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The article presents the findings of a cohort study conducted on the recovery of health and wellbeing following colorectal cancer. It discusses the methodology of the research. It evaluates the natural history of health and wellbeing in people who have been treated for colorectal cancer. It concludes that the study will help the health care providers about what helps or hinders in rapid and effective recovery from cancer.

The article presents findings of a research conducted on examining factors affecting access to health care for malaria in Africa. It focuses on attributes of patients and their communities that act as barriers to access, including education level, financial and cultural factors. It addresses the need to learn about provider characteristics that encourage patients to attend their health services.

Background: Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question 'what interventions and strategies are effective in enabling evidence-informed healthcare?' The strengths and challenges of conducting realist review are also considered. Methods: The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses. Results: Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area. Conclusions: Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review. [ABSTRACT FROM AUTHOR]

The 4th High Level Forum on Aid Effectiveness, held in Busan, South Korea in November 2011 again promised an opportunity for a "new consensus on development cooperation" to emerge. This paper reviews the recent evolution of the concept of coordination for development assistance in health as the basis from which to understand current discourses. The paper reviews peer-reviewed scientific literature and relevant 'grey' literature, revisiting landmark publications and influential authors, examining the transitions in the conceptualisation of coordination, and the related changes in development assistance. Four distinct transitions in the understanding, orientation and application of coordination have been identified: coordination within the sector, involving geographical zoning, sub-sector specialisation, donor consortia, project co-financing, sector aid, harmonisation of procedures, ear-marked budgetary support, donor agency reform and inter-agency intelligence gathering; sector-wide coordination, expressed particularly through the Sector-Wide Approach; coordination across sectors at national level, expressed in the evolution of Poverty Strategy Reduction Papers and the national monitoring of the Millennium Development Goals; and, most recently, global-level coordination, embodied in the Paris Principles, and the emergence of agencies such as the International Health Partnerships Plus. The transitions are largely but not strictly chronological, and each draws on earlier elements, in ways that are redefined in the new context. With the increasing complexity of both the territory of global health and its governance, and increasing stakeholders and networks, current imaginings of coordination are again being challenged. The High Level Forum in Busan may have been successful in recognising a much more complex landscape for development than previously conceived, but the challenges to coordination remain. [ABSTRACT FROM AUTHOR]

Clinical practice guidelines are one of the foundations of efforts to improve health care. In 1999, we authored a paper about methods to develop guidelines. Since it was published, the methods of guideline development have progressed both in terms of methods and necessary procedures and the context for guideline development has changed with the emergence of guideline clearing houses and large scale guideline production organisations (such as the UK National Institute for Health and Clinical Excellence). It therefore seems timely to, in a series of three articles, update and extend our earlier paper. In this third paper we discuss the issues of: reviewing, reporting, and publishing guidelines; updating guidelines; and the two emerging issues of enhancing guideline implementability and how guideline developers should approach dealing with the issue of patients who will be the subject of guidelines having co-morbid conditions. [ABSTRACT FROM AUTHOR]

Background: In Kenya, infant mortality rate increased from 59 deaths per 1000 live births in 1988 to 78 deaths per 1000 live births by 2003. This was an increase of about 32 percent in 15 years. The reasons behind this upturn are poorly understood. This paper investigates the probable factors behind the upsurge in infant mortality in Kenya during the 1988-2003 period. Understanding the causes behind the upsurge is critical in designing high impact public health strategies for the acceleration of national and international public health goals such as the Millennium Development Goals (MDGs). The reversals in early child mortality is also regarded as one of the most important topics in contemporary demography. Methods: A merged dataset drawn from the Kenya Demographic and Health Surveys of 1993, 1998 and 2003 was used. The merged KDHS included a total of 5265 singletons. Permission to use the KDHS data was obtained from ICF international on the following website: http://www.measuredhs.com. Stata version 11.0 was used for data analysis. The paper used regression decomposition techniques as the main method for analysing the contribution of the selected covariates on the upsurge in infant mortality. Results: The duration of breastfeeding; maternal education, regional HIV prevalence and malaria endemicity were the factors that appeared to have contributed much to the observed rise in infant mortality in Kenya over the period. If all the live births that occurred in the 1996/03 period had the same mean values of all explanatory variables as those of live births that occurred in the 1988/95 period, then infant mortality would have increased by a massive 14 deaths per 1000 live births. However, if the live births that occurred in the 1988/95 period had the same mean values of all explanatory variables as those that occurred in the 1996/03 period, the upsurge in infant mortality would have been negligible. While the role of HIV in the upturn in infant mortality in Kenya and other sub Saharan African countries is indisputable, this study demonstrates that it is the duration of breastfeeding and Malaria endemicity that played a more significant role in Kenya's upsurge in infant mortality during the 1988-2003 period. Conclusions: Efforts aimed at controlling and preventing malaria and HIV should be stepped up to avert an upsurge in infant mortality. There is need to step up alternative baby feeding practices among mothers who are HIV positive especially after the first six months of breastfeeding. Owing to the widely known inverse relationship between maternal education and infant mortality, there is need for concerted efforts to promote girl child education. Owing to the important role played by the short preceding birth interval to the upsurge in infant mortality, there is need to promote family planning methods in Kenya. [ABSTRACT FROM AUTHOR]

Background: In spite of effective strategies to eliminate mother-to-child-transmission of HIV, the implementation of such strategies remains a major challenge in developing countries. In India, programs for the prevention of mother-to-child transmission (PMTCT) have been scaled up widely since 2005. However, these programs reach only a small percentage of pregnant women, and their overall effectiveness is low. Evidence-based program planning and implementation could significantly improve their effectiveness. This study sought to systematically retrieve, thematically categorize and review published research on PMTCT of HIV in India, focusing on research related to the provision and/or utilization of the cascade of services provided in a PMTCT program, in order to direct further research to enhance program implementation and effectiveness. Methods: A systematic search using MEDLINE, US National Library of Medicine Gateway system (PubMed) and ISI Web of Knowledge resulted in 1,944 abstracts, of which 167 met our inclusion criteria. Results: A huge share of the empirical literature on PMTCT in India (N = 134) deals with epidemiological studies (N = 60). The 46 papers related to utilization/provision of the cascade of PMTCT services were mostly from the four high HIV prevalence states in southern India and from the public sector. Studies on experiences of implementing a PMTCT program (N = 20) show high rates of drop out of women in the cascade particularly prior to receiving ARV. Studies on individual components of the cascade (N = 26) show that HIV counseling and testing is acceptable and feasible. Literature on other components of the cascade - such as pregnant women's access to ANC care, HIV infected women's immunological assessment using CD4 testing, repeat HIV testing among pregnant women, early infant diagnosis and factors related to linking HIV infected women and children to postnatal care--is lacking. Conclusions: While the scale of the Indian PMTCT program is large, comprehensive understanding of the context-driven factors affecting its efficiency is lacking. Systematic and more focused public health research output is needed on the issues related to reduction of drop outs of women in the cascade, role of PMTCT programs in improving maternal and child health indicators and role of private sector in delivering PMTCT services. [ABSTRACT FROM AUTHOR]

