Cardiometabolic risk reduction through lifestyle intervention programs in the Brazilian public health system

Public health strategies to reduce cardiovascular morbidity and mortality should focus on global cardiometabolic risk reduction. The efficacy of lifestyle changes to prevent type 2 diabetes have been demonstrated, but low-cost interventions to reduce cardiometabolic risk in Latin-America have been rarely reported. Our group developed 2 programs to promote health of high-risk individuals attending a primary care center in Brazil. This study compared the effects of two 9-month lifestyle interventions, one based on medical consultations (traditional) and another with 13 multi-professional group sessions in addition to the medical consultations (intensive) on cardiometabolic parameters. Adults were eligible if they had pre-diabetes (according to the American Diabetes Association) and/or metabolic syndrome (International Diabetes Federation criteria for Latin-America). Data were expressed as means and standard deviations or percentages and compared between groups or testing visits. A p-value < 0.05 was considered significant. Results: 180 individuals agreed to participate (35.0% men, mean age 54.7 ± 12.3 years, 86.1% overweight or obese). 83 were allocated to the traditional and 97 to the intensive program. Both interventions reduced body mass index, waist circumference and tumor necrosis factor-α. Only intensive program reduced 2-hour plasma glucose and blood pressure and increased adiponectin values, but HDL-cholesterol increased only in the traditional. Also, responses to programs were better in intensive compared to traditional program in terms of blood pressure and adiponectin improvements. No new case of diabetes in intensive but 3 cases and one myocardial infarction in traditional program were detected. Both programs induced metabolic improvement in the short-term, but if better results in the intensive are due to higher awareness about risk and self-motivation deserves further investigation. In conclusion, these low-cost interventions are able to minimize cardiometabolic risk factors involved in the progression to type 2 diabetes and/or cardiovascular disease.

Access to oral care --- A systematic review of a continuing public health issue among older adults

Oral health is essential for the general well being of the individual and collectively for the health of the population. Oral health can be maintained by routine dental care and visits to dental professionals, but accessing professional dental care may be a continuing difficulty in vulnerable older adult population. Many older adults are not frequent users of dental care, though oral health is crucial to their well-being and overall health. Access to care is the timely use of personal health services to achieve the best possible health outcomes. ^ Objectives: The aims of this review are to (i) to analyze and elucidate the relationship between socio-economic disparities in gender, ethnicity, poverty status, education and the continuing public issue of access to oral care, (ii) to identify the underlying causes through which these factors can affect access to oral care. This review will provide a knowledgeable basis for development of interventions to provide adequate access to oral care in older adults and implementing policies to ensure access to oral care; through highlighting the various socio economic factors that affect access to oral care among older adults. ^ Methods: This paper used a purposeful review of literature on socioeconomic disparities in access to oral care among older adults. The references considered in this review included all the relevant articles, surveys and reports published in English language, since the year 1985 to 2010, in the United States. The articles selected were scrutinized for relevancy to the topic of access to oral care and which included discussions of the effects of gender, ethnicity, poverty status, educational status in accessing oral care. ^ Results: Evidence confirmed the continuing disparity in access to oral care among older adults. The possible links identified were gender inequality, ethnic differences, income levels and educational differences affecting access to oral care. The underlying causes linking these factors with access to oral care were established. ^ Conclusion: The analysis of the literature review findings supported the prevalence of disparities in gender, ethnicity, income and education with its possible links affecting access to oral care. The underlying causes helped to understand the reasons behind this growing issue of inaccessible oral care. Further research is needed to develop policies and target dental public health efforts towards specific problem areas ensuring equitable access to oral services and consequently, improve the health of older adults.^

Towards a public health approach to parenting

There are various parenting, school and personal factors at play in determining a child’s risk of developing serious conduct problems. The temptation is therefore to conclude that “more is better than less”, but we think that has not been convincingly demonstrated. Some large-scale multi-risk-factor reduction approaches that include parenting, school and child-specific interventions with older school-aged children have shown promise but are complex to administer, costly to implement and have yet to show strong long-term outcomes. But in young children (toddler and preschool-aged children) there is strong evidence that social-learning-based parenting programmes are effective with a wide range of families from quite diverse socio-economic and ethnic backgrounds. We choose to focus on such programmes.

