Addressing the under-reporting of adverse drug reactions in public health programs controlling HIV/AIDS, Tuberculosis and Malaria: A prospective cohort study.

BACKGROUND: Adverse Drug Reactions (ADRs) are a major clinical and public health problem world-wide. The prompt reporting of suspected ADRs to regulatory authorities to activate drug safety surveillance and regulation appears to be the most pragmatic measure for addressing the problem. This paper evaluated a pharmacovigilance (PV) training model that was designed to improve the reporting of ADRs in public health programs treating the Human Immunodeficiency Virus (HIV), Tuberculosis (TB) and Malaria. METHODS: A Structured Pharmacovigilance and Training Initiative (SPHAR-TI) model based on the World Health Organization accredited Structured Operational Research and Training Initiative (SOR-IT) model was designed and implemented over a period of 12 months. A prospective cohort design was deployed to evaluate the outcomes of the model. The primary outcomes were knowledge gained and Individual Case Safety Reports (ICSR) (completed adverse drug reactions monitoring forms) submitted, while the secondary outcomes were facility based Pharmacovigilance Committees activated and health facility healthcare workers trained by the participants. RESULTS: Fifty-five (98%) participants were trained and followed up for 12 months. More than three quarter of the participants have never received training on pharmacovigilance prior to the course. Yet, a significant gain in knowledge was observed after the participants completed a comprehensive training for six days. In only seven months, 3000 ICSRs (with 100% completeness) were submitted, 2,937 facility based healthcare workers trained and 46 Pharmacovigilance Committees activated by the participants. Overall, a 273% increase in ICSRs submission to the National Agency for Food and Drug Administration and Control (NAFDAC) was observed. CONCLUSION: Participants gained knowledge, which tended to increase the reporting of ADRs. The SPHAR-TI model could be an option for strengthening the continuous reporting of ADRs in public health programs in resource limited settings.

Quantifying spatial accessibility in public health practice and research: an application to on-premise alcohol outlets, United States, 2013.

OBJECTIVE: To assess spatial accessibility measures to on-premise alcohol outlets at census block, census tract, county, and state levels for the United States. METHODS: Using network analysis in a geographic information system, we computed distance-based measures (Euclidean distance, driving distance, and driving time) to on-premise alcohol outlets for the entire U.S. at the census block level. We then calculated spatial access-based measures, specifically a population-weighted spatial accessibility index and population-weighted distances (Euclidean distance, driving distance, and driving time) to alcohol outlets at the census tract, county, and state levels. A multilevel model-based sensitivity analysis was conducted to evaluate the associations between different on-premise alcohol outlet accessibility measures and excessive drinking outcomes. RESULTS: The national average population-weighted driving time to the nearest 7 on-premise alcohol outlets was 5.89 min, and the average population-weighted driving distance was 2.63 miles. At the state level, population-weighted driving times ranged from 1.67 min (DC) to 15.29 min (Arizona). Population-weighted driving distances ranged from 0.67 miles (DC) to 7.91 miles (Arkansas). At the county level, population-weighted driving times and distances exhibited significant geographic variations, and averages for both measures increased by the degree of county rurality. The population-weighted spatial accessibility indexes were highly correlated to respective population-weighted distance measures. Sensitivity analysis demonstrated that population weighted accessibility measures were more sensitive to excessive drinking outcomes than were population weighted distance measures. CONCLUSIONS: These results can be used to assess the relationship between geographic access to on-premise alcohol outlets and health outcomes. This study demonstrates a flexible and robust method that can be applied or modified to quantify spatial accessibility to public resources such as healthy food stores, medical care providers, and parks and greenspaces, as well as, quantify spatial exposure to local adverse environments such as tobacco stores and fast food restaurants.

When public health intervention is not successful: Cost sharing, crowd-out, and selection in Korea's National Cancer Screening Program.

This study investigates the impact of and behavioral responses to cost sharing in Korea's National Cancer Screening Program, which provides free stomach and breast cancer screenings to those with an income below a certain cutoff. Free cancer screening substantially increases the screening take up rate, yielding more cancer detections. However, the increase in cancer detection is quickly crowded out by cancer detection through other channels such as diagnostic testing and private cancer screening. Further, compliers are much less likely to have cancer than never takers. Crowd-out and selection help explain why the program has been unable to reduce cancer mortality.

