Building the future one health workforce

A ‘new normal’ in public health and healthcare has arisen with socioeconomic shifts, technological developments, political strife, climate change, environmental degradation, and COVID-19. Challenges cannot be solved by one discipline or profession alone, but requires multiple sectors coming together, combining knowledge, expertise and methods. One Health is an integrated epidemiological and economic approach aiming to sustainably optimise the health of people, animals and ecosystem. This article reflects on the roles of Association of Schools of Public Health in the European Region (ASPHER) and European Health Management Association (EHMA) and the concrete steps needed to address skills for One Health.

Reassessing the health impacts of trade and investment agreements: a systematic review of quantitative studies, 2016-20.

To ensure a high level of health protection, governments must ensure that health and trade policy objectives are aligned. We conducted a systematic review of the health impacts of trade policies, including trade and investment agreements (TIAs), to provide a timely overview of this field. We systematically reviewed studies evaluating the health impacts of trade policies published between Jan 19, 2016, and July 10, 2020. Included studies were quantitative studies evaluating the impact of TIAs and trade policies on health determinants or outcomes. We evaluated methodological quality and performed a narrative synthesis. 21 of 28 067 articles identified via searches met our criteria. Methodologically strong studies found reduced child mortality, deteriorating worker health, rising supplies of sugar, ultra-processed food, tobacco, and alcohol supplies, and increased drug overdoses following trade reforms, compared with the time periods before trade reform. However, associations varied substantially across contexts and socioeconomic characteristics. Our findings show that trade policies, including TIAs, have diverse effects on health and health determinants. These effects vary substantially across contexts and socioeconomic groups. Governments seeking to adopt healthy trade policies should consider these updated findings to ensure that opportunities for health improvement are leveraged and widely shared, while harms are avoided, especially among vulnerable groups.

Filling the Gaps in the Pharmacy Workforce in Post-Conflict Areas: Experience from Four Countries in Sub-Saharan Africa.

BACKGROUND: While the pharmacy workforce is the third largest professional healthcare group worldwide, the pharmacy workforce landscape remains unclear in post-conflict areas in sub-Saharan Africa. METHOD: Key informants were selected for semi-structured interviews due to their role in providing pharmacy services in the selected country: the Central African Republic (CAR), the Democratic Republic of Congo (DRC), Ethiopia, and South Sudan. Transcripts from the interviews were anonymized, coded, and analyzed. RESULTS: Nine participants were recruited (CAR: 2; DRC: 2; Ethiopia: 2; South Sudan: 3), and all except two were pharmacists. Conflict-specific challenges in pharmacy service delivery were identified as the following: unpredictable health needs and/or mismatched pharmaceutical supply, transport difficulties due to insecure roads, and shortage of pharmacy workforce due to brain drain or interrupted schooling. Barriers to health workforce retention and growth were identified to be brain drain as a result of suboptimal living and working conditions or remuneration, the perception of an unsafe work environment, and a career pathway or commitment duration that does not fit the diaspora or expatriate staff. CONCLUSION: To tackle the barriers of pharmacy health workforce retention and growth, policy solutions will be required and efforts that can bring about long-term improvement should be prioritized. This is essential to achieve universal health coverage and the targets of the sustainable development goals for conflict affected areas, as well as to "leave no one behind".

Ethnic and minority group differences in engagement with COVID-19 vaccination programmes - at Pandemic Pace; when vaccine confidence in mass rollout meets local vaccine hesitancy.

Israel, the UK, the USA, and some other wealthier countries lead in the implementation of COVID-19 vaccine mass vaccination programmes. Evidence from these countries indicates that their ethnic minorities could be as disproportionately disadvantaged in COVID-19 vaccines roll-out as they were affected by COVID-19-related serious illnesses. Their disadvantage is linked to their lower social status and fewer social goods compared with dominant population groups.Albeit limited by methodology, early studies attribute lower uptake of COVID-19 amongst ethnic minorities to the wider determinants of vaccine uptake, hesitancy or lack of vaccine confidence, including lower levels of trust and greater concerns about vaccine safety. Early sentinel studies are needed in all early adopter countries.One emerging theme among those of reproductive age in minority communities concerns a worry regarding COVID-19 vaccine's potential adverse effect on fertility. Respected professional groups reassure this is not a credible rationale. Drug and vaccine regulators use understandable, cautious and conditional language in emergency licencing of new gene-based vaccines. Technical assessments on whether there is any potential genotoxicity or reproductive toxicity should be more emphatic.From a public health perspective, sentinel studies should identify such community concerns and act early to produce convincing explanations and evidence. Local public health workforces need to be diverse, multiskilled, and able to engage well with minorities and vulnerable groups. The local Directors of Public Health in the UK are based in each local government area and have a remit and opportunity to stimulate speedy action to increase vaccine uptake.During the rapid Pandemic Pace of the vaccines roll-out, extra efforts to minimise uptake variations are likely to achieve improvements in the next year or two. We expect variations will not disappear however, given that underlying inequalities persist in less inclusive social systems.

