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PubMed2001

Equity in health in unequal societies: meeting health needs in contexts of social change.

The paper explores the implications for health policy of the segmentation of society into social groups with very different levels of income and wealth. Discourses on equity in health are presently dominated by a debate between 'European' and 'American' models of health delivery. This has led to a focus on ideal outcomes rather than practical options for organising and financing health services in poor countries undergoing rapid change. The paper argues for a more explicit acknowledgement of the dynamic character of health development and the political nature of the negotiations regarding the use of government powers. Unregulated markets for health care are neither equitable nor efficient. Government must play a role in supporting the organisation of health services used by different social groups. Countries with low levels of inequality may be able to provide universal access to relatively sophisticated health services. Otherwise, governments need to operate within a segmented system. This means the negotiation of strategies to reduce the burden of sickness and premature death, whilst meeting the needs of different social groups. The discussion is organised in terms of the powers of government to require individuals and institutions to transfer resources for social uses, enforce regulations and generate and disseminate information. The paper concludes that governments committed to equity-enhancing health development need to increase their capacity to facilitate coalition building and manage change. It proposes an international public health legal framework that might include a definition of minimum standards for certain health services, to be underwritten by national and international financial commitments.

Developing Countries↗

PubMed1998

Multiparasitism, Production and Economics in Domestic Animals in sub-Saharan West Africa.

Over the past ten years, an informal West African animal helminthosis network has developed (), with the aims of both improving livestock productivity through parasite control and, ultimately, increasing rural income. The network places a strong emphasis on building up local research capacity through scientific partnership. This article highlights recent findings from projects of the network.

Journal Article↗

PubMed2003

Our legacy for leadership in MCH.

The history of Maternal and Child Health (MCH) in the United States provides some important lessons for us today. Emerging from the child labor abolition and progressive reform movements of the late 1800s, the basis of MCH in the United States can be traced to fundamental concerns regarding how our society should protect children from a host of threats, including abuse, the adverse practices of childhood labor, disease, and the ill effects of unclean milk and water, poor sanitation, and an unsafe environment. These and additional concerns about how to assure that children and families have access to adequate healthcare and to health and social systems that understand the special developmental needs of children persist to this day. A review of the history of MCH fosters an appreciation of the many accomplishments made by early MCH leaders during some very difficult times in this country. Today, with the advent of war and an unclear economic forecast, to say nothing of continuing health care reforms and the reinvention of the roles and purposes of public health, it may offer modest comfort to know that our predecessors faced grim circumstances too and prevailed. As MCH continues to evolve in response to the major social events of the times, there is an ongoing need to revisit and reflect upon the role and purpose of MCH in the society. Our inherited legacy of leadership in MCH both inspires and challenges us as we strive to responsibly advocate, align constituencies, build and use data capacities for need assessment and evaluation, question our premises, identify and courageously confront pressing health and social issues, and continue our efforts to formulate and articulate a vision for the future of MCH.

Child↗

PubMed2002

Malaria control: constraints and opportunities.

The malaria eradication campaign of the 1950s and 1960s achieved elimination of malaria from the industrialized world and drastic reduction of malaria elsewhere, especially Asia. In Africa, eradication was hardly attempted. For various reasons, results could not be maintained. Eradication had to be given up, control became the policy. Since 1992 malaria control is based on four principles: early diagnosis and treatment; selective and sustainable preventive measures, including vector control; detection, containment and prevention of epidemics, and building up of local capacity. Several constraints with the presently available tools are discussed. Major problems are drug resistance and poor performance of the health sector. International awareness of the problem and international co-operation, the financial resources now available and scientific advances offer opportunities for a concerted effort to reduce the burden of malaria. Operational research, field research and implementation and improvement of the peripheral health service will be of paramount importance.

Africa↗

PubMed2003

Encouraging Vietnamese-American women to obtain Pap tests through lay health worker outreach and media education.