Background: It is widely acknowledged that adverse lifestyle behaviours in the population now will place an unsustainable burden on health service resources in the future. It has been estimated that the combined cost to the NHS in Wales of overweight and obesity, alcohol and tobacco is in excess of £540 million. In the current climate of financial austerity, there can be a tendency for the case for prevention efforts to be judged on the basis of their scope for cost savings. This paper was prompted by discussion in Wales about the evidence for the cost savings from prevention and early intervention and a resulting concern that these programmes were thus being evaluated in policy terms using an incorrect metric. Following a review of the literature, this paper contributes to the discussion of the potential role that economics can play in informing decisions in this area. Discussion: This paper argues that whilst studies of the economic burden of diseases provide information about the magnitude of the problem faced, they should not be used as a means of priority setting. Similarly, studies discussing the likelihood of savings as a result of prevention programmes may be distorting the arguments for public health. Prevention spend needs to be considered purposefully, resulting in a strategic commitment to spending. The role of economics in this process is to provide evidence demonstrating that information and support can be provided cost effectively to individuals to change their lifestyles thus avoiding lifestyle related morbidity and mortality. There is growing evidence that prevention programmes represent value for money using the currently accepted techniques and decision making metrics such as those advocated by NICE. Summary: The issue here is not one of arguing that the economic evaluation of prevention and early intervention should be treated differently, although in some instances that may be appropriate, rather it is about making the case for these interventions to be treated and evaluated to the same standard. The difficulty arises when a higher standard of cost saving may be expected from prevention and public health programmes. The paper concludes that it is of vital importance that during times of budget constraints, as currently faced, the public health budgets are not eroded to fund secondary care budget shortfalls, which are more easily identifiable. To do so would diminish any possibility of reducing the future burden faced by the NHS of lifestyle-related illnesses. [ABSTRACT FROM AUTHOR]

Background: Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities. Results: Some see doctors as bound by a notion of care that is blind to a patient's social position, while others respond to this issue through invoking notions of justice and human rights where access to care is a prime focus. Both care and justice orientations however conceal important tensions linked to the presence of bioethical principles underpinning these. Other normative ethical theories like deontology, virtue ethics and utilitarianism do not provide adequate guidance on the problem of social health inequities either. Conclusion: This paper explores if Bauman's notion of "forms of togetherness" provides the basis of a relational ethical theory that can help to develop a response to social health inequities of relevance to individual physicians. This theory goes beyond silence on the influence of social position of health and avoids amoral regulatory approaches to monitoring equity of care provision. [ABSTRACT FROM AUTHOR]

Background: Tobacco taxes are one of the most effective ways to reduce tobacco use. Transnational tobacco companies (TTCs) claim they wish to develop and secure excise systems that benefit both governments and the profitability of the companies themselves. The objective of the paper is to use the case of Ukraine, with its inconsistent history of excise tax changes in 1992-2008, to explore tobacco industry taxation strategies and tactics, and their implications for governmental revenues. Methods: Details of tobacco industry policy on tobacco taxation in Ukraine were obtained by searching tobacco industry internal documents and various published reports. Results: Even before entering the market in Ukraine, TTCs had made efforts to change the excise system in the country. In 1993-1994, TTCs lobbied the Ukrainian Government, and succeeded in achieving a lowering in tobacco tax. This, however, did not produce revenue increase they promised the Government. In 1996-1998, Ukrainian authorities increased excise several times, ignoring the wishes of TTCs, caused significant growth in revenue. Due to TTCs lobbying activities in 1999-2007 the tax increases were very moderate and it resulted in increased tobacco consumption in Ukraine. In 2008, despite the TTCs position, excise rates were increased twice and it was very beneficial for revenues. Conclusions: The Framework Convention on Tobacco Control includes provisions both on tobacco taxation policy and on protection of public health policy from vested interests of tobacco industry. This paper provides arguments why tobacco taxation policy should also be protected from vested interests of tobacco industry. TTCs taxation strategy appears to be consistent: keep excise as low as possible. Apparent conflicts between TTCs concerning tax structures often hide their real aim to change tax structures for competing interests without increasing total tax incidence. Governments, that aim to reduce levels of tobacco use, should not allow tobacco companies to influence the development and implementation of tobacco taxation policy. [ABSTRACT FROM AUTHOR]

Infant feeding by HIV-infected mothers has been a major global public health dilemma and a highly controversial matter. The controversy is reflected in the different sets of WHO infant feeding guidelines that have been issued over the last two decades. This thematic series, 'Infant feeding and HIV: lessons learnt and ways ahead' highlights the multiple challenges that HIV-infected women, infant feeding counsellors and health systems have encountered trying to translate and implement the shifting infant feeding recommendations in different local contexts in sub- Saharan Africa. As a background for the papers making up the series, this editorial reviews the changes in the guidelines in view of the roll out of prevention of mother to child transmission (PMTCT) programmes in sub- Saharan Africa between 2001 and 2010. [ABSTRACT FROM AUTHOR]

The article offers information on the evolving role of decision-analytic modelling in healthcare economic evaluations. Topics include the preference for decision-analytic models over trial-based economic evaluations, the underlying philosophies that have influenced this shift, and the circumstances under which trial-based analyses might be more appropriate or preferable.

