A Critical Realist Translational Social Epidemiology Protocol for Concretising and Contextualising a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)", Sydney Australia.

BACKGROUND: We will describe here a translational social epidemiology protocol for confirming a critical realist "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD). The approach will include the concretising and contextualising of the above causal theory into programme theories for child and adolescent interventions that aim to break intergenerational cycles of disadvantage and poor life outcomes. In undertaking this work we seek to advance realist translational methodology within the discipline of applied perinatal and paediatric social epidemiology. THEORY AND METHODS: The research settings are in metropolitan Sydney. The design will be a longitudinal, multi-level, mixed method realist evaluation of applied programme interventions that seek to break the intergeneration cycle of social disadvantage and poor child health and developmental outcomes. The programme of research will consist of three components: 1) Operationalisation of the theory and designing of programme initiatives for implementation; 2) Evaluation of the translated programme and implementation theory using Theory of Change and critical realist evaluation; and 3) Theory Testing of realist hypotheses using both intensive and extensive critical realist research methods including realist structural modelling. DISCUSSION: The proposed programme of research will assist in translating empirical explanatory theory building to theory driven interventions. The research will be situated in socially disadvantaged regions of Sydney where the local child and family inter-agencies will collaborate to design and implement new initiatives that address significant disparities in childhood development and adolescent outcomes attributed to neighbourhood circumstances, family stress and intergenerational cycles of disadvantage and poor mental health.

Designing Initiatives for Vulnerable Families: From Theory to Design in Sydney, Australia.

INTRODUCTION: Intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours require innovative models of health care delivery to break them. We describe a programme of research informed service development targeting vulnerable families in inner metropolitan Sydney, Australia that is designed to build and confirm a "Theory of Neighbourhood Context, Stress, Depression, and the Developmental Origins of Health and Disease (DOHaD)". We describe the development of an intervention design and business case that drew on earlier realist causal and programme theoretical work. METHODS: Realist causal and programme theory were used to inform the collaborative design of initiatives for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, consultation forums, interagency planning, and development of a service proposal. RESULTS: The design elements included: perinatal coordination, sustained home visiting, integrated service model development, two place-based hubs, health promotion and strengthened research and analysis capability. CONCLUSIONS: We demonstrate here the design of interventions for vulnerable families in Sydney utilising translational research from previous realist causal and program theory building to operational service design. We have identified the importance of our earlier analysis of underlying causal mechanisms and related programme mechanisms for identifying the elements for the full intervention design. The application of theory added rigour to the design of the integrated care initiatives. In applying the theory to the local situation the analysis took into account: the role of the local agencies; evidence of program effectiveness; determinants and outcomes for local children and their families; the current deployment of service resources; and insights from front-line staff and interagency partners.

Designing an Integrated Care Initiative for Vulnerable Families: Operationalisation of Realist Causal and Programme Theory, Sydney Australia.

INTRODUCTION: In July 2015 Sydney Local Health District (SLHD) implemented an integrated care initiative for vulnerable families in the Inner West region of Sydney, Australia. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. We will describe the development of the design that drew on earlier realist causal and program theoretical work. METHODS: Realist causal and program theory were used to inform the collaborative design of an initiative for vulnerable families. The collaborative design process included: identification of desirable and undesirable outcomes and contextual factors, stakeholder consultation, interagency planning, and development of a service proposal. RESULTS: The design elements included: identification of vulnerable family cohorts; care coordination; evidence-informed intervention(s); general practice engagement and support; family health improvement; placed-based neighbourhood initiatives; interagency system change and collaborative planning; monitoring of individual and family outcomes; and evaluation. CONCLUSIONS: The design study described advances toward the implementation of a whole-of-government integrated health and social care initiative. The initiative was designed as a cross-agency care coordination network that would ensure that vulnerable families: had their complex health and social needs met; kept themselves and their children safe; and were connected to society. In so doing we aim to break intergenerational cycles of poverty, violence and crime, poor education and employment opportunities, psychopathology, and poor lifestyle and health behaviours, through strengthening family resilience, improving access to services, and addressing the social determinants of health and wellbeing.

Evidence use in equity focused health impact assessment: a realist evaluation.

BACKGROUND: Equity-focused health impact assessment (EFHIA) can function as a framework and tool that supports users to collate data, information, and evidence related to health equity in order to identify and mitigate the impact of a current or proposed initiative on health inequities. Despite education efforts in both the clinical and public health settings, practitioners have found implementation and the use of evidence in completing equity focussed assessment tools to be challenging. METHODS: We conducted a realist evaluation of evidence use in EFHIA in three phases: 1) developing propositions informed by a literature scan, existing theoretical frameworks, and stakeholder engagement; 2) data collection at four case study sites using online surveys, semi-structured interviews, document analysis, and observation; and 3) a realist analysis and identification of context-mechanism-outcome patterns and demi-regularities. RESULTS: We identified limited use of academic evidence in EFHIA with two explanatory demi-regularities: 1) participants were unable to "identify with" academic sources, acknowledging that evidence based practice and use of academic literature was valued in their organization, but seen as less likely to provide answers needed for practice and 2) use of academic evidence was not associated with a perceived "positive return on investment" of participant energy and time. However, we found that knowledge brokering at the local site can facilitate evidence familiarity and manageability, increase user confidence in using evidence, and increase the likelihood of evidence use in future work. CONCLUSIONS: The findings of this study provide a realist perspective on evidence use in practice, specifically for EFHIA. These findings can inform ongoing development and refinement of various knowledge translation interventions, particularly for practitioners delivering front-line public health services.