BACKGROUND: Five times more Vietnamese-American women develop cervical cancer than white women. Few studies have examined whether community-based participatory research can effectively address Asian immigrants' health problems. This article reports the preliminary evaluation of 1 such project. METHODS: A coalition of 11 organizations in Santa Clara County, California worked with university researchers to design and simultaneously implement a media education (ME) campaign and a lay health worker outreach (LHWO) program to increase Vietnamese-American women's cervical cancer awareness, knowledge, and screening. Two agencies each recruited 10 lay health workers (LHWs), who, in turn, each recruited 20 women who were then randomized into 2 groups: 10 to LHWO+ME (n = 200) and 10 to ME alone (n = 200). LHWs organized meetings with women to increase their knowledge and to motivate them to obtain Pap tests. Participants completed pre- and post-intervention questionnaires. RESULTS: At post-intervention, significantly more LHWO+ME women understood that human papillomavirus and smoking cause cervical cancer. The number of women who had obtained a Pap test increased significantly among women in both LHWO+ME and ME groups, but substantially more in the LHWO+ME group. Significantly more LHWO+ME women said they intended to have a Pap test. CONCLUSIONS: Media education campaigns can increase Vietnamese women's awareness of the importance of Pap tests, but lay health workers are more effective at encouraging women to actually obtain the tests. Lay health workers are effective because they use their cultural knowledge and social networks to create change. Researchers, community members, and community-based organizations can share expert knowledge and skills, and build one another's capacities.

Adult↗

PubMed2006

'We are no longer called club members but caregivers': Involving youth in HIV and AIDS caregiving in rural Zambia.

This study assessed the strategy of building young people's capacity to provide care and support to people living with HIV and AIDS in rural Zambia. Members of youth anti-AIDS clubs in schools and communities were trained as adjunct caregivers using a locally developed curriculum that allowed them to explore and challenge gendered notions of caregiving and emphasized networking with existing resources. Results show that caregiving increased among males (47% to 82%) and females (41% to 78%). Both sexes provided similar caregiving services, including help with household chores and personal care tasks. Youth also undertook activities with children to decrease their isolation, help them stay in school, and reach additional services. While clients and caregivers reported positive aspects of the programme, both reported frustration with the youths' inability to meet material needs. This study demonstrates that trained youth already involved in anti-AIDS efforts can meet a range of care needs and be valuable assets to their community. It also highlights the importance of communicating clearly what youth can and cannot do, ongoing monitoring and support of youth caregivers, and involving community leaders to give youth credibility and access to local resources.

Adolescent↗

PubMed2004

A national survey of flexible sigmoidoscopy training in primary care graduate and postgraduate education programs.

OBJECTIVES: Expanding the pool of primary care endoscopists to perform flexible sigmoidoscopy (FS) has been advocated as a strategy for building colorectal cancer screening capacity. The principal aim of this study was to evaluate the availability and structure of FS training among internal medicine (IM), family practice (FP), physician assistant (PA), and nurse practitioner (NP) training programs. METHODS: A postal survey of all accredited IM (n = 445), FP (n = 471), PA (n = 118), and NP (n = 149) training programs nationwide was conducted. The primary outcome was the proportion of programs offering or mandating FS training; and secondary outcomes, if applicable, were the number of participating trainees, the number of required procedures, the availability of instruction in endoscopic biopsy technique, mentors, and barriers. RESULTS: The overall response rate was 63%. Most IM (89%) and FP (99%) programs offered FS training versus only 12% of PA and 0% of NP programs. Family practice programs were more likely to offer training (p < 0.0001), require training (p < 0.0001), and teach biopsy techniques (p < 0.0001); Internal medicine programs were more likely to have minimum requirements (p < 0.0001) and required >/= 25 procedures per trainee (p < 0.0001). Physician assistant programs were less structured and often lacked minimum requirements. CONCLUSIONS: Flexible sigmoidoscopy training is widely available among FP and IM programs but more restricted or nonexistent among PA and NP programs. The lack of minimum standards for ensuring competency highlights the need for a standardized credentialing process.

Clinical Competence↗

PubMed2002

Variations in rural AIDS epidemiology and service delivery models in the United States.

This article reviews AIDS surveillance data and the rural health literature to summarize what is known about the rural AIDS epidemic, characteristics of rural environments that affect HIV service delivery, and approaches that rural areas are using to address the health and support service needs of HIV-positive residents. During 1999, nonmetropolitan (non-MSA) adult/adolescent AIDS rates were highest in the South (11 per 100,000) and Northeast (9 per 100,000). The South had the highest non-MSA proportion of adult/adolescent AIDS cases (12%), followed by the North Central region (9%), the West (4%), and the Northeast (3%). Variations in rural HIV/AIDS epidemiologic patterns and the demographic, socio-economic, and cultural characteristics of rural environments are likely to require different levels of resource investment and different methods of organizing and delivering HIV services. Currently, many HIV-positive rural residents are traveling to metropolitan areas for medical care because of concerns about confidentiality or a lack of confidence in the HIV management capabilities of local physicians. Rural communities are attempting to address these problems by developing the HIV care capacity of existing clinics, building local networks of physicians with HIV management experience, and cultivating "shared care" arrangements with urban-based specialists.