Homelessness Is Socially Created: Cluster Analysis of Social Determinants of Homelessness (SODH) in North West England in 2020.

Poverty creates social conditions that increase the likelihood of homelessness. These include exposure to traumatic life experiences; social disadvantages such as poor educational experiences; being raised in a broken family, care homes or foster care; physical, emotional, and sexual abuse; and neglect at an early age. These conditions reduce people's ability to negotiate through life challenges. This cross-sectional study documents the clustering and frequency of adverse social conditions among 152 homeless people from four cities in North West England between January and August 2020. Two-step cluster analysis showed that having parents with a criminal record, care history, and child neglect/abuse history was predictive of homelessness. The cluster of indicator variables among homeless people included sexual abuse (χ2 (N = 152) = 220.684, p < 0.001, Cramer's V = 0.7), inappropriate sexual behaviour (χ2 (N = 152) = 207.737, p < 0.001, Cramer's V = 0.7), emotional neglect (χ2 (N = 152) = 181.671, p < 0.001, Cramer's V = 0.7), physical abuse by step-parent (χ2 (N = 152) = 195.882, p < 0.001, Cramer's V = 0.8), and physical neglect (χ2 (N = 152) = 205.632, p < 0.001, Cramer's V = 0.8). Poverty and homelessness are intertwined because of the high prevalence of poverty among the homeless. Poverty sets up a chain of interactions between social conditions that increase the likelihood of unfavourable outcomes: homelessness is at the end of the interaction chain. Interventions supporting families to rise out of poverty may also reduce entry into homelessness.

Cost of non-alcoholic steatohepatitis in Europe and the USA: The GAIN study.

BACKGROUND & AIMS: Non-alcoholic steatohepatitis (NASH) leads to cirrhosis and is associated with a substantial socioeconomic burden, which, coupled with rising prevalence, is a growing public health challenge. However, there are few real-world data available describing the impact of NASH. METHODS: The Global Assessment of the Impact of NASH (GAIN) study is a prevalence-based burden of illness study across Europe (France, Germany, Italy, Spain, and the UK) and the USA. Physicians provided demographic, clinical, and economic patient information via an online survey. In total, 3,754 patients found to have NASH on liver biopsy were stratified by fibrosis score and by biomarkers as either early or advanced fibrosis. Per-patient costs were estimated using national unit price data and extrapolated to the population level to calculate the economic burden. Of the patients, 767 (20%) provided information on indirect costs and health-related quality of life using the EuroQOL 5-D (EQ-5D; n = 749) and Chronic Liver Disease Questionnaire - Non-Alcoholic Fatty Liver Disease (CLDQ-NAFLD) (n = 723). RESULTS: Mean EQ-5D and CLDQ-NAFLD index scores were 0.75 and 4.9, respectively. For 2018, the mean total annual per patient cost of NASH was €2,763, €4,917, and €5,509 for direct medical, direct non-medical, and indirect costs, respectively. National per-patient cost was highest in the USA and lowest in France. Costs increased with fibrosis and decompensation, driven by hospitalisation and comorbidities. Indirect costs were driven by work loss. CONCLUSIONS: The GAIN study provides real-world data on the direct medical, direct non-medical, and indirect costs associated with NASH, including patient-reported outcomes in Europe and the USA, showing a substantial burden on health services and individuals. LAY SUMMARY: There has been little research into the socioeconomic burden associated with non-alcoholic steatohepatitis (NASH). The GAIN study provides real-world data on the direct medical, direct non-medical, and indirect costs associated with NASH, including patient-reported outcomes in five European countries (UK, France, Germany, Spain, and Italy) and the USA. Mean total annual per patient cost of NASH was estimated at €2,763, €4,917, and €5,509 for the direct medical, direct non-medical, and indirect cost categories, respectively.

Effectiveness of nitric oxide agents in preventing the early onset of pre-eclampsia and possible modification of metabolic factors in high-risk pregnancies: a systematic review protocol.

