Environmental health risk assessment of dioxin in foods and the sustainability of public health interventions at severe dioxin hot spots in Vietnam

This study assessed environmental health risk from dioxin in foods and sustainability of risk reduction programs at two heavily contaminated former military sites in Vietnam. The study involved 1000 household surveys, analysis of food samples and in-depth discussions with residents and officials. The findings indicate that more than 40 years after the war, local residents still experience high exposure to dioxin if they consume local high risk foods. Public health intervention programs were rated moderately to well sustained. Internal migration, and lack of clear, official guidance and sensitivity regarding dioxin issues were the main challenges for sustainability of prevention programs.

Efficacy and feasibility of a tele-health intervention for acute coronary syndrome patients with depression: Results of the 'MoodCare' randomized controlled trial

Background Depression is common after a cardiac event, yet there remain few approaches to management that are both effective and scalable. Purpose We aimed to evaluate the 6-month efficacy and feasibility of a tele-health program (MoodCare) that integrates depression management into a cardiovascular disease risk reduction program for acute coronary syndrome patients with low mood. Methods A two-arm, parallel, randomized design was used comprising 121 patients admitted to one of six hospitals for acute coronary syndrome. Results Significant treatment effects were observed for Patient Health Questionnaire 9 (PHQ9) depression (mean difference [change] = −1.8; p = 0.025; effect size: d = 0.36) for the overall sample, when compared with usual medical care. Results were more pronounced effects for those with a history of depression (mean difference [change] = −2.7; p = 0.043; effect size: d = 0.65). Conclusions MoodCare was effective for improving depression in acute coronary syndrome patients, producing effect sizes exceeding those of some face-to-face psychotherapeutic interventions and pharmacotherapy. (Trial Registration Number: ACTRN1260900038623.)

Predicting health programme participation: A gravity‐based, hierarchical modelling approach

Statistical analyses of health program participation seek to address a number of objectives compatible with the evaluation of demand for current resources. In this spirit, a spatial hierarchical model is developed for disentangling patterns in participation at the small area level, as a function of population-based demand and additional variation. For the former, a constrained gravity model is proposed to quantify factors associated with spatial choice and account for competition effects, for programs delivered by multiple clinics. The implications of gravity model misspecification within a mixed effects framework are also explored. The proposed model is applied to participation data from a no-fee mammography program in Brisbane, Australia. Attention is paid to the interpretation of various model outputs and their relevance for public health policy.

Ideological notions in public health care rationing : Case studies from Oregon, New Zealand and Finland

The purpose of this dissertation is to analyze and explicate the ideological content, which is often implicit, in the health care rationing discussion. The phrase "ideological content" refers to viewpoints and assumptions expressed in the rationing discussion that may be widespread and accepted, but without clear evidential support. The study method is philosophical text analysis. The study begins by exploring the literature from the 1970s that affects the present-day rationing discussion. Since ideological contents may have different emphases in realm of health care, three representative cases were studied. The first was a case study of the first and best-known rationing experiment in the American state of Oregon, namely, an experimental rationing plan within the public health program Medicaid, which is designed to provide care for the poor and underprivileged. The second was a study of the only national-level public priority setting that has been conducted in New Zealand. The third examined the Finnish Care Guarantee plan introduced in March 2005. The findings show that several problematic and scientifically mostly unproven concepts have remained largely uncontested in the debate about public health care rationing. Some of these notions already originated decades ago in studies that relied on outdated data or research paradigms. The problematic ideological contents have also been taken up from one publication into another, thereby affecting the rationing debate. The study suggests that before any new public health care rationing experiments are undertaken, these ideological factors should be properly examined, especially in order to avoid repetitious research and perhaps erroneous rationing decisions.

Implementation progress of mental health services in Rwanda: Bugesera district case