Leptospirosis in northern Tanzania: exploring the role of rodents and ruminant livestock in a neglected public health problem

Leptospirosis is an important but neglected zoonotic disease that is often overlooked in Africa. Although comprehensive data on the incidence of human disease are lacking, robust evidence of infection has been demonstrated in people and animals from all regions of the continent. However, to date, there are few examples of direct epidemiological linkages between human disease and animal infection. In East Africa, awareness of the importance of human leptospirosis as a cause of non-malarial febrile illness is growing. In northern Tanzania, acute leptospirosis has been diagnosed in 9% of patients with severe febrile illness compared to only 2% with malaria. However, little is known about the relative importance of different potential animal hosts as sources of human infection in this area. This project was established to investigate the roles of rodents and ruminant livestock, important hosts of Leptospira in other settings, in the epidemiology of leptospirosis in northern Tanzania. A cross-sectional survey of rodents living in and around human settlements was performed alongside an abattoir survey of ruminant livestock. Unusual patterns of animal infection were detected by real-time PCR detection. Renal Leptospira infection was absent from rodents but was detected in cattle from several geographic areas. Infection was demonstrated for the first time in small ruminants sub-Saharan Africa. Two major Leptospira species and a novel Leptospira genotype were detected in livestock. L. borgpetersenii was seen only in cattle but L. kirschneri infection was detected in multiple livestock species (cattle, sheep and goats), suggesting that at least two distinct patterns of Leptospira infection occur in livestock in northern Tanzania. Analysis of samples from acute leptospirosis in febrile human patients could not detect Leptospira DNA by real-time PCR but identified social and behavioural factors that may limit the utility of acute-phase diagnostic tests in this community. Analysis of serological data revealed considerable overlap between serogroups detected in cattle and human leptospirosis cases. Human disease was most commonly attributed to the serogroups Mini and Australis, which were also predominant reactive serogroups in cattle. Collectively, the results of this study led to the hypothesis that livestock are an important reservoir of Leptospira infection for people in northern Tanzania. These results also challenge our understanding of the relationship between Leptospira and common invasive rodent species, which do not appear to maintain infection in this setting. Livestock Leptospira infection has substantial potential to affect the well-being of people in East Africa, through direct transmission of infection or through indirect effects on food production and economic security. Further research is needed to quantify the impact of livestock leptospirosis in Africa and to develop effective interventions for the control of human and animal disease.

Educating the public health workforce : issues and challenges

Background: In public health, as well as other health education contexts, there is increasing recognition of the transformation in public health practice and the necessity for educational providers to keep pace. Traditionally, public health education has been at the postgraduate level; however, over the past decade an upsurge in the growth of undergraduate public health degrees has taken place. Discussion: This article explores the impact of these changes on the traditional sphere of Master of Public Health programs, the range of competencies required at undergraduate and postgraduate levels, and the relevance of these changes to the public health workforce. It raises questions about the complexity of educational issues facing tertiary institutions and discusses the implications of these issues on undergraduate and postgraduate programs in public health. Conclusion: The planning and provisioning of education in public health must differentiate between the requirements of undergraduate and postgraduate students – while also addressing the changing needs of the health workforce. Within Australia, although significant research has been undertaken regarding the competencies required by postgraduate public health students, the approach is still somewhat piecemeal, and does not address undergraduate public health. This paper argues for a consistent approach to competencies that describe and differentiate entry-level and advanced practice.

Environmental and public health issues in Mount Isa : 2007 community survey

This report presents the results of a random telephone survey of 500 adult residents of Mount Isa, conducted in early November 2007. The study was funded by Xstrata Mount Isa Mines. The primary aim of the survey was to collect data about community perceptions and experiences of air quality in Mount Isa and to compare these results with those of a similar survey conducted in 2000 (MacLennan, Lloyd & Hensley, 2000). Both surveys also included questions relating to other aspects of the Mount Isa environment (e.g. water quality, heat, amount of greenery) as well as questions aimed at ascertaining respondents’ general attitudes towards environmental protection.

Ecological sustainability : what role for public health education?

This article explores the notion of ecological sustainability in the context of public health education and the contribution Universities can make in creating environments that include ecologically sustainable practices. It considers the important role of environmental health in building a sustainable future for the population as a central plank of public health. It presents the evidence for the need for comprehensive approaches to ecological sustainability within the University and offers suggestions about how this can take place. It concludes by arguing that to date there is a substantial gap between the rhetoric and the reality in the University context.

A qualitative investigation of sources of value in social marketing from the lens of a public health service

This paper seeks to identify the sources of value in a government health screening service. Consumers' use of such services for their won benefits demonstrates desirable behaviour and their continued use of these services indicates maintenance of the behaviour. There are also positive outcomes for society as the health of its members is improved overall through this behaviour. Individual-depth interview with 25 women who use breast cancer screening services provided by BreastScreen (BSQ) revealed five categories of sources of value. They are information sources, interaction sources, service, environment, and consumer participation. These findings provide valuable insights into the value construction of consumers and contribute towards our understanding of the value concept in social marketing.