Building the evidence for decision-making: the relationship between local public health capacity and community mortality.

OBJECTIVES: We examined associations between local health department (LHD) spending, staffing, and services and community health outcomes in North Carolina. METHODS: We analyzed LHD investments and community mortality in North Carolina from 2005 through 2010. We obtained LHD spending, staffing, and services data from the National Association of City and County Health Officials 2005 and 2008 profile surveys. Five mortality rates were constructed using Centers for Disease Control and Prevention mortality files, North Carolina vital statistics data, and census data for LHD service jurisdictions: heart disease, cancer, diabetes, pneumonia and influenza, and infant mortality. RESULTS: Spending, staffing, and services varied widely by location and over time in the 85 North Carolina LHDs. A 1% increase in full-time-equivalent staffing (per 1000 population) was associated with decrease of 0.01 infant deaths per 1000 live births (P < .05). Provision of women and children's services was associated with a reduction of 1 to 2 infant deaths per 1000 live births (P < .05). CONCLUSIONS: Our findings, in the context of other studies, provide support for investment in local public health services to improve community health.

How health economic evaluation (HEE) contributes to decision-making in public health care: the case of Brazil.

The universal access to a health care system for the Brazilian population was established in 1990. Brazil is a country with no tradition in the production and use of health economic evaluation (HEE) to guide decision making in the public health system. It is only within the last two decades that HEEs using a microeconomic approach have appeared in the academic field. On a national level, HEE and Health Technology Assessment (HTA), in a wider sense, were first taken into account in 2003. Two policies deserve to be mentioned - (i) the regulation of medicines in the Brazilian market, and (ii) science, technology and innovation policy. The latter required the fostering of applied research to encourage the application of methods which employ systematic reviews and economic analyses of cost-effectiveness to guide the incorporation of technologies in the Brazilian health care system. The Ministry of Health has initiated the process of incorporating these new technologies on a federal level during the last ten years. In spite of the improvement of HEE methods at Brazilian universities and research institutes, these technologies have not yet reached the governmental bodies. In Brazil, the main challenge lies in the production, interpretation and application of HEE to all technologies within the access scheme(s), and there is limited capacity building. Setting priorities can be the solution for Brazil to be able to perform HEE for relevant technologies within the access scheme(s) while the universal coverage system struggles with a triple burden of disease.

Assessing the level of public health partner spending using the funding formula analysis tool.

Public health services are delivered through a variety of organizations. Traditional accounting of public health expenditures typically captures only spending by government agencies. New Hampshire collected information from public health partners, such as community centers that host smoking cessation classes or health education done by Girls, Inc. This study compares the new data to spending by government agencies, focusing on breakdowns by fund source and service categories. Expanded funds secured by these partners account for a 42% of all local public health spending, and they spent 4 times more than government agencies on promoting healthy behavior. The funding formula analysis tool revealed that these partners spent in ways that would be politically difficult to achieve. In an era of declining budgets, an understanding of public health's partners is increasingly vital.

Public health services, an essential determinant of health during crisis. Lessons from Cuba, 1989-2000.

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989-2000 analyses the country's strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population.

Exploring Thailand's mortality transition with the aid of life tables.

The project Thai Health-Risk Transition: A National Cohort Study seeks to better understand the health implications of modernisation and globalisation forces impacting on Thailand. As part of its "look-back" component this paper seeks, using available life tables, to document the country's post-war mortality transition. The onset of transition through mass campaigns of the late 1940s and 1950s is first discussed before attention turns to the life tables. They are predictably far from flawless, but careful analysis does permit trends that have seen around 30 years added to life expectancy to be traced, and age patterns of improved survivorship and their relation to initiatives to improve health to be examined. The broad benefits generated by mass campaigns, ongoing improvements in infant and early childhood mortality, and a phased impact of the expansion of primary health care in rural areas on adult survival prospects after the mid-1970s are demonstrated. The paper also investigates the consequences for mortality of a motorcycle-focused rapid increase in road fatalities in the late 1980s and early 1990s and the HIV/AIDS epidemic that developed after 1984.

An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health.