Acquired Immunodeficiency Syndrome↗

PubMed1991

Biochemical adaptations to training: implications for resisting muscle fatigue.

Skeletal muscle activity is invariably associated with a decline in force-generating capacity (fatigue). The build-up of metabolic by-products such as intracellular H+ and inorganic phosphate (Pi) has been shown to be one of the potential mechanisms of muscle fatigue. The use of phosphorus magnetic resonance spectroscopy is a repeatable and useful tool to study the effect of pH and Pi on force development. When maximal exercise is preceded by submaximal exercise to reduce the starting muscle pH and increase Pi, the degree of muscle fatigue correlates more strongly with H2PO4- than pH or Pi alone. However, other studies in humans have found that H2PO4- does not always correlate well with fatigue. The use of ramp exercise protocols allow repeatable and sensitive measurement of changes in muscle metabolism in response to endurance training. Chronic electrical stimulation in dogs and endurance training in humans results in reduced pH and Pi changes at the same exercise intensities. This means that the effect of pH and Pi in depressing force development is reduced, which could partially explain the increased fatigue resistance seen following endurance training.

Exercise↗

PubMed1999

The impact of closing a state psychiatric hospital on the county mental health system and its clients.

OBJECTIVE: This three-year study examined the impact of closing a state psychiatric hospital in 1991 on service utilization patterns and related costs for clients with and without serious mental illness. METHODS: The cohort consisted of all individuals discharged from state hospitals and those diverted from inpatient to community services and enrolled in the unified systems project, a state-county initiative to build up the service capacity of the community system. The size of the cohort grew from 1,533 enrollees to 2,240 over the three years. Information on the types, amounts, and cost of all services received by each enrollee was compiled from multiple administrative databases, beginning two years before enrollment and for up to three years after. The data were analyzed to reveal patterns of and changes in service utilization and related costs. RESULTS: Replacement of most inpatient services with residential and ambulatory services resulted in significant cost reduction. For project enrollees, a 94 percent reduction in state hospital services resulted in cost savings of more than $45 million during the three-year evaluation period. These savings more than offset the funds used to expand community services. Overall, the net savings to the system for mental health services for this group was $3.4 million over three years. CONCLUSIONS: The hospital closure and infusion of funds into community services produced desired growth of those services. The project reduced reliance on state psychiatric hospitalization and demonstrated that persons with serious mental illness can be effectively treated and maintained in the community.

Aged↗

PubMedDate not supplied

Developing an action-based health and safety training project in southern China.

A project brought together international footwear manufacturers, labor rights groups, local contract factories, and occupational health professionals to strengthen factory health and safety programs in southern China. Steps involved in the two-year project, including needs assessment, interviews and focus groups with workers and supervisors; design and development of a participatory workshop; development of plant-wide health and safety committees in three footwear factories; and evaluation project impact, are discussed. The project significantly increased occupational safety and health knowledge, and hazards in the factories were identified and corrected. Successes and challenges faced by three functioning worker-management health and safety committees are discussed. Key elements to create effective programs with meaningful participation by workers include: 1) developing clear guidelines that enable multi-stakeholder groups to collaborate; 2) obtaining top-level management support; 3) building workers' knowledge and capacity to fully participate; 4) involving local labor rights groups and occupational professionals in support and technical assistance; and 5) connecting project goals to larger issues within a country and the global economy.

Accidents, Occupational↗

PubMed2006

Status of national health research systems in ten countries of the WHO African Region.