RESUMO: O Ministério da Saúde do Governo do Ruanda identifica a saúde mental como uma área de prioridade estratégica para a intervenção em resposta à alta carga dos transtornos mentais no Ruanda. Ao longo dos últimos 20 anos após o genocídio, o sector público reconstruiu sua Resposta Nacional de Saúde Mental com base no acesso equitativo aos cuidados, através do desenvolvimento de uma Política Nacional de Saúde Mental e novas estruturas de saúde mental. A política de Saúde Mental do Ruanda, revista em 2010, prima pela descentralização e integração dos serviços de saúde mental em todas as estruturas nacionais do sistema de saúde e ao nível da comunidade. O presente estudo de caso tem como objetivo avaliar a situação do sistema de saúde mental de um distrito típico de uma área rural no Ruanda, e sugerir melhorias, incluindo algumas estratégias para monitoras as mudanças. Os resultados do estudo permitirão ao Ruanda reforçar a sua capacidade para implementar o Plano Nacional de Saúde Mental ao nível dos distritos. O relatório também será útil para monitorar o progresso da implementação de serviços de saúde mental nos distritos, incluindo a prestação de serviços de base comunitária e a participação dos usuários, suas famílias e outros interessados na promoção, prevenção, assistência e reabilitação em saúde mental. Este estudo também procurou avaliar o progresso da implementação dos cuidados de saúde mental a nível descentralizado, com vista a compreender as implicações em termos de recursos desses processos. Foi realizada uma análise situacional num local do distrito, baseado em entrevistas com as principais partes interessadas responsáveis, usando o Instrumento de Avaliação de Sistemas de Saúde Mental da Organização Mundial da Saúde (WHO-AIMS). Os resultados sugerem que os recursos humanos para a saúde mental e serviços de base comunitária de saúde mental no distrito continuam a ser extremamente limitados. Os profissionais de saúde mental são adicionalmente limitados na sua capacidade para oferecer intervenções de emergência a pacientes psiquiátricos e garantir a continuidade do tratamento farmacológico a pacientes com condições crônicas. Para planejar efetivamente, de acordo com as necessidades da comunidade, sugerimos que o sistema de saúde mental deve envolver também os representantes das famílias e dos usuários no processo de planificação de modo a melhorar a sua contribuição no processo de implementação das atividades de saúde mental. Este estudo de caso do Distrito de Bugesera oferece a primeira análise de nível distrital dos serviços de saúde mental no Ruanda, e pode servir como uma mais-valia para a melhoria do sistema de saúde mental, incluindo a advocacia para a melhoria da qualidade dos cuidados de saúde mental a este nível, aumentando o financiamento para a implementação de serviços clínicos de saúde mental e os recursos humanos disponíveis para a prestação de cuidados de saúde mental, principalmente a nível dos cuidados primários.--------------------- ABSTRACT: To deal with the high burden of mental health disorders resulting from consequences of the 1994 genocide against Tutsis, the Rwanda Ministry of Health (MoH) considers mental health as a priority intervention. For the last 20 years, Ministry of Health focused on rebuilding a national and equity-oriented mental health program responding to the population needs in mental health. Mental health services are now decentralized and integrated in the national health system, from the community level up to the referral level. This study assessed the situation of mental health services in one rural district in Rwanda. It was aimed at assessing the progress of implementation of mental health care at the decentralized level, focusing on resource implications and processes. This study is based on interviews conducted with key stakeholders, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). Findings show that human resources for mental health care and community-based mental health services of the assessed district remain extremely limited. Mental health professionals face limitation regarding the ability to provide emergency management of psychiatric patients and to ensure continuity of psychopharmacological treatment of patients with chronic conditions. To improve the implementation process of mental health interventions and activities, a planning process based on community needs and the involvement of representatives of families and users in planning process should be considered. The Bugesera case study on the situation of mental health services can serve as a baseline for improvement of the mental health program in Rwanda, in terms of quality care services, infrastructure and equipment, human and financial resources.

Health in Brazil 2 Maternal and child health in Brazil: progress and challenges

In the past three decades, Brazil has undergone rapid changes in major social determinants of health and in the organisation of health services. In this report, we examine how these changes have affected indicators of maternal health, child health, and child nutrition. We use data from vital statistics, population censuses, demographic and health surveys, and published reports. In the past three decades, infant mortality rates have reduced substantially, decreasing by 5.5% a year in the 1980s and 1990s, and by 4.4% a year since 2000 to reach 20 deaths per 1000 livebirths in 2008. Neonatal deaths account for 68% of infant deaths. Stunting prevalence among children younger than 5 years decreased from 37% in 1974-75 to 7% in 2006-07. Regional differences in stunting and child mortality also decreased. Access to most maternal-health and child-health interventions increased sharply to almost universal coverage, and regional and socioeconomic inequalities in access to such interventions were notably reduced. The median duration of breastfeeding increased from 2.5 months in the 1970s to 14 months by 2006-07. Official statistics show stable maternal mortality ratios during the past 10 years, but modelled data indicate a yearly decrease of 4%, a trend which might not have been noticeable in official reports because of improvements in death registration and the increased number of investigations into deaths of women of reproductive age. The reasons behind Brazil`s progress include: socioeconomic and demographic changes (economic growth, reduction in income disparities between the poorest and wealthiest populations, urbanisation, improved education of women, and decreased fertility rates), interventions outside the health sector (a conditional cash transfer programme and improvements in water and sanitation), vertical health programmes in the 1980s (promotion of breastfeeding, oral rehydration, and immunisations), creation of a tax-funded national health service in 1988 (coverage of which expanded to reach the poorest areas of the country through the Family Health Program in the mid-1990s); and implementation of many national and state-wide programmes to improve child health and child nutrition and, to a lesser extent, to promote women`s health. Nevertheless, substantial challenges remain, including overmedicalisation of childbirth (nearly 50% of babies are delivered by caesarean section), maternal deaths caused by illegal abortions, and a high frequency of preterm deliveries.