BACKGROUND: There is a need to identify and analyse the range of models developed to date for delivering health-related lifestyle advice (HRLA), or training, for effectiveness and cost-effectiveness in improving the health and well-being of individuals and communities in the UK, with particular reference to the reduction of inequalities. OBJECTIVES: To identify the component intervention techniques of lifestyle advisors (LAs) in the UK and similar contexts, and the outcomes of HRLA interventions. DATA SOURCES: Stakeholder views, secondary analysis of the National Survey of Health Trainer Activity, telephone survey of health trainer leads/coordinators. A search of a range of electronic databases was undertaken [including the Applied Social Sciences Index and Abstracts (ASSIA), EMBASE, NHS Economic Evaluation Database (NHS EED), MEDLINE, Psyc INFO, etc.], as well searching relevant journals and reference lists, conducted from inception to September 2008. REVIEW METHODS: Identified studies were scanned by two reviewers and those meeting the following criteria were included: studies carrying out an evaluation of HRLA; those taking place in developed countries similar to the UK context; those looking at adult groups; interventions with the explicit aim of health improvement; interventions that involved paid or voluntary work with an individual or group of peers acting in an advisory role; advice delivered by post, online or electronically; training, support or counselling delivered to patients, communities or members of the public. After quality assessment, studies were selected for inclusion in the review. Data were abstracted from each study according to an agreed procedure and narrative, and realist and economic approaches were used to synthesise the data. Cost-effectiveness analysis of interventions was undertaken. RESULTS: In total, 269 studies were identified but 243 were excluded. The 26 included studies addressing chronic care, mental health, breastfeeding, smoking, diet and physical activity, screening and human immunodeficiency virus (HIV) infection prevention. Overall, there was insufficient evidence to either support or refute the use of LAs to promote health and improve quality of life (QoL), and thus uncertainty about the interventions' cost-effectiveness. However, the economic analysis showed that LA interventions were cost-effective in chronic care and smoking cessation, inconclusive for breastfeeding and mental health and not cost-effective for screening uptake and diet/physical activity. LA interventions for HIV prevention were cost-effective, but not in a UK context. LIMITATIONS: The wide variety of LA models, delivery settings and target populations prevented the reviewers from establishing firm causal relationships between intervention mode and study outcomes. CONCLUSIONS: Evidence was variable, giving only limited support to LAs having a positive impact on health knowledge, behaviours and outcomes. Levels of acceptability appeared to be high. LAs acted as translational agents, sometimes removing barriers to prescribed behaviour or helping to create facilitative social environments. Reporting of processes of accessing or capitalising on indigenous knowledge was limited. Ambiguity was apparent with respect to the role and impact of lay and peer characteristics of the interventions. A future programme of research on HRLA could benefit from further emphasis on identification of needs, the broadening of population focus and intervention aims, the measurement of outcomes and the reviewing of evidence. FUNDING: This study was funded by the Health Technology Assessment programme of the National Institute for Health Research.

The ethics of sin taxes.

ABSTRACT The current global economic crisis is forcing governments to consider a variety of methods to generate funds for infrastructure. In the United States, smoking-related illness and an obesity epidemic are forcing public health institutions to consider a variety of methods to influence health behaviors of entire target groups. In this paper, the author uses a public health nursing model, the Public Health Code of Ethics (Public Health Leadership Society, 2002), the American Nurses' Association (ANA) Code of Ethics (2001), and other relevant ethical theory to weigh and balance the arguments for and against the use of sin taxes. A position advocating the limited use of sin taxes is supported as a reasonable stance for the public health professional.

Modelo multidimensional para o controle da dengue: uma proposta com base na reprodução social e situações de riscos / Multidimensional model for dengue control: a proposal based on social reproduction and risk situations

O objetivo do artigo consiste em apresentar e discutir um modelo compreensivo/explicativo, de caráter ecossistêmico, sobre o processo de transmissão da dengue nos níveis de micro e macrocontexto, a partir da identificação das situações de riscos envolvidas. Considerou-se a dengue como doença infecciosa viral de transmissão vetorial que traz, na sua dinâmica de transmissão, elementos das dimensões biológicas, de conduta, ecológicas, políticas e econômicas, o que a caracteriza como um problema complexo e exige um enfoque sistêmico para seu controle. Assim, para a construção da modelagem, utilizaram-se o enfoque teórico da reprodução social de Juan Samaja e seus condicionantes de macro e microcontexto, e o enfoque operativo ecossistêmico, que buscou responder à pergunta condutora desta construção: quais são as situações de risco para transmissão da dengue, considerando as diversas dimensões da "reprodução social da saúde" no nível local? A visão ampliada das inter-relações entre as diversas situações de risco envolvidas na determinação multidimensional da dengue poderá servir como eixo direcionador para uma gestão integrada das ações do programa de controle da doença, articuladas entre os diversos setores envolvidos.