Background: In the developed world, information on vital events is routinely collected nationally to inform population and health policies. However, in many low-and middle-income countries, especially those in sub-Saharan Africa (SSA), there is a lack of effective and comprehensive national civil registration and vital statistics system. In the past decades, the number of Health and Demographic Surveillance Systems (HDSSs) has increased throughout SSA. An HDSS monitors births, deaths, causes of death, migration, and other health and socio-economic indicators within a defined population over time. Currently, the International Network for the Continuous Demographic Evaluation of Populations and Their Health (INDEPTH) brings together 38 member research centers which run 44 HDSS sites from 20 countries in Africa, Asia and Oceana. Thirty two of these HDSS sites are in SSA. Discussion: This paper argues that, in the absence of an adequate national CRVS, HDSSs should be more effectively utilised to generate relevant public health data, and also to create local capacity for longitudinal data collection and management systems in SSA. If HDSSs get strategically located to cover different geographical regions in a country, data from these sites could be used to provide a more complete national picture of the health of the population. They provide useful data that can be extrapolated for national estimates if their regional coverage is well planned. HDSSs are however resource-intensive. Efforts are being put towards getting them linked to local or national policy contexts and to reduce their dependence on external funding. Increasing their number in SSA to cover a critical proportion of the population, especially urban populations, must be carefully planned. Strategic planning is needed at national levels to geographically locate HDSS sites and to support these through national funding mechanisms. Summary: The paper does not suggest that HDSSs should be seen as a replacement for civil registration systems. Rather, they should serve as a short- to medium-term measure to provide data for health and population planning at regional levels with possible extrapolation to national levels. HDSSs can also provide useful lessons for countries that intend to set up nationally representative sample vital registration systems in the long term. [ABSTRACT FROM AUTHOR]

Background: Although daily emergency department (ED) data is a source of information that often includes residence, its potential for space-time analyses at the individual level has not been fully explored. We propose that ED data collected for surveillance purposes can also be used to inform spatial and temporal patterns of disease using generalized additive models (GAMs). This paper describes the methods for adapting GAMs so they can be applied to ED data. Methods: GAMs are an effective approach for modeling spatial and temporal distributions of point-wise data, producing smoothed surfaces of continuous risk while adjusting for confounders. In addition to disease mapping, the method allows for global and pointwise hypothesis testing and selection of statistically optimum degree of smoothing using standard statistical software. We applied a two-dimensional GAM for location to ED data of overlapping calendar time using a locally-weighted regression smoother. To illustrate our methods, we investigated the association between participants' address and the risk of gastrointestinal illness in Cape Cod, Massachusetts over time. Results: The GAM space-time analyses simultaneously smooth in units of distance and time by using the optimum degree of smoothing to create data frames of overlapping time periods and then spatially analyzing each data frame. When resulting maps are viewed in series, each data frame contributes a movie frame, allowing us to visualize changes in magnitude, geographic size, and location of elevated risk smoothed over space and time. In our example data, we observed an underlying geographic pattern of gastrointestinal illness with risks consistently higher in the eastern part of our study area over time and intermittent variations of increased risk during brief periods. Conclusions: Spatial-temporal analysis of emergency department data with GAMs can be used to map underlying disease risk at the individual-level and view changes in geographic patterns of disease over time while accounting for multiple confounders. Despite the advantages of GAMs, analyses should be considered exploratory in nature. It is possible that even with a conservative cutoff for statistical significance, results of hypothesis testing may be due to chance. This paper illustrates that GAMs can be adapted to measure geographic trends in public health over time using ED data. [ABSTRACT FROM AUTHOR]

Background: Idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF) remains a complex and unclear phenomenon, often characterized by the report of various, non-specific physical symptoms (NSPS) when an EMF source is present or perceived by the individual. The lack of validated criteria for defining and assessing IEI-EMF affects the quality of the relevant research, hindering not only the comparison or integration of study findings, but also the identification and management of patients by health care providers. The objective of this review was to evaluate and summarize the criteria that previous studies employed to identify IEI-EMF participants. Methods: An extensive literature search was performed for studies published up to June 2011. We searched EMBASE, Medline, Psychinfo, Scopus and Web of Science. Additionally, citation analyses were performed for key papers, reference sections of relevant papers were searched, conference proceedings were examined and a literature database held by the Mobile Phones Research Unit of King's College London was reviewed. Results: Sixty-three studies were included. "Hypersensitivity to EMF" was the most frequently used descriptive term. Despite heterogeneity, the criteria predominantly used to identify IEI-EMF individuals were: 1. Self-report of being (hyper)sensitive to EMF. 2. Attribution of NSPS to at least one EMF source. 3. Absence of medical or psychiatric/ psychological disorder capable of accounting for these symptoms 4. Symptoms should occur soon (up to 24 hours) after the individual perceives an exposure source or exposed area. (Hyper)sensitivity to EMF was either generalized (attribution to various EMF sources) or source-specific. Experimental studies used a larger number of criteria than those of observational design and performed more frequently a medical examination or interview as prerequisite for inclusion. Conclusions: Considerable heterogeneity exists in the criteria used by the researchers to identify IEI-EMF, due to explicit differences in their conceptual frameworks. Further work is required to produce consensus criteria not only for research purposes but also for use in clinical practice. This could be achieved by the development of an international protocol enabling a clearly defined case definition for IEI-EMF and a validated screening tool, with active involvement of medical practitioners. [ABSTRACT FROM AUTHOR]

The article discusses a white paper that refer developmental period as a plastic phase, which allows the organism to adapt to changes in the environment to maintain or improve reproductive capability in part through sustained health. The paper indicates research and policy changes to develop a stronger focus on prevention of non-communicable conditions. It also discusses the Developmental Origins of Health and Disease (DOHaD) concept that provides significant insight into new strategies

Background: Mental health problems are disproportionately higher amongst homeless people. Many barriers exist for homeless people with mental health problems in accessing treatment yet little research has been done on service provision and quality of care for this group. The aim of this paper is to assess current service provision and identify barriers to care for homeless people with mental health problems in 14 European capital cities. Method: Two methods of data collection were employed; (i) In two highly deprived areas in each of the 14 European capital cities, homeless-specific services providing mental health, social care or general health services were assessed. Data were obtained on service characteristics, staff and programmes provided. (ii) Semi-structured interviews were conducted in each area with experts in mental health care provision for homeless people in order to determine the barriers to care and ways to overcome them. Results: Across the 14 capital cities, 111 homeless-specific services were assessed. Input from professionally qualified mental health staff was reported as low, as were levels of active outreach and case finding. Out-of-hours service provision appears inadequate and high levels of service exclusion criteria were evident. Prejudice in the services towards homeless people, a lack of co-ordination amongst services, and the difficulties homeless people face in obtaining health insurance were identified as major barriers to service provision. Conclusions: While there is variability in service provision across European capital cities, the reported barriers to service accessibility are common. Homeless-specific services are more responsive to the initial needs of homeless people with mental health problems, while generic services tend to be more conducive to long term care. Further research is needed to determine the effectiveness of different service delivery models, including the most effective coordination of homeless specific and generic services. [ABSTRACT FROM AUTHOR]

