder (22.4% vs. 11.7%, p=0.04). Discussion: Local and national datasets can be used for epidemiological study to inform local practice and complement existing national and international studies. While the strengths of this thesis include the large data sets used and therefore their likely representativeness to the wider population, some limitations largely associated with using secondary data sources are acknowledged. While this thesis has confirmed evidence of increased physical health comorbidity and multimorbidity in individuals with MMI, it is likely that these findings represent a significant under reporting and likely under recognition of physical health comorbidity in this population. This is likely due to a combination of patient, health professional and healthcare system factors and requires further investigation. Moreover, evidence of inequality in access to healthcare in terms of: physical health promotion (namely smoking cessation advice), recording of physical health indices (BMI and BP), prescribing of medications for the treatment of physical illness and prescribing of NRT has been found at a national level. While significant premature mortality in individuals with MMI within a Scottish setting has been confirmed, more work is required to further detail and investigate the impact of socioeconomic deprivation on cause and rate of death in this population. It is clear that further education and training is required for all healthcare staff to improve the recognition, diagnosis and treatment of physical health problems in this population with the aim of addressing the significant premature mortality that is seen. Conclusions: Future work lies in the challenge of designing strategies to reduce health inequalities and narrow the gap in premature mortality reported in individuals with MMI. Models of care that allow a much more integrated approach to diagnosing, monitoring and treating both the physical and mental health of individuals with MMI, particularly in areas of social and economic deprivation may be helpful. Strategies to engage this “hard to reach” population also need to be developed. While greater integration of psychiatric services with primary care and with specialist medical services is clearly vital the evidence on how best to achieve this is limited. While the National Health Service (NHS) is currently undergoing major reform, attention needs to be paid to designing better ways to improve the current disconnect between primary and secondary care. This should then help to improve physical, psychological and social outcomes for individuals with MMI.

Social representations of nursing students about hospital assistance and primary health care

Objective: To analyze how social representations of hospital and community care are structured in two groups of nursing students – 1st and 4th years. Method: Qualitative research oriented by the Theory of Social Representations. We used a questionnaire with Free Association of Words. Data were analyzed in the Software IRaMuTeQ 0.6 alpha 3. Results: We applied the method of Descending Hierarchical Classifi cation and obtained four classes. Class 4 has the largest social representation (30.41%) within the corpus. The two organizational axes are nurse and disease/patient in the central core. On the periphery are the care and help related to the nurse and the treatment and prevention associated with the disease. Conclusion: Social representations focus on disease/patient and on the role of nurses in the treatment, prevention, and care. Health promotion and the social determinants of health are absent from the social representations of students.

Communities of practice as professional and organizational development strategy in local public health organizations in Québec, Canada : an evaluation model

Communities of practice (CoPs) are among the professional development strategies most widely used in such fields as management and education. Though the approach has elicited keen interest, knowledge pertaining to its conceptual underpinnings is still limited, thus hindering proper assessment of CoPs' effects and the processes generating the latter. To address this shortcoming, this paper presents a conceptual model that was developed to evaluate an initiative based on a CoP strategy: Health Promotion Laboratories are a professional development intervention that was implemented in local public health organizations in Montreal (Quebec, Canada). The model is based on latest theories on work-group effectiveness and organizational learning and can be usefully adopted by evaluators who are increasingly called upon to illuminate decision-making about CoPs. Ultimately, validation of this conceptual model will help advance knowledge and practice pertaining to CoPs as well as professional and organizational development strategies in public health.

Nutritional guide for a modern woman: a strategy for health education

"In the present article, we introduce a Health Education instrument that stems from a refection on the lay knowledge, salutogenic habits and daily nutritional practices of modern women in our current society. We developed a guide aimed at modern women, where the different food groups and food hygiene and safety measures are addressed. The guide includes eleven original pictograms that help the reader to locate and look up specific issues. The guide employs the label reading and interpretation principles, following the nutrition traffic-light internationally instituted, for it renders scientific information on nutrition clear and accessible to the general population. We believe that using this guide as a central strategy in health promotion will lead its users to adopt essential changes in their eating patterns and, in so doing, contribute to prevent diseases associated to bad eating habits. We also emphasize the role of mass media in spreading the conveyed information."

