Progress and the Lack of Progress in Addressing Infant Health and Infant Health Inequalities in Ireland during the 20th Century

There is a growing literature which documents the importance of early life environment for outcomes across the life cycle. Research, including studies based on Irish data, demonstrates that those who experience better childhood conditions go on to be wealthier and healthier adults. Therefore, inequalities at birth and in childhood shape inequality in wellbeing in later life, and the historical evolution of the mortality and morbidity of children born in Ireland is important for understanding the current status of the Irish population. In this paper, I describe these patterns by reviewing the existing literature on infant health in Ireland over the course of the 20th century. Up to the 1950s, infant mortality in Ireland (both North and South) was substantially higher than in other developed countries, with a large penalty for those born in urban areas. The subsequent reduction in this penalty, and the sustained decline in infant death rates, occurred later than would be expected from the experience in other contexts. Using records from the Rotunda Lying-in Hospital in Dublin, I discuss sources of disparities in stillbirth in the early 1900s. Despite impressive improvements in death rates since that time, a comparison with those born at the end of the century reveals that Irish children continue to be born unequal. Evidence from studies which track people across the life course, for example research on the returns to birthweight, suggests that the economic cost of this early life inequality is substantial.

The interpersonal and mental health implications of the coherence of coming out narratives for a sample of gay men in committed romantic relationships

The coming out process has been conceptualized as a developmental imperative for those who will eventually accept their same-sex attractions. It is widely accepted that homophobia, heterosexism, and homonegativity are cultural realities that may complicate this developmental process for gay men. The current study views coming out as an extra-developmental life task that is at best a stressful event, and at worst traumatic when coming out results in the rupture of salient relationships with parents, siblings, and/or close friends. To date, the minority stress model (Meyer, 1995; 2003) has been utilized as an organizing framework for how to empirically examine external stressors and mental health disparities for lesbians, gay men, and bisexual individuals in the United States. The current study builds on this literature by focusing on the influence of how gay men make sense of and represent the coming out process in a semi-structured interview, more specifically, by examining the legacy of the coming out process on indicators of wellness. In a two-part process, this study first employs the framework well articulated in the adult attachment literature of coherence of narratives to explore both variation and implications of the coming out experience for a sample of gay men (n = 60) in romantic relationships (n = 30). In particular, this study employed constructs identified in the adult attachment literature, namely Preoccupied and Dismissing current state of mind, to code a Coming Out Interview (COI). In the present study current state of mind refers to the degree of coherent discourse produced about coming out experiences as relayed during the COI. Multilevel analyses tested the extent to which these COI dimensions, as revealed through an analysis of coming out narratives in the COI, were associated with relationship quality, including self-reported satisfaction and observed emotional tone in a standard laboratory interaction task and self-reported symptoms of psychopathology. In addition, multilevel analyses also assessed the Acceptance by primary relationship figures at the time of disclosure, as well as the degree of Outness at the time of the study. Results revealed that participant’s narratives on the COI varied with regard to Preoccupied and Dismissing current state of mind, suggesting that the AAI coding system provides a viable organizing framework for extracting meaning from coming out narratives as related to attachment relevant constructs. Multilevel modeling revealed construct validity of the attachment dimensions assessed via the COI; attachment (i.e., Preoccupied and Dismissing current state of mind) as assessed via the Adult Attachment Interview (AAI) was significantly correlated with the corresponding COI variables. These finding suggest both methodological and conceptual convergence between these two measures. However, with one exception, COI Preoccupied and Dismissing current state of mind did not predict relationship outcomes or self-reported internalizing and externalizing symptoms. However, further analyses revealed that the degree to which one is out to others moderated the relationship between COI Preoccupied and internalizing. Specifically, for those who were less out to others, there was a significant and positive relationship between Preoccupied current state of mind towards coming out and internalizing symptoms. In addition, the degree of perceived acceptance of sexual orientation by salient relationship figures at the time of disclosure emerged as a predictor of mental health. In particular, Acceptance was significantly negatively related to internalizing symptoms. Overall, the results offer preliminary support that gay men’s narratives do reflect variation as assessed by attachment dimensions and highlights the role of Acceptance by salient relationship figures at the time of disclosure. Still, for the most part, current state of mind towards coming out in this study was not associated with relationship quality and self-reported indicators of mental health. This finding may be a function of low statistical power given the modest sample size. However, the relationship between Preoccupied current state of mind and mental health (i.e., internalizing) appears to depend on degree of Outness. In addition, the response of primary relationships figures to coming out may be a relevant factor in shaping mental health outcomes for gay men. Limitations and suggestions for future research and clinical intervention are offered.