It takes a village: a realist synthesis of social pediatrics program.

OBJECTIVES: To better understand how social pediatric initiatives (SPIs) enact equitable, integrated, embedded approaches with high-needs children and families while facilitating proportionate distribution of health resources. METHODS: The realist review method incorporated the following steps: (1) identifying the review question, (2) formulating the initial theory, (3) searching for primary studies, (4) selecting and appraising study quality, (5) synthesizing relevant data and (6) refining the theory. RESULTS: Our analysis identified four consistent patterns of care that may be effective in social pediatrics: (1) horizontal partnerships based on willingness to share status and power; (2) bridged trust initiated through previously established third party relationships; (3) knowledge support increasing providers' confidence and skills for engaging community; and (4) increasing vulnerable families' self-reliance through empowerment strategies. CONCLUSIONS: This research is unique because it focused on "how" outcomes are achieved and offers insight into the knowledge, skills and philosophical orientation clinicians need to effectively deliver care in SPIs. Research insights offer guidance for organizational leaders with a mandate to address child and youth health inequities and may be applicable to other health initiatives.

Influence of revised public health standards on health equity action: a qualitative study in Ontario, Canada.

BACKGROUND: In 2008, a revised set of public health standards was released in the province of Ontario, Canada. The updated Ontario Public Health Standards (OPHS) introduced a new policy mandate that required local public health units (PHUs) to identify "priority populations" for public health programs and services. The aim of this study was to understand how this Priority Populations Mandate (PPM) facilitated or hindered action on health equity or the social determinants of health through PHUs in Ontario. METHODS: This study used two sets of qualitative data that were part of a larger study. The first set of data was 16 semi-structured key informant interviews with policymakers involved in developing the OPHS and public health practitioners. The second set of data was the qualitative component of a role-based survey sent out to all the 36 PHUs in Ontario. Thematic content analysis was conducted to iteratively develop themes to answer the research question. RESULTS: We identified six factors that both facilitated and hindered action on health equity and social determinants of health action in the province resulting from the OPHS and PPM. These six factors were grouped into three categories or themes: OPHS policy attributes (1. introducing new terminology, 2. allowing flexibility in implementation and 3. ensuring evidence-informed decision-making), health sector context into which the PPM was introduced (4. different understandings of health equity and 5. variability in existing partnerships) and implementation by PHUs (6. requirement to address the PPM). CONCLUSIONS: Although the revised OPHS and the PPM facilitated action on health equity and the social determinants of health, on the whole, this objective could have been better met. The mandate within the OPHS could have been strengthened with respect to promoting action on health equity and the social determinants of health through more clearly defined terminology, conveying a guiding health equity vision and uniting different PHU approaches to addressing health equity.

Enhancing undergraduate public health education through public health interest groups.

PURPOSE: Since 2007, all Canadian medical schools have had at least one established student-led public health interest group (PHIG). The Association of Faculties of Medicine of Canada (AFMC), the Public Health Task Group, and the Public Health Agency of Canada (PHAC) have supported these PHIGs. The authors describe the activities and structure of PHIGs in Canada from 2007 to 2011, plus the extent to which PHIGs met the objectives set out for them by the AFMC Public Health Task Group. METHOD: Using a standardized template, the authors analyzed funding applications and reports that PHIG executives submitted to the AFMC from 2007 through 2011. The authors created activity categories and collected simple counts of activities within categories. They then used these data to assess how successfully PHIGs have been able to meet their objectives. RESULTS: Fifty-two funding applications, 50 interim reports, and 48 final reports were available for analysis. All 17 Canadian medical schools had at least one established PHIG between 2007 and 2011, and 9 schools (53%) applied for PHIG funding in all four years. Academic activities such as lectures, seminars, and workshops were the most common activities conducted by PHIGs, followed by career exploration and networking. CONCLUSIONS: This study found that the AFMC, with funding support from PHAC, was instrumental in initiating PHIGs in 82% (n = 14) of Canadian medical schools. With consistent funding, national networking opportunities, and a common operating structure, PHIGs have been able to accomplish AFMC's objectives for increasing public health awareness amongst medical students.

Canadian medical students' perceptions of public health education in the undergraduate medical curriculum.