This paper aims to present and discuss a comprehensive / explanatory model, of ecosystem approach, on the process of transmission of dengue in the levels of micro and macro context, from the identification of the risks involved. Dengue was considered a viral infectious disease of vectorial transmission that carries on its transmission dynamics, elements of the biological, behavioral, ecological, political and economic dimensions, that make it a complex problem and require a systemic approach to its control. Thus, for the construction of modeling, we used the theoretical framework of social reproduction of Juan Samaja and its conditions of macro and micro-context, and the operating ecosystem approach, which sought to answer the question driving this construction: what are the risk situations for the transmission of dengue, considering the different dimensions of "social reproduction of health" at the local level? The enlarged view of the interrelationships among the various risk situations involved in determining multidimensional dengue could guide the integrated management of actions of a disease control program, coordinated by the several sectors involved.

Americans' conflicting views about the public health system, and how to shore up support.

This analysis of national opinion polls shows that a majority of Americans support increased spending on public health in general and that they see public health interventions as saving money in the long term. At the same time, many do not favor increased federal spending in a number of areas that public health officials deem important. In addition, polls show striking partisan differences, with Republicans much less supportive than Democrats of additional spending on public health. This split may have political implications for the public health component of the new health reform law if there is a change in party control of one or more houses of Congress after the November 2010 elections. As a result, in order to sustain public support for increased spending, it will be critically important to give examples of cost savings from public health programs and to highlight how they have reduced mortality from major chronic illnesses, such as cancer, heart disease, and HIV/AIDS.

HIV/AIDS information by African companies: an empirical analysis.

This article investigates the extent of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome Disclosures (HIV/AIDSD) in online annual reports by 200 listed companies from 10 African countries for the year ending 2006. Descriptive statistics reveal a very low level of overall HIV/AIDSD practices with a mean of 6 per cent disclosure, with half (100 out of 200) of the African companies making no disclosures at all. Logistic regression analysis reveals that company size and country are highly significant predictors of any disclosure of HIV/AIDS in annual reports. Profitability is also statistically significantly associated with the extent of disclosure.

How to measure the impact of musculoskeletal conditions.

Musculoskeletal conditions are universally prevalent among all age and gender groups, across all socio-demographic strata of society. Their impact is pervasive yet this is not widely recognised at the level of health policy and priority. Musculoskeletal conditions are a diverse group of disorders with regard to pathophysiology but are linked anatomically and by their association with pain and impaired physical function; encompassing a spectrum of conditions, including inflammatory diseases such as rheumatoid arthritis or gout; age-related conditions such as osteoporosis and osteoarthritis; common conditions of unclear aetiology such as back pain and fibromyalgia; and those related to activity or injuries such as occupational musculoskeletal disorders, sports injuries or the consequences of falls and major trauma. The increasing number of older people and the changes in lifestyle throughout the world with increasing obesity and reduced physical activity mean that the burden on people and society will increase dramatically. The growing awareness of the burden increases the need for accurate measurement and assessment of the burden as well as measurement of the impact of any public health action. This chapter considers theoretical and practical issues relevant to measuring the buden of musculoskeltal conditions in populations, societies and individuals.

Manhattan transfer: lethal radiation, bone marrow transplantation, and the birth of stem cell biology, ca. 1942-1961.

This study investigates how, in the late 1940s and 1950s, fears of nuclear accidents and nuclear warfare shaped postwar radiobiology. The new and intense forms of radiation generated by nuclear reactor technology, and which would be released in the event of a nuclear war, created concerns about a public-health hazard unprecedented in form and scale. Fears of inadvertent exposure to acute and potentially lethal radiation launched a search for anti-radiation therapies, out of which emerged the new technique of bone marrow transplantation (BMT). This study analyzes the use of BMT first as a research tool to explore the biological effects of ionizing radiation, and then as an adjunct to radiotherapy for the treatment of cancer. In highlighting how BMT became the province of different research and clinical constituencies, this study develops an understanding of the forces and contingencies that shaped its development. Exploring the emergence of BMT and the uses to which it was put, it reveals that BMT remained a technique in the making -- unstable and far from standardized, even as it became both a widely used research tool and rapidly made its way into the clinic. More broadly, it casts new light on one route through which the Manhattan Project influenced postwar radiobiology; it also affords new insights into one means by which radiobiology came to serve the interests of the Cold War state. In its focus on BMT this paper provides a new perspective on the evolving relationship between radiobiology and biomedicine in the postwar period.