Should female health providers be involved in medical male circumcision? Narratives of newly circumcised men in Malawi

Background The Malawi government has endorsed voluntary medical male circumcision (VMMC) as a biomedical strategy for HIV prevention after a decade of debating its effectiveness in the local setting. The “policy” recommends that male circumcision (MC) should be clinically based, as opposed to the alternative of traditional male circumcision (TMC). Limited finances, acceptability concerns, and the health system’s limited capacity to meet demand are among the challenges threatening the mass rollout of VMMC. In terms of acceptability, the gender of clinicians conducting the operations may particularly influence health facility-based circumcision. This study explored the acceptability, by male clients, of female clinicians taking part in the circumcision procedure. Methods Six focus group discussions (FGDs) were conducted, with a total of 47 newly circumcised men from non-circumcising ethnic groups in Malawi participating in this study. The men had been circumcised at three health facilities in Lilongwe District in 2010. Data were audio recorded and transcribed verbatim. Data were analysed using narrative analysis. Results Participants in the FGDs indicated that they were not comfortable with women clinicians being part of the circumcising team. While few mentioned that they were not entirely opposed to female health providers’ participation, arguing that their involvement was similar to male clinicians’ involvement in child delivery, most of them opposed to female involvement, arguing that MC was not an illness that necessitates the involvement of clinicians regardless of their gender. Most of the participants said that it was not negotiable for females to be involved, as they could wait until an all-male clinician team could be available. Thematically, the arguments against female clinicians’ involvement include sexual undertones and the influences of traditional male circumcision practices, among others. Conclusion Men preferred that VMMC should be conducted by male health providers only. Traditionally, male circumcision has been a male-only affair shrouded in secrecy and rituals. Although being medical, this study strongly suggested that it may be difficult for VMMC to immediately move to a public space where female health providers can participate, even for men coming from traditionally non-circumcising backgrounds.

Application of the UK Foresight Obesity Model in Ireland: The Health and Economic Consequences of Projected Obesity Trends in Ireland

Given the scale of the current obesity epidemic and associated health consequences there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland these costs were estimated at €1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at €2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for these conditions in Ireland to 2030 using the established model developed by the Health Forum (UK) for the Foresight: Tackling Obesities project.

Inequalities in mortality of men by oral and pharyngeal cancer in Barcelona, Spain and Sao Paulo, Brazil, 1995-2003

Background: Large inequalities of mortality by most cancers in general, by mouth and pharynx cancer in particular, have been associated to behaviour and geopolitical factors. The assessment of socioeconomic covariates of cancer mortality may be relevant to a full comprehension of distal determinants of the disease, and to appraise opportune interventions. The objective of this study was to compare socioeconomic inequalities in male mortality by oral and pharyngeal cancer in two major cities of Europe and South America. Methods: The official system of information on mortality provided data on deaths in each city; general censuses informed population data. Age-adjusted death rates by oral and pharyngeal cancer for men were independently assessed for neighbourhoods of Barcelona, Spain, and Sao Paulo, Brazil, from 1995 to 2003. Uniform methodological criteria instructed the comparative assessment of magnitude, trends and spatial distribution of mortality. General linear models assessed ecologic correlations between death rates and socioeconomic indices (unemployment, schooling levels and the human development index) at the inner-city area level. Results obtained for each city were subsequently compared. Results: Mortality of men by oral and pharyngeal cancer ranked higher in Barcelona (9.45 yearly deaths per 100,000 male inhabitants) than in Spain and Europe as a whole; rates were on decrease. Sao Paulo presented a poorer profile, with higher magnitude (11.86) and stationary trend. The appraisal of ecologic correlations indicated an unequal and inequitably distributed burden of disease in both cities, with poorer areas tending to present higher mortality. Barcelona had a larger gradient of mortality than Sao Paulo, indicating a higher inequality of cancer deaths across its neighbourhoods. Conclusion: The quantitative monitoring of inequalities in health may contribute to the formulation of redistributive policies aimed at the concurrent promotion of wellbeing and social justice. The assessment of groups experiencing a higher burden of disease can instruct health services to provide additional resources for expanding preventive actions and facilities aimed at early diagnosis, standardized treatments and rehabilitation.