The mental health Risk Assessment and Management Process (RAMP) for schools: II. Process evaluation

The Risk Assessment and Management Process (RAMP) is a whole-school process for the assessment and management of student’s mental health and wellbeing in primary and secondary schools. A process evaluation revealed that RAMP was implemented as intended across six primary and three secondary schools in Melbourne, Australia. Using the RAMP risk and protective factors monitoring form and screening processes, each school identified ‘at-risk’ students who had not previously been identified or received assistance from welfare staff at the school. School staff and mental health workers from local agencies reported improvements in their knowledge of risk and protective factors, and their ability to identify at-risk students following RAMP. They also reported satisfaction in outcomes for at-risk students managed within the school using RAMP. All the primary schools and one of the
secondary schools continued to use some RAMP processes in their school up to 6 months after the initial implementation of the program.

Impact of shifts in health policy on the role and practice of generalist community health nurses

Provides a critical analysis of trends in health policy which are impacting on the role and practice of generalist community nurses in Victoria. The thesis draws on critical social theory to research and analyse trends in health policy in relation to the Community Health Program.

A randomised, feasibility trial of a tele-health intervention for acute coronary syndrome patients with depression (‘MoodCare’): study protocol

Background Coronary heart disease (CHD) and depression are leading causes of disease burden globally and the two often co-exist. Depression is common after Myocardial Infarction (MI) and it has been estimated that 15-35% of patients experience depressive symptoms. Co-morbid depression can impair health related quality of life (HRQOL), decrease medication adherence and appropriate utilisation of health services, lead to increased morbidity and suicide risk, and is associated with poorer CHD risk factor profiles and reduced survival. We aim to determine the feasibility of conducting a randomised, multi-centre trial designed to compare a tele-health program (MoodCare) for depression and CHD secondary prevention, with Usual Care (UC).

Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome (ACS) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensland. Consenting participants are then contacted at two weeks post-discharge for baseline assessment. One hundred eligible participants are to be randomised to an intervention or a usual medical care control group (50 per group). The intervention consists of up to 10 × 30-40 minute structured telephone sessions, delivered by registered psychologists, commencing within two weeks of baseline screening. The intervention focuses on depression management, lifestyle factors (physical activity, healthy eating, smoking cessation, alcohol intake), medication adherence and managing co-morbidities. Data collection occurs at baseline (Time 1), 6 months (post-intervention) (Time 2), 12 months (Time 3) and 24 months follow-up for longer term effects (Time 4). We are comparing depression (Cardiac Depression Scale [CDS]) and HRQOL (Short Form-12 [SF-12]) scores between treatment and UC groups, assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects. A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government.

Discussion This manuscript presents the protocol for a randomised, multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients. The results of this trial will provide valuable new information about potential psychological and wellbeing benefits, cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression.

Mercy health mental health nurse practitioner project report

The Nurse Practitioner – Mental Health model investigates the options for providing a service to a group of clients who present at Werribee and Western Emergency Departments (ED) and currently receive either limited mental health service or have an undiagnosed mental illness. This group comprises at risk young adults who do not meet the criteria for ongoing treatment in public mental health services at present. At risk young adults are those who fit known demographic variables for risk and have a risk catalyst (eg relationship break up) and a situational response to this (self harm). Mercy Mental Health Program service survey indicates gaps in services to this group using current referral pathway with potentially 40-70% lost to follow-up and a significant increase in risk for suicide.

How significant is partnership formation in area-based projects to increase parental attendance at maternal and child health services

Objectives: 

Process evaluation of an integrated health promotion/occupational health model in WellWorks-2

Disparities in chronic disease risk by occupation call for newapproaches to health promotion. Well Works-2 was a randomized, controlled study comparing the effectiveness of a health promotion/occupational health program (HP/OHS) with a standard intervention (HP). Interventions in both studies were based on the same theoretical foundations. Results from process evaluation revealed that a similar number of activities were offered in both conditions and that in the HP/OHS condition there were higher levels of worker participation using three measures: mean participation per activity (HP: 14.2% vs. HP/OHS: 21.2%), mean minutes of worker exposure to the intervention/site (HP: 14.9 vs. HP/OHS: 33.3), and overall mean participation per site (HP: 34.4% vs. HP/ OHS: 45.8%). There were a greater number of contacts with management (HP: 8.8 vs. HP/OHS: 24.9) in the HP/ OHS condition. Addressing occupational health may have contributed to higher levels of worker and management participation and smoking cessation among blue-collar workers.