Background: In India, while the total fertility rate has been declined from 3.39 in 1992-93 to 2.68 in 2005-06, the prevalence of unintended pregnancy is still stagnant over the same period. A review of existing literature shows that within the country, there are variations in fertility preferences between different regions. Also there is a strong argument that the availability of a health facility at the village level plays an important role in reshaping the fertility behavior of women. Keeping in mind the fact that there is no information at the village level (which is the lowest geographical boundary) in the recent round of National Family Health Survey (NFHS-3), the specific objective of this study is to examine the impact of individual and household level variables on unwanted pregnancies without controlling the village level variation. Further, once the village level variation (i.e. unobserved variation) has been controlled, it is necessary to study whether there has been any alteration in the contribution of factors from earlier results of without adjusting the village level variation. Methods: This paper attempts to examine the associated factors of unwanted pregnancies, without matching the village and after matching the village, by using the matched case-control design. Nationwide data from India's latest NFHS-3 conducted during 2005-06 was used for the present study. Frequency and pair wise matching has been applied in the present paper and conditional logistic regression analysis was used to work out the models and to find out the factors associated with unwanted pregnancies. Results: A major finding of this study was that 1:3 case-control study (without matching the village) shows that women belonging to non Hindu/Muslim religion, Scheduled Tribe, women who have experienced child loss and if the previous birth interval is 24 through 36 months were significant predictors of unwanted pregnancy. However, this relationship did not hold significant after village wise matching. Other factors such as Muslim religion, women and their partners with high school education and above, women belonging to the richest wealth index and if the sex of the last child was female, emerge as significant predictors of unwanted pregnancies. Conclusions: This study clearly underscores the importance of adjusting the village (PSU) level variation in explaining unwanted pregnancies. [ABSTRACT FROM AUTHOR]

Background: Comparisons of birth outcomes between Australian Indigenous and non-Indigenous populations show marked inequalities. These comparisons obscure Indigenous disparities. There is much variation in terms of culture, language, residence, and access to services amongst Australian Indigenous peoples. We examined outcomes by region and remoteness for Indigenous subgroups and explored data for communities to inform health service delivery and interventions.Methods: Our population-based study examined maternal and neonatal outcomes for 7,560 mothers with singleton pregnancies from Australia's Northern Territory Midwives' Data Collection (2003-2005) using uni- and multivariate analyses. Groupings were by Indigenous status; region (Top End (TE)/Central Australia (CA)); Remote/Urban residence; and across two large TE communities.Results: Of the sample, 34.1% were Indigenous women, of whom 65.6% were remote-dwelling versus 6.7% of non-Indigenous women. In comparison to CA Urban mothers: TE Remote (adjusted odds ratio [aOR] 1.47, 95%CI: 1.13,1.90) and TE Urban mothers (aOR 1.36 (95% CI: 1.02, 1.80) were more likely, but CA Remote mothers (aOR 0.43; 95%CI: 0.31, 0.58) less likely to smoke during pregnancy; CA Remote mothers giving birth at >32 weeks gestation were less likely to have attended ≥ five antenatal visits (aOR 0.55; 95%CI: 0.36, 0.86); TE Remote (aOR 0.71; 95%CI: 0.53,0.95) and CA Remote women (aOR 0.68; 95%CI: 0.49, 0.95) who experienced labour had lower odds of epidural/spinal/narcotic pain relief; and TE Remote (aOR 0.47; 95%CI: 0.34, 0.66), TE Urban (aOR 0.67; 95%CI: 0.46, 0.96) and CA Remote mothers (aOR 0.52; 95%CI: 0.35, 0.76) all had lower odds of having a 'normal' birth. The aOR for preterm birth for TE Remote newborns was 2.09 (95%CI: 1.20, 3.64) and they weighed 137 g (95%CI: -216 g, -59 g) less than CA Urban babies. There were few significant differences for communities, except for smoking prevalence.Conclusions: This paper is one of few quantifying inequalities between groups of Australian Indigenous women and newborns at a regional level. Indigenous mothers and newborns do worse on some outcomes if they live remotely, especially if they live in the TE. Smoking prevention and high-quality antenatal care is fundamental to addressing many of the adverse outcomes identified in this paper. [ABSTRACT FROM AUTHOR]

Background: Sexual violence within marriage is a public health and human rights issue; yet it remains a much neglected research area, especially in Nepal. This paper represents one of the first attempts to quantify the extent of sexual violence and its determinants among young married women in Nepal. Methods: A cross-sectional survey was conducted among 1,296 married women aged 15-24 years in four major ethnic groups in rural Nepal. The survey data were used to estimate the prevalence and identify determinants of sexual violence. The relative importance of different correlates of sexual violence in the past 12 months at the individual, household and community levels were examined by using a multi-level multi variate statistical approach.Results: Of the young women surveyed 46% had experienced sexual violence at some point and 31% had experienced sexual violence in the past 12 months. Women's autonomy was found to be particularly protective against sexual violence both at the individual and community level. Women's educational level was not found to be protective, while the educational level of the husband was found to be highly protective. [ABSTRACT FROM AUTHOR]

Background: The 'overall insecticidal effect' is a key measure used to evaluate public health pesticides for indoor use in experimental hut trials. It depends on the proportion of mosquitoes that are killed out of those that enter the treated hut, intrinsic mortality in the control hut, and the ratio of mosquitoes entering the treatment hut to those entering the control hut. This paper critically examines the way the effect is defined, and discusses how it can be used to infer effectiveness of intervention programmes. Findings: The overall insecticidal effect, as defined by the World Health Organization in 2006, can be negative when deterrence from entering the treated hut is high, even if all mosquitoes that enter are killed, wrongly suggesting that the insecticide enhances mosquito survival. Also in the absence of deterrence, even if the insecticide kills all mosquitoes in the treatment hut, the insecticidal effect is less than 100%, unless intrinsic mortality is nil. A proposed alternative definition for the measurement of the overall insecticidal effect has the desirable range of 0 to 1 (100%), provided mortality among non-repelled mosquitoes in the treated hut is less than the corresponding mortality in the control hut. This definition can be built upon to formulate the coverage-dependent insecticidal effectiveness of an intervention programme. Coverage-dependent population protection against feeding can be formulated similarly. Conclusions: This paper shows that the 2006 recommended quantity for measuring the overall insecticidal effect is problematic, and proposes an alternative quantity with more desirable properties. [ABSTRACT FROM AUTHOR]