Antiretroviral Drug Resistance in a Respondent-Driven Sample of HIV-Infected Men Who Have Sex With Men in Brazil

Background: There are few studies on HIV subtypes and primary and secondary antiretroviral drug resistance (ADR) in community-recruited samples in Brazil. We analyzed HIV clade diversity and prevalence of mutations associated with ADR in men who have sex with men in all five regions of Brazil. Methods: Using respondent-driven sampling, we recruited 3515 men who have sex with men in nine cities: 299 (9.5%) were HIV-positive; 143 subjects had adequate genotyping and epidemiologic data. Forty-four (30.8%) subjects were antiretroviral therapy-experienced (AE) and 99 (69.2%) antiretroviral therapy-naive (AN). We sequenced the reverse transcriptase and protease regions of the virus and analyzed them for drug resistant mutations using World Health Organization guidelines. Results: The most common subtypes were B (81.8%), C (7.7%), and recombinant forms (6.9%). The overall prevalence of primary ADR resistance was 21.4% (i.e. among the AN) and secondary ADR was 35.8% (i.e. among the AE). The prevalence of resistance to protease inhibitors was 3.9% (AN) and 4.4% (AE); to nucleoside reverse transcriptase inhibitors 15.0% (AN) and 31.0% (AE) and to nonnucleoside reverse transcriptase inhibitors 5.5% (AN) and 13.2% (AE). The most common resistance mutation for nucleoside reverse transcriptase inhibitors was 184V (17 cases) and for nonnucleoside reverse transcriptase inhibitors 103N (16 cases). Conclusions: Our data suggest a high level of both primary and secondary ADR in men who have sex with men in Brazil. Additional studies are needed to identify the correlates and causes of antiretroviral therapy resistance to limit the development of resistance among those in care and the transmission of resistant strains in the wider epidemic.

Analysis of mental health service financial models with a particular emphasis of Ireland

ABSTRACT: Financing is a critical factor in ensuring the optimal development and delivery of a mental health system. The primary method of financing worldwide is tax-based. However many low income countries depend on out-of-pocket payments. There is a report on Irish Health Care funding but none that deals exclusively with mental health care. This paper analyses the various financial models that exist globally with respect to financing the mental health sector, examines the impact of various models on service users, especially in terms of relative ‘financial burden’ and provides a more detailed examination of the current mental health funding situation in Ireland After extensive internet and hardcopy research on the above topics, the findings were analysed and a number of recommendations were reached. Mental health service should be free at the point of delivery to achieve universal coverage. Government tax-based funding or mandatory social insurance with government top-ups, as required, appears the optimal option, although there is no one funding system applicable everywhere. Out-of-pocket funding can create a crippling financial burden for service users. It is important to employ improved revenue collection systems, eliminate waste, provide equitable resource distribution, ring fence mental health funding and cap the number of visits, where necessary. Political, economic, social and cultural factors play a role in funding decisions and this can be clearly seen in the context of the current economic recession in Ireland. Only 33% of the Irish population has access to free public health care and the number health insurance policy holders has dramatically declined, resulting in increased out-of-pocket payments. This approach risks negatively impacting on the social determinants of health, increasing health inequalities and negatively affecting economic productivity. It is therefore important the Irish government examines other options to provide funding for mental health services.