Vitamin D and sun protection : the impact of mixed public health messages in Australia

Exposure of the skin to sunlight can cause skin cancer and is also necessary for cutaneous vitamin D production. Media reports have highlighted the purported health benefits of vitamin D. Our aim was to examine attitudes and behaviours related to sun protection and vitamin D. A cross-sectional study of 2,001 residents in Queensland, Australia aged 20-70 years was undertaken. Information collected included: skin cancer risk factors; perceptions about levels of sun exposure required to maintain vitamin D; belief that sun protection increases risk of vitamin D deficiency; intention, and actual change in sun protection practices for adults and children. Multivariate models examined predictors of attitudinal and behavioural change. One-third (32%) believed a fair-skinned adult, and 31% thought a child required at least 30 minutes per day in summer sun to maintain vitamin D levels. Reductions in sun protection were reported by 21% of adults and 14% of children. Factors associated with belief that sun protection may result in not obtaining enough vitamin D included aged ≥ 60 years (OR=1.35, 95% CI 1.09-1.66) and having skin that tanned easily (OR=1.96, 95% CI 1.38-2.78). Participants from low income households, and those who frequently used sun protective clothing were more likely to have reduced sun protection practices (OR=1.33, 95% CI 1.10-1.73 and OR=1.73, 95% CI 1.36-2.20, respectively). This study provides evidence of reductions in sun protection practices in a population living in a high UV environment. There is an urgent need to re-focus messages regarding sun exposure and for continued sun protection practices.

Paving pathways : shaping the public health workforce through tertiary education

Public health educational pathways in Australia have traditionally been the province of Universities, with the Master of Public Health (MPH) recognised as the flagship professional entry program. Public health education also occurs within the fellowship training of the Faculty of Public Health Medicine, but within Australia this remains confined to medical graduates. In recent years, however, we have seen a proliferation of undergraduate degrees as well as an increasing public health presence in the Vocational Education and Training (VET) sector. ----- Following the 2007 Australian Federal election, the new Labour government brought with it a refreshing commitment to a more inclusive and strategic style of government. An important example of this was the 2020 visioning process that identified key issues of public health concern, including an acknowledgment that it was unacceptable to allocate less than 2% of the health budget towards disease prevention. This led to the recommendation for the establishment of a national preventive health agency (Australia: the healthiest country by 2020 National Preventative Health Strategy, Prepared by the Preventative Health Taskforce 2009). ----- The focus on disease prevention places a spotlight on the workforce that will be required to deliver the new investment in health prevention, and also on the role of public health education in developing and upskilling the workforce. It is therefore timely to reflect on trends, challenges and opportunities from a tertiary sector perspective. Is it more desirable to focus education efforts on selected lead issues such as the “obesity epidemic”, climate change, Indigenous health and so on, or on the underlying theory and skills that build a flexible workforce capable of responding to a range of health challenges? Or should we aspire to both? ----- This paper presents some of the key discussion points from 2008 – 2009 of the Public Health Educational Pathways workshops and working group of the Australian Network of Public Health Institutions. We highlight some of the competing tensions in public health tertiary education, their impact on public health training programs, and the educational pathways that are needed to grow, shape and prepare the public health workforce for future challenges.

Public health and clinical dilemmas resulting from imprecise vitamin D tests

Objective: To determine whether there are clinical and public health dilemmas resulting from the reproducibility of routine vitamin D assays. Methods: Blinded agreement studies were conducted in eight clinical laboratories using two commonly used assays to measure serum 25-hydroxyvitamin D (25(OH)D) levels in Australasia and Canada (DiaSorin Radioimmunoassay (RIA) and DiaSorin LIAISON® one). Results: Only one laboratory measured 25(OH)D with excellent precision. Replicate 25(OH)D measurements varied by up to 97% and 15% of paired results differed by more than 50%. Thirteen percent of subjects received one result indicating insufficiency [25-50 nmol/l] and another suggesting adequacy [>50 nmol/l]). Agreement ranged from poor to excellent for laboratories using the manual RIA, while the precision of the semi-automated Liaison® system was consistently poor. Conclusions: Recent interest in the relevance of vitamin D to human health has increased demand for 25(OH)D testing and associated costs. Our results suggest clinicians and public health authorities are making decisions about treatment or changes to public health policy based on imprecise data. Clinicians, researchers and policy makers should be made aware of the imprecision of current 25(OH)D testing so that they exercise caution when using these assays for clinical practice, and when interpreting the findings of epidemiological studies based on vitamin D levels measured using these assays. Development of a rapid, reproducible, accurate and robust assay should be a priority due to interest in populationbased screening programs and research to inform public health policy about the amount of sun exposure required for human health. In the interim, 25(OH)D results should routinely include a statement of measurement uncertainty.

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.