Background: Sexual coercion is an important public health issue due to its negative association with social and health outcomes. The paper aims to examine the prevalence of sexual coercion perpetrated by husbands on their wives in Nepal and to identify the characteristics associated with this phenomenon. Methods: The data used in this paper comes from a cross-sectional survey on "Domestic Violence in Nepal" carried out in 2009. A total of 1,536 married women were interviewed and associations between sexual coercion and the explanatory variables were assessed via bivariate analysis using Chi-square tests. Logistic regression was then applied to assess the net effect of several independent variables on sexual coercion. Results: Overall, about three in five women (58%) had experienced some form of sexual coercion by their husbands. Logistic regression analysis found that the literacy status of women, decision-making power regarding their own health care, husband-wife age differences, alcohol consumption by the husband, and male patriarchal control all had significant associations with women's experience of sexual coercion. Literate women had 28% less chance (adjusted odds ratio (aOR) = 0.72) of experiencing sexual coercion by their husbands than did illiterate women. Women who made decisions jointly with their husbands with regard to their own health care were 36% less likely (aOR = 0.64) to experience sexual coercion than those whose health care was decided upon by their mothers/fathers-in-law. On the other hand, women whose husbands were 5 or more years older than they were more likely to report sexual coercion (aOR = 1.33) than were their counterparts, as were women whose husbands consumed alcohol (aOR = 1.27). Furthermore, women who experienced higher levels of patriarchal control from their husbands were also more likely to experience sexual coercion by their husbands (aOR = 7.2) compared to those who did not face such control. Conclusion: The study indicates that sexual coercion among married women is widespread in Nepal. Programs should focus on education and women's empowerment to reduce sexual coercion and protect women's health and rights. Furthermore, campaigns against alcohol abuse and awareness programs targeting husbands should also focus attention on the issue of sexual coercion. [ABSTRACT FROM AUTHOR]

Background: The success of the Global Polio Eradication Initiative was remarkable, but four countries - Afghanistan, Pakistan, India and Nigeria - never interrupted polio transmission. Pakistan reportedly achieved all milestones except interrupting virus transmission. This paper describes the perceptions of health workers and managers regarding constraints in the Polio Eradication Initiative (PEI) to ultimately provide evidence for designing future interventions. Methods: A qualitative cross-sectional study using focus group discussions and in-depth interviews was conducted in the Nankana Sahib District of Pakistan's Punjab province. Study subjects included staff at all levels in the PEI at district headquarters, in all 4 tehsils (sub-districts) and at 20 randomly selected primary health centers. In total, 4 FGD and 7 interview sessions were conducted and individual session summary notes were prepared and later synthesized, consolidated and subjected to conceptual analysis. Results: The main constraints identified in the study were the poor condition of the cold chain in all aspects, poor skills and a lack of authority in resource allocation and human resource management, limited advocacy and communication resources, a lack of skills and training among staff at all levels in the PEI/EPI in almost all aspects of the program, a deficiency of public health professionals, poor health services structure, administrative issues (including ineffective means of performance evaluation, bureaucratic and political influences, problems in vaccination areas and field programs, no birth records at health facilities, and poor linkage between different preventive programs), unreliable reporting and poor monitoring and supervision systems, limited use of local data for interventions, and unclear roles and responsibilities after decentralization. Conclusion: The study highlights various shortcomings and bottlenecks in the PEI, and the barriers identified should be considered in prioritizing future strategies. [ABSTRACT FROM AUTHOR]

Background: Large scale usage of tobacco causes a lot of health troubles in human. Various formulations of tobacco are extensively used by the people particularly in developing world. Besides several toxic tobacco constituents some metals and metalloids are also believed to pose health risks. This paper describes inductively coupled plasma-mass spectrometric (ICP-MS) quantification of some important metals and metalloids in various brands of smoked, sniffed, dipped and chewed tobacco products. Results: A microwave-assisted digestion method was used for sample preparation. The method was validated by analyzing a certified reference material. Percentage relative standard deviation (% R.S.D.) between recovered and certified values was<5.8. Linearity value for calibration curve of each metal was 1>r>0.999. Improved limits of detection (LODs) were in range of ng/L for all elements. Fe, Al and Mn were found to be in the highest concentration in all types of tobacco products, while Zn, Cu, Ni and Cr were below the average concentration of 40 μg/g, and Pb, Co, As, Se and Cd were below 5μg/g. All elements, apart from Pb, were high in concentration in dipping tobacco in comparison to other tobacco products. Generally, the order of all elemental concentration can be expressed in different tobacco products as chewing

Background: Copper (Cu), zinc (Zn), cadmium (Cd), and lead (Pb) can pose serious threats to environmental health because they tend to bioaccumulate in terrestrial ecosystems. We investigated under field conditions the transfer of these heavy metals in a soil-plant-snail food chain in Banat area, Romania. The main goal of this paper was to assess the Roman snail (Helix pomatia) usefulness in environmental monitoring as bioindicator of heavy metal accumulation. Eight sampling sites, selected by different history of heavy metal (HM) exposure, were chosen to be sampled for soil, nettle leaves, and newly matured snails. This study also aimed to identify the putative effects of HM accumulation in the environment on phenotypic variability in selected shell features, which included shell height (SH), relative shell height (RSH), and whorl number (WN). Results: Significantly higher amounts of HMs were accumulated in snail hepatopancreas and not in foot. Cu, Zn, and Cd have biomagnified in the snail body, particularly in the hepatopancreas. In contrast, Pb decreased when going up into the food chain. Zn, Cd, and Pb correlated highly with each other at all levels of the investigated food chain. Zn and Pb exhibited an effective soil-plant transfer, whereas in the snail body only foot Cu concentration was correlated with that in soil. There were significant differences among sampling sites for WN, SH, and RSH when compared with reference snails. WN was strongly correlated with Cd and Pb concentrations in nettle leaves but not with Cu and Zn. SH was independent of HM concentrations in soil, snail hepatopancreas, and foot. However, SH correlated negatively with nettle leaves concentrations for each HM except Cu. In contrast, RSH correlated significantly only with Pb concentration in hepatopancreas. Conclusions: The snail hepatopancreas accumulates high amounts of HMs, and therefore, this organ can function as a reliable biomarker for tracking HM bioavailability in soil. Long-term exposure to HMs via contaminated food might influence the variability of shell traits in snail populations. Therefore, our results highlight the Roman snail (Helix pomatia) potential to be used in environmental monitoring studies as bioindicator of HM pollution. [ABSTRACT FROM AUTHOR]