BACKGROUND: The World Health Organization (WHO) Regional Committee for Africa, in 1998, passed a resolution (AFR/RC48/R4) which urged its Member States in the Region to develop national research policies and strategies and to build national health research capacities, particularly through resource allocation, training of senior officials, strengthening of research institutions and establishment of coordination mechanisms. The purpose of this study was to take stock of some aspects of national resources for health research in the countries of the Region; identify current constraints facing national health research systems; and propose the way forward. METHODS: A questionnaire was prepared and sent by pouch to all the 46 Member States in the WHO African Region through the WHO Country Representatives for facilitation and follow up. The health research focal person in each of the countries Ministry of Health (in consultation with other relevant health research bodies in the country) bore the responsibility for completing the questionnaire. The data were entered and analysed in Excel spreadsheet. RESULTS: The key findings were as follows: the response rate was 21.7% (10/46); three countries had a health research policy; one country reported that it had a law relating to health research; two countries had a strategic health research plan; three countries reported that they had a functional national health research system (NHRS); two countries confirmed the existence of a functional national health research management forum (NHRMF); six countries had a functional ethical review committee (ERC); five countries had a scientific review committee (SRC); five countries reported the existence of health institutions with institutional review committees (IRC); two countries had a health research programme; and three countries had a national health research institute (NHRI) and a faculty of health sciences in the national university that conducted health research. Four out of the ten countries reported that they had a budget line for health research in the Ministry of Health budget document. CONCLUSION: Governments of countries of the African Region, with the support of development partners, private sector and civil society, urgently need to improve the research policy environment by developing health research policies, strategic plans, legislations, programmes and rolling plans with the involvement of all stakeholders, e.g., relevant sectors, research organizations, communities, industry and donors. In a nutshell, development of high-performing national health research systems in the countries of the WHO African Region, though optional, is an imperative. It may be the only way of breaking free from the current vicious cycle of ill-health and poverty.

Africa↗

PubMed2001

Evaluation of health-related programmes in Africa: a vision for 2020.

BACKGROUND: Whereas systematic evaluation practice is over five decades old in economically developed continents (DCs), that culture has not yet taken root in Africa. OBJECTIVE(S): To provide an overview of the current situation of health-related evaluation in the African Region; to envision an appropriate evaluation framework for the next two decades; and to provide overviews of what formative (FE) and summative (SE) evaluations are and how they could be conducted. DESIGN: Descriptive study. SETTING: Health policies and plans evaluation in the WHO African Region. SUBJECTS OR PARTICIPANTS: WHO Country Representatives for 25 African Countries. INTERVENTIONS: Non-intervention descriptive study. MAIN OUTCOME MEASURES: Availability and quality of long-term health plan (LTHP), health policy (HP), strategic plan (SP), operational plan (OP), and an evaluation culture. RESULTS: The study found that: 88%, 8%, 36%, 28% and 48% of the countries in the Region do not have LTHP, HP, SP, OP and evaluation culture. A conceptual evaluation framework, tools for formative and summative evaluations are proposed. CONCLUSION: It is envisioned that all partners for health development in Africa will cooperate with individual countries to develop (or strengthen) LTHPs, HPs, SPs, and Ministries of Health OPs (national, provincial and district level); and to make complementary investments in building technical and administrative capacity for evaluating implementation of District Operational Plans (DOPs).

Africa↗

PubMed2004

Multidisciplinary studies of disease burden in the Diseases of the Most Impoverished Programme.

With limited healthcare resources, rational prioritization of healthcare interventions requires knowledge and analysis of disease burden. In the absence of actual disease-burden data from less-developed countries, various types of morbidity and mortality estimates have been made. Besides having questionable reliability, these estimates do not capture the full burden of a disease since they provide only the number of cases and deaths. The modelling methods that include disability are more comprehensive but are difficult to understand, and their reliability is affected by baseline approximations. To provide policy-makers with information needed for rational decision-making, the Diseases of the Most Impoverished (DOMI) Programme of the International Vaccine Institute has used a multidisciplinary approach to describe the burden of disease due to typhoid fever, shigellosis, and cholera. Recognizing the relative advantages and disadvantages of various methodologies, the programme employs passive clinic-based surveillance in defined communities to provide prospective data. The prospective data are complemented with retrospectively-collected information from existing sources, frequently less accurate and complete but readily available for the whole population over extended periods. To create a more complete picture, economic and qualitative studies specific to each disease are incorporated in these prospective studies. The goal is to achieve a more complete and realistic picture by combining the results of these various methodologies, acknowledging the strengths and limitations of each. These projects also build in-country capacity in terms of treatment, diagnosis, epidemiology, and data management.

Cholera↗

PubMed2004

[Antioxidant characteristics of a newly developed vermouth wine].