A cohort-based analysis of the evolution of lifetime prevalence of recourse to prostitution by men in the general population of Switzerland, 1987-2000

Background: Despite their relevance to the prevention of sexually transmitted infections, there are few data on the frequency of recourse to prostitution in the male population in Switzerland. Using data gathered for the evaluation of the Swiss AIDS prevention strategy, we analysed net aggregate change and cohort-based change in lifetime prevalence of recourse to prostitution. Methods: Seven repeated cross-sectional telephone surveys of the general population aged 17-45 years (17-30 years only for the 1987 and 1988 surveys) were undertaken from 1987 to 2000 providing information on sexual behaviour including men's recourse to prostitution (total n¼9318). Age categories were: 17-20, 21-25, 26-30, 31-35, 36-40 and 41-45 years. Prevalence at 17-30 years was available in all surveys and prevalence at 41-45 was available for 1989-2000, though not for the same cohorts. Intra-cohort increase in prevalence over 10 years was analysed using truncated information for cohorts aged 21-25 and 26-30 years in 1987 and 1990. Population estimates were computed with 95% confidence intervals (CI). Results: No net change occurred in the 17-45 years male population prevalence between 1989 (17.6%, CI ¼ 15.4; 20.0) and 2000 (17.7%, CI ¼ 15.6; 20.0). The median starting prevalence of recourse to prostitution at age 17-20 was 4.8% (in 1989, CI ¼ 2.0; 9.7) and the range was from 1.8 (in 1994) to 10.4% (in 1990). The median ending prevalence at age 41-45 was 21.9% (in 1994, CI 16.7; 27.9) and the range was from 17.9 (in 2000) to 26.1% (in 1992). No clear trend was observed in either starting or ending prevalence. Intra-cohort evolution of the 1997 and 1990 cohorts was very similar. Conclusions: Based on available data, there was no net (aggregate) change in the prevalence of recourse to prostitution by males in Switzerland between 1989 and 2000. Within the time frame available, intra-cohort evolution was also very similar.

IPH response to A Healthier Future: A 20 year vision for health and wellbeing in Northern Ireland

The Institute of Public Health in Ireland aims to promote cooperation for public health between Northern Ireland and Ireland, to tackle inequalities in health and influence public polices in favour of health. In its work, the Institute emphasises a holistic model of health which recognises the interplay of a wide range of health determinants, including economic, social and environmental factors as well as health and social services.

Pilot HIA of European Employment Strategy in Ireland

This pilot Health Impact Assessment (HIA) exercise was conducted as part of the ‘Policy Health Impact Assessment for the European Union’, commissioned by the European Commission ’s Directorate Generale Health and Consumer Protection (DG Sanco). The project is coordinated by Liverpool University and the research partners are from Ireland, Germany and the Netherlands. The aim of the European project is to develop a HIA methodology for assessing the health impacts of EU policies and activities. The purpose of the pilot HIA in Ireland was to test the methodology produced in the first phase of the project in 2002. The policy chosen for assessment was the European Employment Strategy. The Irish pilot used a range of methods suggested in the draft methodology but concentrated particularly on the participatory aspects of HIA. A key stakeholder group with knowledge of employment (including decision makers in labour market policy) was established to provide expert advice and support. Other methods used included policy analysis, information gathering from key informants, community profiling (including demographic and labour force data), data analysis, literature review, the production of a report and the development of recommendations.

IPH response to the DSD consultation on regulations to prohibit or restrict irresponsible promotions of alcohol in Northern Ireland