Background: Successful cancer prevention policies and programming for youth must be based on a solid understanding of youth's conceptualization of cancer and cancer prevention. Accordingly, a qualitative study examining youth's perspectives of cancer and its prevention was undertaken. Not surprisingly, smoking (i.e., tobacco cigarette smoking) was one of the dominant lines of discourse in the youth's narratives. This paper reports findings of how youth conceptualize smoking with attention to their perspectives on parental and family-related smoking issues and experiences. Methods: Seventy-five Canadian youth ranging in age from 11-19 years participated in the study. Six of the 75 youth had a history of smoking and 29 had parents with a history of smoking. Youth were involved in traditional ethnographic methods of interviewing and photovoice. Data analysis involved multiple levels of analysis congruent with ethnography. Results: Youth's perspectives of parents and other family members' cigarette smoking around them was salient as represented by the theme: It's not fair. Youth struggled to make sense of why parents would smoke around their children and perceived their smoking as an unjust act. The theme was supported by four subthemes: 1) parenting the parent about the dangers of smoking; 2) the good/bad parent; 3) distancing family relationships; and 4) the prisoner. Instead of being talked to about smoking it was more common for youth to share stories of talking to their parents about the dangers of smoking. Parents who did not smoke were seen by youth as the good parent, as opposed to the bad parent who smoked. Smoking was an agent that altered relationships with parents and other family members. Youth who lived in homes where they were exposed to cigarette smoke felt like a trapped prisoner. Conclusions: Further research is needed to investigate youth's perceptions about parental cigarette smoking as well as possible linkages between youth exposed to second hand smoke in their home environment and emotional and lifestyle-related health difficulties. Results emphasize the relational impact of smoking when developing anti-tobacco and cancer prevention campaigns. Recognizing the potential toll that second-hand smoke can have on youth's emotional well-being, health care professionals are encouraged to give youth positive messages in coping with their parents' smoking behaviour. [ABSTRACT FROM AUTHOR]

Background: Appropriate home management of illness is vital to efforts to control malaria. The strategy of home management relies on caregivers to recognize malaria symptoms, assess severity and promptly seek appropriate care at a health facility if necessary. This paper examines the management of severe febrile illness (presumed malaria) among children under the age of five in rural Koulikoro Region, Mali. Methods: This research examines in-depth case studies of twenty-five households in which a child recently experienced a severe febrile illness, as well as key informant interviews and focus group discussions with community members. These techniques were used to explore the sequence of treatment steps taken during a severe illness episode and the context in which decisions were made pertaining to pursing treatments and sources of care, while incorporating the perspective and input of the mother as well as the larger household. Results: Eighty-one participants were recruited in 25 households meeting inclusion criteria. Children's illness episodes involved multiple treatment steps, with an average of 4.4 treatment steps per episode (range: 2-10). For 76% of children, treatment began in the home, but 80% were treated outside the home as a second recourse. Most families used both traditional and modern treatments, administered either inside the home by family members, or by traditional or modern healers. Participants' stated preference was for modern care, despite high rates of reported treatment failure (52%, n=12), however, traditional treatments were also often deemed appropriate and effective. The most commonly cited barrier to seeking care at health facilities was cost, especially during the rainy season. Financial constraints often led families to use traditional treatments. Conclusions: Households have few options available to them in moments of overlapping health and economic crises. Public health research and policy should focus on the reducing barriers that inhibit poor households from promptly seeking appropriate health care. Enhancing the quality of care provided at community health facilities and supporting mechanisms by which treatment failures are quickly identified and addressed can contribute to reducing subsequent treatment delays and avoid inappropriate recourse to traditional treatments. [ABSTRACT FROM AUTHOR]

Background: HIV counselling and testing (HCT) is a critical gateway for addressing HIV prevention and linking people to treatment, care, and support. Since national testing rates are often less than optimal, there is growing interest in expanding testing coverage through the implementation of innovative models such as home-based HIV counselling and testing (HBHCT). With the aim of informing scale up, this paper discusses client characteristics and acceptability of an HBHCT intervention implemented in rural South Africa. Methods: Trained lay counsellors offered door-to-door rapid HIV testing in a rural sub-district of KwaZulu-Natal, South Africa. Household and client data were captured on cellular phones and transmitted to a web-based data management system. Descriptive analysis was undertaken to examine client characteristics, testing history, HBHCT uptake, and reasons for refusal. Chi-square tests were performed to assess the association between client characteristics and uptake. Results: Lay counsellors visited 3,328 households and tested 75% (5,086) of the 6,757 people met. The majority of testers (73.7%) were female, and 57% had never previously tested. With regard to marital status, 1,916 (37.7%), 2,123 (41.7%), and 818 (16.1%) were single, married, and widowed, respectively. Testers ranged in age from 14 to 98 years, with a median of 37 years. Two hundred and twenty-nine couples received couples counselling and testing; 87.8%, 4.8%, and 7.4% were concordant negative, concordant positive, and discordant, respectively. There were significant differences in characteristics between testers and non-testers as well as between male and female testers. The most common reasons for not testing were: not being ready/feeling scared/needing to think about it (34.1%); knowing his/her status (22.6%), being HIV-positive (18.5%), and not feeling at risk of having or acquiring HIV (10.1%). The distribution of reasons for refusal differed significantly by gender and age. Conclusions: These findings indicate that HBHCT is acceptable in rural South Africa. However, future HBHCT programmes should carefully consider community context, develop strategies to reach a broad range of clients, and tailor intervention messages and services to meet the unique needs of different sub-groups. It will also be important to understand and address factors related to refusal of testing. [ABSTRACT FROM AUTHOR]