Impact of worksite health-promotion programs in hospital admission costs and medical leaves in a sample of brazilian companies

Programas de saúde e bem-estar têm sido adotados por empresas como forma de melhorar a saúde de empregados, e muitos estudos descrevem retornos econômicos positivos sobre os investimentos envolvidos. Entretanto, estudos mais recentes com metodologia melhor têm demonstrado retornos menores. O objetivo deste estudo foi investigar se características de programas de saúde e bem-estar agem como preditores de custos de internação hospitalar (em Reais correntes) e da proporção de funcionários que têm licença médica, entre Abril de 2014 e Maio de 2015, em uma amostra não-aleatória de empresas no Brasil, através de parceria com uma empresa gestora de ‘big data’ para saúde. Um questionário sobre características de programas de saúde no ambiente de trabalho foi respondida por seis grandes empresas brasileiras. Dados retirados destes seis questionários (presença e idade de programa de saúde, suas características – inclusão de atividades de screening, educação sobre saúde, ligação com outros programas da empresa, integração do programa à estrutura da empresa, e ambientes de trabalho voltado para a saúde – e a adoção de incentivos financeiros para aderência de funcionários ao programa), bem como dados individuais de idade, gênero e categoria de plano de saúde de cada empregado , foram usados para construir um banco de dados com mais de 76.000 indivíduos. Através de um modelo de regressão múltipla e seleção ‘stepwise’ de variáveis, a idade do empregado foi positivamente associada e a idade do programa de saúde e a categoria ‘premium’ de plano de saúde do funcionário foram negativamente associadas aos custos de internação hospitalar (como esperado). Inesperadamente, a inclusão de programas de screening e iniciativas de educação de saúde nos programas de saúde e bem-estar nas empresas foram identificados como preditores positivos significativos para custos de admissão hospitalar. Para evitar a inclusão errônea de licenças-maternidade, apenas os dados de licença médica de pacientes do sexo masculino foram analisados (dados disponíveis apenas para duas entre as companhias incluídas, com um total de 18.957 pacientes do sexo masculino). Analisando estes dados através de um teste Z para comparação de proporções, a empresa com programa de saúde que inclui atividades voltadas a cessação de hábitos ruins (como tabagismo e etilismo), controle de diabetes e hipertensão, e que adota incentivos financeiros para a aderência de funcionários ao programa tem menor proporção de empregados com licençca médica no período analisado, quando comparada com a outra empresa que não tem estas características (também conforme esperado). Entretanto, a companhia com menor proporção de funcionários com licença médica também foi aquela que adota programa de screening entre as atividades de seu programa de saúde. Potenciais fontes de ameaça à validade interna e externa destes resultados são discutidas, bem como possíveis explicações para a associação entre programas de screening e educação médica a piores indicadores de saúde nesta amostra de companhias são discutidas. Novos estudos com melhor desenho, com amostras maiores e randômicas são necessários para validar estes resultados e possivelmente melhorar a validade interna e externa destes resultados.

Spatial spillovers and political coordination in public health provision

We estimate the impact of the main unconditional federal grant (Fundo de Participaçãodos Municípios - FPM) to Brazilian municipalities as well as its spillover from the neighboring cities on local health outcomes. We consider data from 2002 to 2007 (Brollo et al, 2013) and explore the FPM distribution rule according to population brackets to apply a fuzzy Regression Discontinuity Design (RDD) using cities near the thresholds. In elasticity terms, we nd a reduction on infant mortality rate (-0.18) and on morbidity rate (- 0.41), except in the largest cities of our sample. We also nd an increase on the access to the main program of visiting the vulnerable families, the Family Health Program (Programa Sa ude da Família - PSF). The e ects are stronger for the smallest cities of our sample and we nd increase: (i) On the percentage of residents enrolled in the program (0.36), (ii) On the per capita number of PSF visits (1.59), and (iii) On the per capita number of PSF visits with a doctor (1.8) and nurse (2). After we control for the FPM spillover using neighboring cities near diferent thresholds, our results show that the reduction in morbidity and mortality is largely due to the spillover e ect, but there are negative spillover on preventive actions, as PSF doctors visits and vaccination. Finally, the negative spillover e ect on health resources may be due free riding or political coordination problems, as in the case of the number of hospital beds, but also due to to competition for health professionals, as in the case of number of doctors (-0.35 and -0.87, respectively), specially general practitioners and surgeons (-1.84 and -2.45).