OBJECTIVES: To determine the effectiveness of nitric oxide agents in modifying the metabolic factors of pre-eclampsia and its effectiveness in preventing the onset of pre-eclampsia in high-risk pregnancies. INTRODUCTION: Pre-eclampsia is a major cause of maternal death during the prenatal and neonatal periods. Nitric oxide is a vasodilator and platelet aggregation inhibitor responsible for the vascular adaptation of the placenta. Although various studies have established that nitric oxide is effective in preventing complications from pre-eclampsia, there is limited evidence to show that administering nitric oxide agents to high-risk women before 20 weeks' gestation will prevent the onset of pre-eclampsia. INCLUSION CRITERIA: This review will consider randomized controlled trials that compare nitric oxide donors and precursors with a placebo or no intervention on pregnant women (18 to 44 years) with ≤ 20-week gestational age that are at high risk of pre-eclampsia. The primary outcome of interest will be the onset of pre-eclampsia. Secondary outcomes include increased systolic and diastolic blood pressure, elevated asymmetric dimethylarginine levels, decreased endothelial nitric oxide synthase activity, reduced maternal placental vasculature, and abnormal Doppler ultrasound waveforms. METHODS: Data sources will be drawn up from MEDLINE, CINAHL, ProQuest (Health and Medicine), and Web of Science from inception till current date. No language restrictions will be applied in the search strategy. Selected studies will be assessed against the JBI critical appraisal checklist, and the certainty of evidence and strength of recommendations from findings will also be ascertained. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42018099298.

Mind your Language: Discursive Practices Produce Unequal Power and Control Over Infectious Disease: A Critical Discourse Analysis.

BACKGROUND: Power, socioeconomic inequalities, and poverty are recognized as some of the fundamental determinants of differences in vulnerability of societies to infectious disease threats. The economic south is carrying a higher burden than those in the economic north. This raises questions about whether social preventions and biomedical preventions for infectious disease are given equal consideration, and about social institutions and structures that frame the debate about infectious disease. This article examines how institutionalized ways of talking about infectious disease reinforces, creates, and sustains health inequalities. METHODS: Critical discourse analysis was considered to be epistemologically and ontologically consistent with the aims and context of this study. RESULTS: The study examined three types of infectious disease: • Emerging infectious diseases/pathogens • Neglected tropical diseases • Vector-borne infections. Examination revealed that poverty is the most common determinant of all three. CONCLUSIONS: A sustainable reduction in infectious disease in the southern countries is most likely to be achieved through tackling socioeconomic determinants. There is a need for a change in the discourse on infectious disease, and adopt a discourse that promotes self-determination, rather than one that reinforces the hero-victim scenario and power inequalities.

Being at the Bottom Rung of the Ladder in an Unequal Society: A Qualitative Analysis of Stories of People without a Home.

Background: Homelessness is rising in the United Kingdom, despite investment in measures to eradicate it made by the government and charity organisations. Aim: The aim is to examine the stories of homeless people in order to document their perceptions of their social status, the reasons that led to their homelessness, and propose a conceptual explanation. Method: We conducted 26 semi-structured interviews in three centres for homeless people in Cheshire, North West of England. Results: Three categories-education, employment, and health-emerged from the data and provided a theoretical explanation for the reasons that led to their homelessness. These are vital not only for the successful negotiation of one's way out of homelessness, but also for achieving other social goods, including social connections, social mobility, and engaging in positive social relationships. Conclusion: Participants catalogued the adverse childhood experiences, which they believe limited their capacity to meaningfully engage with the social institution for social goods, such as education, social services, and institutions of employment. Since not all people who have misfortunes of poor education, poor health, and loss of job end up being homeless, we contend that a combination of these with multiple adverse childhood experiences may have weakened their resilience to traumatic life changes, such as loss of job and poor health.

Common causes of EID sample rejection in Zimbabwe and how to mitigate them.

Early infant diagnosis (EID) of HIV provides an opportunity for early HIV detection and access to appropriate Antiretroviral treatment (ART). Dried Blood Spot (DBS) samples are used for EID of exposed infants, born to HIV-positive mothers. However, DBS rejection rates in Zimbabwe have been exceeding the target of less than 2% per month set by the National Microbiology Reference Laboratory (NMRL), in Harare. The aim of this study was to determine the DBS sample rejection rate, the reasons for rejection and the possible associations between rejection and level of health facility where the samples were collected. This is an analytical cross-sectional study using routine DBS sample data from the NMRL in Harare, Zimbabwe, between January and December 2017.A total of 34 950 DBS samples were received at the NMRL. Of these, 1291(4%) were rejected. Reasons for rejection were insufficient specimen volume (72%), missing request form (11%), missing sample (6%), cross-contamination (6%), mismatch of information (4%) and clotted sample (1%). Samples collected from clinics/rural health facilities were five times more likely to be rejected compared to those from a central hospital. Rejection rates were above the set target of <2%. The reasons for rejection were 'pre-analytical' errors including labelling errors, missing or inconsistent data, and insufficient blood collected. Samples collected at primary healthcare facilities had higher rejection rates.

Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples.