Background: The increasing popularity of commercial movies showing three dimensional (3D) computer generated images has raised concern about image safety and possible side effects on population health. This study aims to (1) quantify the occurrence of visually induced symptoms suffered by the spectators during and after viewing a commercial 3D movie and (2) to assess individual and environmental factors associated to those symptoms. Methods: A cross-sectional survey was carried out using a paper based, self administered questionnaire. The questionnaire includes individual and movie characteristics and selected visually induced symptoms (tired eyes, double vision, headache, dizziness, nausea and palpitations). Symptoms were queried at 3 different times: during, right after and after 2 hours from the movie. Results: We collected 953 questionnaires. In our sample, 539 (60.4%) individuals reported 1 or more symptoms during the movie, 392 (43.2%) right after and 139 (15.3%) at 2 hours from the movie. The most frequently reported symptoms were tired eyes (during the movie by 34.8%, right after by 24.0%, after 2 hours by 5.7% of individuals) and headache (during the movie by 13.7%, right after by 16.8%, after 2 hours by 8.3% of individuals). Individual history for frequent headache was associated with tired eyes (OR = 1.34, 95%CI = 1.01-1.79), double vision (OR = 1.96; 95%CI = 1.13-3.41), headache (OR = 2.09; 95%CI = 1.41-3.10) during the movie and of headache after the movie (OR = 1.64; 95%CI = 1.16-2.32). Individual susceptibility to car sickness, dizziness, anxiety level, movie show time, animation 3D movie were also associated to several other symptoms. Conclusions: The high occurrence of visually induced symptoms resulting from this survey suggests the need of raising public awareness on possible discomfort that susceptible individuals may suffer during and after the vision of 3D movies. [ABSTRACT FROM AUTHOR]

Background: Legislating restrictions on alcohol advertising is a cost-effective measure to reduce consumption of alcohol. Yet Australia relies upon industry self-regulation through voluntary codes of practice regarding the content, timing and placement of alcohol advertising. Ending industry self-regulation was recommended by the National Preventative Health Taskforce; a suggestion contested by the drinks industry. Debates about emerging alcohol-control policies regularly play out in the news media, with various groups seeking to influence the discussion. This paper examines news coverage of recommendations to restrict alcohol advertising to see how supporters and opponents frame the debate, with a view to providing some suggestions for policy advocates to advance the discussion. Methods: We used content and framing analyses to examine 329 Australian newspaper items mentioning alcohol advertising restrictions over 24 months. All items were coded for mentions of specific types of advertising and types of advertising restrictions, the presence of news frames that opposed or endorsed advertising restrictions, statements made within each frame and the news-actors who appeared. Results: Restrictions were the main focus in only 36% of 329 items. Alcohol advertising was conceived of as television (47%) and sport-related (56%). Restrictions were mentioned in non-specific terms (45%), or specified as restrictions on timing and placement (49%), or content (22%). Public health professionals (47%) appeared more frequently than drinks industry representatives (18%). Five supportive news frames suggested the policy is a sensible public health response, essential to protect children, needed to combat the drinks industry, required to stop pervasive branding, or as only an issue in sport. Four unsupportive frames positioned restrictions as unnecessary for a responsible industry, an attack on legitimate commercial activities, ineffective and 'nannyist', or inessential to government policy. Support varied among news-actors, with public health professionals (94%) more supportive than the public (68%), community-based organisations (76%), the government (72%), and the sports (16%), drinks (3%), or advertising (4%) industries. Conclusion: Restrictions on alcohol advertising currently have low newsworthiness as a standalone issue. Future advocacy might better define the exact nature of required restrictions, anticipate vocal opposition and address forms of advertising beyond televised sport if exposure to advertising, especially among children, is to be reduced. [ABSTRACT FROM AUTHOR]

Background: Due to the uncommon nature of large-scale disasters and emergencies, public health practitioners often turn to simulated emergencies, known as "exercises", for preparedness assessment and improvement. Under the right conditions, exercises can also be used to conduct original public health systems research. This paper describes the integration of a research framework into a statewide operations-based exercise program in California as a systems-based approach for studying public health emergency preparedness and response. Methods: We developed a research framework based on the premise that operations-based exercises conducted by medical and public health agencies can be described using epidemiologic concepts. Using this framework, we conducted a survey of key local and regional medical and health agencies throughout California following the 2010 Statewide Medical and Health Exercise. The survey evaluated: (1) the emergency preparedness capabilities activated and functions performed in response to the emergency scenario, and (2) the major challenges to inter-organizational communications and information management. Results: Thirty-five local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) responded to our survey, representing 57%, 77%, 26% and 83%, respectively, of target agencies in California. We found two sets of response capabilities were activated during the 2010 Statewide Exercise: a set of core capabilities that were common across all agencies, and a set of agency-specific capabilities that were more common among certain agency types. With respect to one response capability in particular, inter-organizational information sharing, we found that the majority of respondents' comments were related to the complete or partial failure of communications equipment or systems. Conclusions: Using the 2010 Statewide Exercise in California as an opportunity to develop our research framework, we characterized several aspects of the public health and medical system's response to a standardized emergency scenario. From a research perspective, this study provides a potential new framework for conducting exercise-based research. From a practitioner's perspective, our results provide a starting point for preparedness professionals' dialogue about expected and actual organizational roles, responsibilities, and resource capacities within the public health system. Additionally, the identification of specific challenges to inter-organizational communications and information management offer specific areas for intervention. [ABSTRACT FROM AUTHOR]

Background: Estimates of the absolute risk of death based on the combined effects of sex, age and health behaviours are scarce for elderly people. The aim of this paper is to calculate population based estimates and display them using simple charts that may be useful communication tools for public health authorities, health care providers and policy makers. Methods: Data were drawn from two concurrent prospective observational cohort studies of community-based older Australian women (N = 7,438) and men (N = 6,053) aged 71 to 79. The outcome measure was death within ten years. The predictor variables were: sex, age, smoking status, alcohol consumption, body mass index and physical activity. Results: Patterns of risks were similar in men and women but absolute risk of death was between 9 percentage points higher in men (17 %) than in women (8 %) in the lowest risk group (aged 71-73 years, never smoked, overweight, physically active and consumed alcohol weekly) and 21 % higher in men (73-74 %) than women (51-52 %) in the highest risk group (aged 77-79 years, normal weight or obese, current smoker, physically inactive and drink alcohol less than weekly). Conclusions: These absolute risk charts provide a tool for understanding the combined effects of behavioural risk factors for death among older people. [ABSTRACT FROM AUTHOR]

Background: Weight management constitutes a substantial problem particularly among groups of low socio-economic status. Interventions at work places may be a solution, but high quality worksite interventions documenting prolonged weight loss are lacking. This paper presents results of an intervention aimed to achieve a 12 months weight loss among overweight health care workers. Methods: Ninety-eight overweight female health care workers were randomized into an intervention or a reference group. The intervention consisted of diet, physical exercise and cognitive behavioral training during working hours 1 hour/week. The reference group was offered monthly oral presentations. Several anthropometric measures, blood pressure, cardiorespiratory fitness, maximal muscle strength, and musculoskeletal pain were measured before and after the 12-months intervention period. Data were analyzed by intention-to-treat analysis. Results: The intervention group significantly reduced body weight by 6 kg (p < 0.001), BMI by 2.2 (p < 0.001) and body fat percentage by 2.8 (p < 0.001). There were no statistical reductions in the control group, resulting in significant differences between the two groups over time. Conclusions: The intervention generated substantial reductions in body weight, BMI and body fat percentage among overweight female health care workers over 12 months. The positive results support the workplace as an efficient arena for weight loss among overweight females. Trial registration: NCT01015716. [ABSTRACT FROM AUTHOR]