IPH responded to the Department for Social Development consultation on the banning of certain promotions that may encourage irresponsible and excessive drinking. The consultation relates to regulations Article 57A(2)(d) of the 1996 Licensing Order “involving the supply of unlimited amounts of intoxicating liquor for a fixed charge (including any charge for entry to the premises)” and Article 31A(2)(d) of the Registration of Clubs Order “restricting the price at which the holder of a licence or the licence holder’s servant or agent may sell on licensed premises a package containing two or more intoxicating liquor products”. IPH welcomes this consultation and supports the Department’s proposals to restrict promotions that involve the supply of unlimited amounts of intoxicating liquor for a fixed charge. IPH welcomes this tangible action linked to the renewed commitment to tackling alcohol-related harms on the island of Ireland set out in the Steering Group Report on a National Substance Strategy (Dept of Health, 2012) and in the New Strategic Direction on Alcohol and Drugs (DHSSPS, 2011). IPH considers that irresponsible alcohol promotions can contribute to this burden of physical and mental ill-health, accidental and non-accidental injury and other harms associated with excessive alcohol consumption in Northern Ireland. As previously stated in the IPH submissions on the introduction of powers to prohibit or restrict irresponsible alcohol promotions (Dec, 2010), IPH considers that the issues of promotion and price are inter-related. The effectiveness of the proposed restrictions could be reinforced by the expeditious introduction of minimum unit pricing of alcohol on an all-island basis.

IPH response to Seanad Consultation Committee on 'Changes in lifestyle can prevent approximately one third of cancers. How does Government and Society respond to this challenge?'

IPH responded to the Seanad Consultation Committee on the consultation topic ‘Changes in lifestyle can prevent approximately one third of cancers.  How does Government and Society respond to this challenge?’. Between 2010 and 2020 the total number of cancers in Ireland is projected to increase by 40% for women and by just over 50% for men (National Cancer Registry).  A focus is needed on developing social, economical and built environments that support healthy choices. IPH presented recommendations based on the international evidence-base as well as national cancer data and research.

IPH response to the Joint Committee on Health and Children and members of the Northern Ireland Assembly on “Cross-border cooperation on healthcare”

The Institute of Public Health in Ireland were asked to submit a paper on 'Cross-border cooperation on healthcare' for a joint meeting between the Oireachtas Joint Committee on Health and Children and the Northern Ireland Assembly Health Committee which took place in Leinster House on 1 March 2012. Key points from the submission included: o    The Institute of Public Health in Ireland (IPH) is an all-island organisation which promotes cooperation between the Republic of Ireland and Northern Ireland with the aim of improving population health on the island and tackling health inequalities. IPH work is focused on addressing the causes of ill health rather than the design and delivery of treatment services. o    North/South cooperation on health was mandated under the Belfast Agreement in 1998 in five domains, including health promotion. IPH has supported the North South Ministerial Council (NSMC) in respect of the health promotion strand since inception. o    The Department of Health and Department of Health, Social Services and Public Safety North-South Feasibility Study (December 2011) states that mutual benefits are most evident from cooperation in the areas of (i) anticipating trends and illnesses in a collective manner (ii) public health issues (iii) specialised services where the population or activity required to sustain the service cannot be met by either jurisdiction alone and (iv) in relation to those areas adjacent to the border. o    The European Directive on Cross-Border Healthcare will be implemented in the next few years which will have implications in relation to patients travelling for healthcare across the Republic of Ireland/Northern Ireland border. o    IPH is supporting the development of new public health strategies in the Republic of Ireland and Northern Ireland which are both due for publication this year. o    There are tangible benefits from cross-border cooperation in the health sector, both in public health and in health service planning and delivery and there are many examples of successful initiatives. However, developments are not occurring in the context of an agreed plan or overall strategic context and tend to be project-based and concentrated in border counties. o    Successful cross-border cooperation requires high level support and integration into departmental policy cycles. The provision of data on an all-island basis supports cross-border cooperation as does the operation of sustainable all-island organisations which can support research, evaluations and programmes. o    In the future, cross-border cooperation in health will be more effective if developed with a strategic planning process intrinsically linked to Departmental priorities. o    North-South cooperation in the areas of alcohol, obesity, tobacco health surveys and rare diseases will be particularly beneficial.

IPH response to Department for Social Development consultation on future regulation of gambling in Northern Ireland

The Department for Social Development (DSD) recently undertook a review of Northern Ireland's gambling law sought views to help strike a balance between developing gambling as a leisure pursuit and minimising its potential negative consequences.  Following the consultation period, DSD aims to produce a balanced package of reforms which will strengthen the regulatory regime while easing some of the current restrictions on industry development.