INTRODUCTION: The polyphenol compounds can be responsible for the beneficial physiological effects of the wine, specially of the red wine. The supposed mechanism in health protecting effect due to the polyphenol components in the wine can be grouped to several biochemical reactions. One of the most important and mostly examined characteristics is their antioxidant and radical scavenging effect. AIM OF THE STUDY: Examination of the antioxidant characteristics of a newly developed vermouth wine. METHODS: Antioxidant characteristics of a newly developed vermouth wine (marked with FB) till now not in the market were studied comparing with those of three red and three white wines as well as of one rose wine. The total polyphenol content, the hydrogen donor activity, the reduction capacity and the complex building activity were determined. RESULTS: Hundred ml of the vermouth wine involves 18.8 mg alcohol, as well as 220 mg polyphenol compounds, comparing to the mean polyphenol content of white wine with 10.5 mg alcohol and 35 mg polyphenol contents. CONCLUSIONS: Usual consumption of one unit from the vermouth wine examined in this paper is medically acceptable, furthermore the organism can have those polyphenol compounds which play substantial role in the protection against oxidative stress.

Antioxidants↗

PubMed2005

Priorities for research for oral health in the 21st century--the approach of the WHO Global Oral Health Programme.

The World Health Organization (WHO) "World Oral Health Report 2003" emphasized that despite great improvements in the oral health status of populations across the world, problems persist. The major challenges of the future will be to translate existing knowledge and sound experiences of disease prevention and health promotion into action programmes, this is particularly the case with developing countries that have not yet benefited from advances in oral health science to the fullest extent possible. The WHO Oral Health programme gives priority to research helping correct the so called 10/90 gap which relates to the fact that only 10% of funding for global health research is allocated to health problems that affect 90% of the world population. As knowledge is a major vehicle for improving the health of the poor in particular, the WHO Oral Health Programme focuses on stimulating oral health research in the developed and developing world to reduce risk factors and the burden of oral disease, and to improve oral health systems and the effectiveness of community oral health programmes. Building and strengthening research capacity in public health are highly recommended by WHO for effective control of disease and the socioeconomic development of any given country.

Dental Caries↗

PubMed1998

Approaches to control sexually transmitted diseases in Haiti, 1992-95.

Despite major obstacles, activities to control sexually transmitted diseases (STDs) were initiated in Haiti in 1992 in collaboration with local nongovernmental organizations. The approaches included review of available local data, assessment of STD case management practices and constraints, and development of specific STD control activities at the primary health care level, such as systematic screening of all pregnant women for syphilis and improved comprehensive syndrome-based STD case management. The activities included conduct of local studies, presentation and dissemination of results to key audiences, training of health care providers, improvement of local capacities, and consensus-building on implementation of STD control approaches. STD awareness and case management improved considerably; for example, 69% of the clinicians interviewed reported correct STD treatments in the north-eastern primary health care centres in 1995, compared with < 10% in 1992. At the end of the project, national STD case management guidelines were developed by consensus between the various organizations and the Ministry of Health. Lessons learned included the importance of local data generation and of communication and collaboration with various institutions for consensus-building, the need for continued training, and field supervision to ensure behaviour change among STD care providers. A national STD control programme should be implemented as soon as possible in both the public and private sector. External funding will remain critical to control this important public health problem in Haiti.

Education, Medical, Continuing↗

PubMed2000

Integration between GPs and hospitals: lessons from a division-hospital program.

The aim of the study reported here was to evaluate current initiatives in GP-hospital integration and highlight areas where further research, development and evaluation are required. Seven pre-existing GP-hospital programs were selected and given supplementary funding to allow for more effective evaluation. These local evaluations were then incorporated into a national program on GP-hospital collaboration. We found that the seven projects made substantial progress towards their goals, and in the process highlighted important aspects of successful collaboration. The collective evaluation of DHIP identified expected benefits of collaboration for patients (improved access to services, reduced anxiety, and fewer post discharge complications), for GPs (increased involvement in acute care and in hospital decision making), and for service organisations (stronger working relationships, increased capacity, and greater efficiency). Barriers to service integration were also identified, including the different cultures of Divisions and hospitals, their lack of internal coherence and the Commonwealth-state divide. The evaluation showed that much has been achieved in building the relationships and the capacity needed for GP-hospital collaboration, and that effective models exist. The current challenge is to extend successful models across health areas and make effective collaboration part of the normal system of care. Substantial progress towards integrated care relies on a shift from a focus on systems within general practice or hospital environments to a patient centred approach. This will require general practice, hospitals, community services and consumer organisations to form long term partnerships and move beyond their currently disjointed view of acute and community care. The development of practical indicators for integrated care will support the process and facilitate shared learning across Commonwealth and state divides.

Australia↗