Socioeconomic effects of HIV/AIDS and farmers' involvement in risky behaviour in southern Nigeria.

This article analyses farmers' perceptions on the socioeconomic effects of HIV/AIDS and factors associated with their involvement in risky behaviour in southern part of Nigeria. The data were collected in 2004 from 515 farmers in five randomly selected states in southern Nigeria. The results show that most of the affected farmers spend reduced hours in daily work, as well as having a reduced income and reduced participation in community development due to HIV/AIDS. Logistic regression reveals that age and education significantly reduce the probability of being involved in behaviour conducive to HIV/AIDS infection, which is increased by not believing in the existence of HIV/AIDS, ignorance about HIV/AIDS methods of prevention, lack of warning about HIV/AIDS, reports of HIV/AIDS in the village, the distance to the public health centre and the lack of a health centre. These findings, while unsurprising, emphasise the importance of HIV/AIDS as a socioeconomic issue.

Seeing the forest and the trees: using network analysis to develop an organizational blueprint of state tobacco control systems.

In the United States, tobacco control activities are organized primarily in state tobacco control programs. These programs are comprised of public and private agencies working together to reduce tobacco use. The human, financial, and informational resources that go into state tobacco control programs are documented, and the outcomes of these programs have been studied in terms of health and health behavior. However, little is known about the organizational infrastructure that transforms the human, financial, and informational resources into positive health outcomes. This study examined the inter-organizational relationships among key partner agencies in eight state tobacco control programs. The state programs varied in terms of funding level, funding stability, and region of the country. Using a network analytic approach we asked an average of 14 agencies in each state program about their contacts and partnerships with the other key tobacco control agencies in their state program. Using network visualization and statistics we determined that the state networks shared some common features such as a highly central lead agency, but also had differences in network structure in terms of density and centralization. Using blockmodeling we found that, despite differences in state and program characteristics, there was a common organizational structure among the eight state programs. Understanding the inter-organizational relationships and the common organizational structures of state programs can aid researchers and practitioners in enhancing program capacity and in developing strategies for organizing effective public health systems.

Demand analysis of tobacco consumption in Malaysia.

We estimated the price and income elasticity of cigarette demand and the impact of cigarette taxes on cigarette demand and cigarette tax revenue in Malaysia. The data on cigarette consumption, cigarette prices, and public policies between 1990 and 2004 were subjected to a time-series regression analysis applying the error-correction model. The preferred cigarette demand model specification resulted in long-run and short-run price elasticities estimates of -0.57 and -0.08, respectively. Income was positively related to cigarette consumption: A 1% increase in real income increased cigarette consumption by 1.46%. The model predicted that an increase in cigarette excise tax from Malaysian ringgit (RM) 1.60 to RM2.00 per pack would reduce cigarette consumption in Malaysia by 3.37%, or by 806,468,873 cigarettes. This reduction would translate to almost 165 fewer tobacco-related lung cancer deaths per year and a 20.8% increase in the government excise tax revenue. We conclude that taxation is an effective method of reducing cigarette consumption and tobacco-related deaths while increasing revenue for the government of Malaysia.

Policy issues related to expanded newborn screening: a review of three genetic/metabolic disorders.

In 2005, a federal advisory committee recommended that the number of disorders in state newborn screening programs be expanded from 9 to 29. In view of this recommendation, state leaders will need to make cogent decisions regarding the expanse of their state newborn screening programs. They must consider several factors, including the costs and outcomes of the screening program. The expense of the initial screening test can be misleading because it does not include the cost of the entire program (testing, tracking, notifying, retesting, confirmatory testing, and follow-up). Also, outcomes such as false positive findings can be costly to newborn screening programs, result in additional testing for infants, and lead to parental concern and worry. This article examines some of the policy issues related to newborn screening and specifically focuses on three disorders recommended for newborn screening, cystic fibrosis (CF), medium-chain acyl CoA dehydrogenase Deficiency (MCADD), and beta-ketothiolase (BKT).