Fiber, a component for health gastrointestinal endocrine system

Dietary fiber was classified according to its solubility in an attempt to relate physiological effects to chemical types of fiber. Soluble fibers (B-glucans, gums, wheat dextrin, psyllium, pectin, inulin) were considered to have benefits on serum lipids, while insoluble fibers (cellulose, lignin, pectins, hemicelluloses) were linked with laxation benefits. More important characteristics of fiber in terms of physiological benefits are viscosity and fermentability. Viscous fibers (pectins, B-glucans, gums, psyllium) are those that have gel-forming properties in the intestinal tract, and fermentable fibers (wheat dextrin, pectins, B-glucans, gum, inulin) are those that can be metabolized by colonic bacteria. Objective: To summarize the beneficial effects of dietary fiber, as nutraceuticals, in order to maintain a healthy gastrointestinal system. Methods: Our study is a systematic review. Electronic databases, including PubMed, Medline, with supplement of relevant websites, were searched. We included randomized and non-randomized clinical trials, epidemiological studies (cohort and case-control). We excluded case series, case reports, in vitro and animal studies. Results: The WHO, the U.S. Food and Drug Administration (FDA), the Heart Foundation and the Romanian Dietary Guidelines recommends that adults should aim to consume approximately 25–30 g fiber daily. Dietary fiber is found in the indigestible parts of cereals, fruits and vegetables. There are countries where people don’t eat enough food fibers, these people need to take some kind of fiber supplement. Evidence has been found that dietary fiber from whole foods or supplements may (1) reduce the risk of cardiovascular disease by improving serum lipids and reducing serum total and low-density lipoprotein (LDL) cholesterol concentrations, (2) decreases the glycaemic index of foods, which leads to an improvement in glycemic response, positive impact on diabetes, (3) protect against development of obesity by increasing satiety hormone leptin concentrations, (4) reduced risk of developing colorectal cancer by normalizes bowel movements, improve the integrity of the epithelial layer of the intestines, increase the resistance against pathogenic colonization, have favorable effects on the gut microbiome, wich is the second genomes of the microorganisms, (5) have a positive impact on the endocrine system by gastrointestinal polypeptide hormonal regulation of digestion, (6) have prebiotic effect by short-chain fatty acids (SCFA) production; butyrate acid is the preferred energy source for colonic epithelial cells, promotes normal cell differentiation and proliferation, and also help regulate sodium and water absorption, and can enhance absorption of calcium and other minerals. Although all prebiotics are fiber, not all fiber is prebiotic. This generally refers to the ability of a fiber to increase the growth of bifidobacteria and lactobacilli, which are beneficial to human health, and (7) play a role in improving immune function via production of SCFAs by increases T helper cells, macrophages, neutrophils, and increased cytotoxic activity of natural killer cells. Conclusion: Fiber consumption is associated with high nutritional value and antioxidant status of the diet, enhancing the effects on human health. Fibers with prebiotic properties can also be recommended as part of fiber intake. Due to the variability of fiber’s effects in the body, it is important to consume fiber from a variety of sources. Increasing fiber consumption for health promotion and disease prevention is a critical public health goal.

Management of safety climate and the psychosocial work environment – new challenges for occupational health and safety professionals?