BACKGROUND: It is increasingly acknowledged that homelessness is a more complex social and public health phenomenon than the absence of a place to live. This view signifies a paradigm shift, from the definition of homelessness in terms of the absence of permanent accommodation, with its focus on pathways out of homelessness through the acquisition and maintenance of permanent housing, to understanding the social context of homelessness and social interventions to prevent it. However, despite evidence of the association between homelessness and social factors, there is very little research that examines the wider social context within which homelessness occurs from the perspective of homeless people themselves. This study aims to examine the stories of homeless people to gain understanding of the social conditions under which homelessness occurs, in order to propose a theoretical explanation for it. METHOD: Twenty-six semi-structured interviews were conducted with homeless people in three centres for homeless people in Cheshire North West of England. RESULTS: The analysis revealed that becoming homeless is a process characterised by a progressive waning of resilience capacity to cope with life challenges created by series of adverse incidents in one's life. The data show that final stage in the process of becoming homeless is complete collapse of relationships with those close to them. Most prominent pattern of behaviours participants often describe as main causes of breakdown of their relationships are: 1. engaging in maladaptive behavioural lifestyle including taking drugs and/or excessive alcohol drinking 2. Being in trouble with people in authorities. CONCLUSION: Homeless people describe the immediate behavioural causes of homelessness, however, the analysis revealed the social and economic conditions within which homelessness occurred. The participants' descriptions of the social conditions in which were raised and their references to maladaptive behaviours which led to them becoming homeless, led us to conclude that they believe that their social condition affected their life chances: that these conditions were responsible for their low quality of social connections, poor educational attainment, insecure employment and other reduced life opportunities available to them.

Eating Behaviours of British University Students: A Cluster Analysis on a Neglected Issue.

Unhealthy diet is a primary risk factor for noncommunicable diseases. University student populations are known to engage in health risking lifestyle behaviours including risky eating behaviours. The purpose of this study was to examine eating behaviour patterns in a population of British university students using a two-step cluster analysis. Consumption prevalence of snack, convenience, and fast foods in addition to fruit and vegetables was measured using a self-report "Student Eating Behaviours" questionnaire on 345 undergraduate university students. Four clusters were identified: "risky eating behaviours," "mixed eating behaviours," "moderate eating behaviours," and "favourable eating behaviours." Nineteen percent of students were categorised as having "favourable eating behaviours" whilst just under a third of students were categorised within the two most risky clusters. Riskier eating behaviour patterns were associated with living on campus and Christian faith. The findings of this study highlight the importance of university microenvironments on eating behaviours in university student populations. Religion as a mediator of eating behaviours is a novel finding.

Public health nurse educators' conceptualisation of public health as a strategy to reduce health inequalities: a qualitative study.

BACKGROUND: Nurses have long been identified as key contributors to strategies to reduce health inequalities. However, health inequalities are increasing in the UK despite policy measures put in place to reduce them. This raises questions about: convergence between policy makers' and nurses' understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities. AIM: The aim of this qualitative research project is to determine public health nurse educators' understanding of public health as a strategy to reduce health inequalities. METHOD: 26 semi-structured interviews were conducted with higher education institution-based public health nurse educators. FINDINGS: Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health. CONCLUSION: Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than take population approaches.

Health inequalities as a foundation for embodying knowledge within public health teaching: a qualitative study.

INTRODUCTION: Recent U.K. health policies identified nurses as key contributors to the social justice agenda of reducing health inequalities, on the assumption that all nurses understand and wish to contribute to public health. Following this policy shift, public health content within pre-registration nursing curricula increased. However, public health nurse educators (PHNEs) had various backgrounds, and some had limited formal public health training, or involvement in or understanding of policy required to contribute effectively to it. Their knowledge of this subject, their understanding and interpretation of how it could be taught, was not fully understood. METHODOLOGY: This research aimed to understand how public health nurse educators' professional knowledge could be conceptualised and to develop a substantive theory of their knowledge of teaching public health, using a qualitative data analysis approach. Qualitative in-depth semi-structured interviews (n=26) were conducted with eleven university-based PHNEs. RESULTS: Integrating public health into all aspects of life was seen as central to the knowing and teaching of public health; this was conceptualised as 'embodying knowledge'. Participants identified the meaning of embodying knowledge for teaching public health as: (a) possessing a wider vision of health; (b) reflecting and learning from experience; and (c) engaging in appropriate pedagogical practices. CONCLUSION: The concept of public health can mean different things to different people. The variations of meaning ascribed to public health reflect the various backgrounds from which the public health workforce is drawn. The analysis indicates that PHNEs are embodying knowledge for teaching through critical pedagogy, which involves them engaging in transformative, interpretive and integrative processes to refashion public health concepts; this requires PHNEs who possess a vision of what to teach, know how to teach, and are able to learn from experience. Their vision of public health is influenced by social justice principles in that health inequalities, socioeconomic determinants of health, epidemiology, and policy and politics are seen as essential areas of the public health curriculum. They believe in forms of teaching that achieve social transformation at individual, behavioural and societal levels, while also enabling learners to recognise their capacity to effect change.