PURPOSE: To understand the perceptions and attitudes of Canadian medical students toward their undergraduate medical public health curriculum and to identify student suggestions and priorities for curriculum change. METHOD: Five focus groups of 11 or 12 medical students from all years of medical school were recruited at McMaster University Faculty of Health Sciences, Université de Sherbrooke Faculty of Medicine and Health Sciences, University of Toronto Faculty of Medicine, University of Manitoba Faculty of Medicine, and University of British Columbia Faculty of Medicine between February and April 2006. A professional facilitator was hired to conduct the focus groups using a unique, computer-based facilitation system. Questions in both the focus group and an accompanying survey sought to determine medical students' understanding and exposure to public health and how this impacted their attitudes and choices toward careers in the public health medical specialty of community medicine. The transcripts were independently reviewed and analyzed by each of the authors to identify themes. RESULTS: Four major themes related to students' desired curriculum change were identified: (1) poor educational experiences in public health courses, (2) lack of positive role models, especially exposure to community medicine specialists, (3) emphasis on statistics and epidemiology, and (4) negative attitudes toward public health topics. CONCLUSIONS: Students are disillusioned, disengaged, and disappointed with the public health curriculum currently being provided at the Canadian medical schools studied. Many medical students would prefer a public health curriculum that is more challenging and has more applied field experience and exposure to public health physician role models.

Assessing Canadian medical students' familiarity with and interest in pursuing a career in community medicine.

OBJECTIVES: Following the SARS outbreak, large gaps in the public health workforce have been identified. This study sought to understand the perceptions and attitudes of Canadian medical students with regard to public health to determine how this impacted their choice towards a career in Community Medicine (CM). METHODS: Five focus groups of 11-12 medical students from all years were recruited at McMaster University, Université de Sherbrooke, University of Toronto, University of Manitoba and the University of British Columbia. A professional facilitator was hired to conduct the focus groups using a unique computer-based facilitation system. Questions in both the focus group and an accompanying survey sought to determine medical students' understanding and exposure to public health and how this impacted their attitude and choice towards a career in community medicine. The transcripts were independently reviewed and analyzed by each of the authors to identify themes. RESULTS: Four major themes related to choosing Community Medicine as a career were identified: 1) poor understanding of the role of Community Medicine specialists in public health practice, 2) perceived lack of clinical work and relevance of public health to clinical practice, 3) perceived lack of exclusivity of Community Medicine specialty, 4) incentives and disincentives to pursuing Community Medicine. CONCLUSION: Better education of students on the role of CM specialists through increasing exposure to role models and demystifying inaccurate perceptions of CM through integration of public health with clinical medicine may potentially increase medical student entry into Community Medicine.

Melanoma detection in British Columbia, Canada.

BACKGROUND: In several studies, delays in malignant melanoma (MM) diagnosis have been correlated with increased tumor thickness, increased morbidity, and increased mortality. OBJECTIVE: We sought to assess how MM is detected in British Columbia, Canada, and to understand the role of patient education and other factors on diagnostic delays. METHODS: A self-administered questionnaire was distributed to 176 consecutive patients with histologically confirmed MM. RESULTS: The total median delay was 4 months. There was no correlation between tumor thickness and delay times. Lesions found incidentally by physicians were less invasive (median Breslow thickness 0.59 vs 1.0 mm, P=.006) than those found by patients. The majority of patients had some knowledge of MM and recognized the importance of early detection. Nearly one fourth of respondents were unaware MM could develop from a melanocytic nevus. In general, MM knowledge did not affect total delay. CONCLUSION: Patients in British Columbia, Canada, report relatively short delays in diagnosis of MM. Delays were not correlated with increased tumor thickness or with patient knowledge regarding melanoma before diagnosis.

Cutaneous manifestations of eating disorders.

BACKGROUND AND OBJECTIVE: No complete review of the cutaneous manifestations of eating disorders exists. We therefore, set out to review and systematically describe the clinical and histopathologic features of dermatologic conditions associated with anorexia nervosa, bulimia nervosa, and obesity. Differential diagnosis, pathophysiology, laboratory studies, and treatment are also reviewed. METHODS: Index Medicus review (1966 to present) using Ovid-MEDLINE. Search terms included eating disorders, anorexia nervosa, bulimia nervosa, eating disorders not otherwise specified (ED-NOS), and obesity, as well as the terms dermatology skin and cutaneous manifestations, with cross-referencing sources. These were combined with our own clinical experience. All relevant publications, including case reports, case series, cohort studies, and histopathologic studies giving at least Level II-3 evidence (evidence from comparisons between times or places with or without the intervention, including dramatic results in uncontrolled experiments), were selected. CONCLUSION: Forty dermatological signs have been reported in eating disorder patients. Eating disorders have many cutaneous manifestations and cutaneous signs may lead to the diagnosis of an occult eating disorder. The resolution of skin eruptions in eating disorder patients often depends on treatment of the underlying disorder.