Introduction: The work environment and Occupational Health and Safety (OHS) practice have changed over the last number of years. A holistic OHS approach has been recommended by the authorities in this field (e.g. World Health Organisation (WHO), European Agency for Safety and Health at Work (EU-OSHA) and the International Labour Organisation (ILO)). This involves a unified action engaging elements of the physical and psychosocial workplace with greater focus on prevention and promotion of health and wellbeing. The health and safety practitioner (HSP) has been recognised as one of the main agents for implementation of OHS. Within an organisation they act as a leader of change and a professional who shapes health and safety while safeguarding the wellbeing of individuals at work. Additionally, safety climate (SC) has been developed as an essential concept for OHS of an organisation, its productivity and the wellbeing of its workforce. Scholars and practitioners have recognised the great need for further empirical evidence on the HSP’s role in a changing work environment that increasingly requires the use of preventative measures and the assessment and management of psychosocial work-related risks. This doctoral research brings together the different concepts used in OHS and Public Health including SC, Psychosocial workplace risks, Health Promotion and OHS performance. The associations between these concepts are analysed bearing in mind the WHO Healthy Workplace Framework and three of its main components (physical and psychosocial work environment and health resources). This thesis aims to establish a deeper understanding of the practice and management of OHS in Ireland and the UK, exploring the role of HSPs (employed in diverse sectors of activity) and of SC in the OHS of organisations. Methods: One systematic review and three cross-sectional research studies were performed. The systematic review focussed on the evidence compiled for the association of SC with accidents and injuries at work, clarifying this concept’s definition and its most relevant dimensions. The second article (chapter 3) explored the association of SC with accidents and injuries in a sample of workers (n=367) from a pharmaceutical industry and compared permanent with non-permanent workers. Associations of safety climate with employment status and with self-reported occupational accidents/injuries were studied through logistic regression modelling. The third and fourth papers in this thesis investigated the main tasks performed by HSPs, their perceptions of SC, health climate (HC), psychosocial risk factors and health outcomes as well as work efficacy. Validated questionnaires were applied to a sample of HSPs in Ireland and UK, members of the Institute of Occupational Safety and Health (n=1444). Chi-square analysis and logistic regression were used to assess the association between HSPs work characteristics and their involvement in the management of Psychosocial Risk Factors, Safety Culture and Health Promotion (paper 3). Multiple linear regression analysis was used to determine the association between SC, HC, psychosocial risk factors and health outcomes (general health and mental wellbeing) and self-efficacy. Results: As shown in the systematic review, scientific evidence is unable to establish the widely assumed causal link between SC and accidents and injuries. Nevertheless, the current results suggested that, particularly, the organisational dimensions of SC were associated with accidents and injuries and that SC is linked to health, wellbeing and safety performance in the organisation. According to the present research, contingent workers had lower SC perceptions but showed a lower accident/injury rate than their permanent colleagues. The associations of safety climate with accidents/injuries had opposite directions for the two types of workers as for permanent employees it showed an inverse relationship while for temporary workers, although not significant, a positive association was found. This thesis’ findings showed that HSPs are, to a very small degree, included in activities related to psychosocial risk management and assessment, to a moderate degree, involved in HP activities and, to a large degree, engaged in the management of safety culture in organisations. In the final research study, SC and HC were linked to job demands-control-support (JDCS), health, wellbeing and efficacy. JDCS were also associated with all three outcomes under study. Results also showed the contribution of psychosocial risk factors to the association of SC and HC with all the studied outcomes. These associations had rarely been recorded previously. Discussion & Conclusions: Health and safety climate showed a significant association with health, wellbeing and efficacy - a relationship which affects working conditions and the health and wellbeing of the workforce. This demonstrates the link of both SC and HC with the OHS and the general strength or viability of organisations. A division was noticed between the area of “health” and “safety” in the workplace and in the approach to the physical and psychosocial work environment. These findings highlighted the current challenge in ensuring a holistic and multidisciplinary approach for prevention of hazards and for an integrated OHS management. HSPs have shown to be a pivotal agent in the shaping and development of OHS in organisations. However, as observed in this thesis, the role of these professionals is still far from the recommended involvement in the management of psychosocial risk factors and could have a more complete engagement in other areas of OHS such as health promotion. Additionally, a strong culture of health and safety with supportive management and buy-in from all stakeholders is essential to achieve the ideal unified and prevention-focussed approach to OHS as recommended by the WHO, EU-OSHA and ILO.