Background: Although physical inactivity has been linked with numerous chronic health conditions and overall mortality, the majority of English adults report doing insufficient physical activity. To increase population physical activity levels, researchers have called for more community-level interventions. To evaluate these complex public health interventions, innovative study designs are required. This study protocol describes Devon Active Villages, a community-level intervention providing physical activity opportunities to 128 rural villages in southwest England, and the methods used to evaluate its effectiveness in increasing physical activity levels. Methods/Design: A stepped wedge cluster randomised trial will be used to evaluate whether Devon Active Villages leads to increased physical activity levels in rural communities. Community engagement will help tailor activity programmes for each village; communities will then be supported for a further twelve months. The intervention will be delivered over four periods, each lasting twelve weeks. Data collection consists of a postal survey of a random sample of adults aged 18 years and over, at baseline and after each of the four intervention periods. The questionnaire includes questions on participant demographics, physical activity behaviour, local environment characteristics, awareness of local activity programmes, and psychosocial factors. Based on detecting an increase in the proportion of people who meet physical activity guidelines (from 25% to 30%), at least ten respondents are needed from each of the 128 villages at each stage (80% power at the 5% level of significance). Anticipating a 20% response rate, 6,400 questionnaires will be sent out at each stage (i.e., 50 surveys to each village). Using data from all five periods, a comparison of study outcomes between intervention and control arms will be performed, allowing for time period (as a fixed effect) and the random effect induced by correlation of outcomes (clustering) within villages. Discussion: This paper describes the use of a stepped wedge cluster randomised trial to evaluate a complex, community-level physical activity intervention in an under-studied population of adults in rural communities in southwest England. The study addresses gaps in the current literature by providing new insights into physical activity levels in this population. Trial Registration Number: Current Controlled Trials ISRCTN37321160 [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) Department of HIV/AIDS led the development of public health guidelines for delivering an evidence-based, essential package of interventions for the prevention and treatment of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) and transgender people in the health sector in low- and middle-income countries. The objective of this paper is to review the methodological challenges faced and solutions applied during the development of the guidelines. Methods: The development of the guidelines followed the WHO guideline development process, which utilizes the GRADE approach. We identified, categorized and labeled the challenges identified in the guidelines development process and described the solutions through an interactive process of in-person and electronic communication. Results: We describe how we dealt with the following challenges: (1) heterogeneous and complex interventions; (2) paucity of trial data; (3) selecting outcomes of interest; (4) using indirect evidence; (5) integrating values and preferences; (6) considering resource use; (7) addressing social and legal barriers; (8) wording of recommendations; and (9) developing global guidelines. Conclusion: We were able to successfully apply the GRADE approach for developing recommendations for public health interventions. Applying the general principles of the approach while carefully considering specific challenges can enhance both the process and the outcome of guideline development. [ABSTRACT FROM AUTHOR]

Background: Improvements in treatment have resulted in an increasing number of cancer survivors potentially being able to return to work after medical treatment. In this paper we focus on the considerations regarding return to work (RTW) of breast cancer absentees in the Belgian context and how these considerations are related to reactions from their social environment. Methods: A qualitative study was performed to understand the RTW considerations of Belgian breast cancer absentees who had undergone breast cancer surgery in 2006. Twenty-two participants (mean age 46) were included and interviewed between May 2008 and August 2009 in their personal environment. An in-depth analysis (Grounded Theory) took place using the Qualitative Analysis Guide of Leuven (Quagol). Results: Before the actual RTW, breast cancer employees try to build an image of the future resumption of work based on medical grounds and their knowledge of the workplace. Four matters are considered prior to RTW: (i) women want to leave the sick role and wish to keep their job; (ii) they consider whether working is worth the effort; (iii) they reflect on their capability; and (iv) they have doubts about being accepted in the workplace after returning. These inner thoughts are both product and input for the interaction with the social environment. The whole process is coloured by uncertainty and vulnerability. Conclusion: Our study demonstrated that mental preparation for RTW is not a linear process of improvement. It shows a detailed picture of four types of considerations made by breast cancer survivors before they actually resume work. Vulnerability appears to be an overarching theme during mental preparation. As the social environment plays an important role, people from that environment must become more aware of their influence on decreasing or increasing a woman's vulnerability while preparing for RTW. [ABSTRACT FROM AUTHOR]

Background: Mortality statistics are essential for population health assessment. Despite limitations in data availability, Pacific Island Countries are considered to be in epidemiological transition, with non-communicable diseases increasingly contributing to premature adult mortality. To address rapidly changing health profiles, countries would require mortality statistics from routine death registration given their relatively small population sizes. Methods: This paper uses a standard analytical framework to examine death registration systems in Fiji, Kiribati, Nauru, Palau, Solomon Islands, Tonga and Vanuatu. Results: In all countries, legislation on death registration exists but does not necessarily reflect current practices. Health departments carry the bulk of responsibility for civil registration functions. Medical cause-of-death certificates are completed for at least hospital deaths in all countries. Overall, significantly more information is available than perceived or used. Use is primarily limited by poor understanding, lack of coordination, limited analytical skills, and insufficient technical resources. Conclusion: Across the region, both registration and statistics systems need strengthening to improve the availability, completeness, and quality of data. Close interaction between health staff and local communities provides a good foundation for further improvements in death reporting. System strengthening activities must include a focus on clear assignment of responsibility, provision of appropriate authority to perform assigned tasks, and fostering ownership of processes and data to ensure sustained improvements. These human elements need to be embedded in a culture of data sharing and use. Lessons from this multi-country exercise would be applicable in other regions afflicted with similar issues of availability and quality of vital statistics. [ABSTRACT FROM AUTHOR]

Background: Insufficient PA has been shown to cluster with other CVD risk factors including insufficient fruit and vegetable intake, overweight, increased serum cholesterol concentrations and elevated blood pressure. This paper describes the development of Working on Wellness (WOW), a worksite intervention program incorporating motivational interviewing by wellness specialists, targeting employees at risk. In addition, we describe the evaluation the effectiveness of the intervention among employees at increased risk for cardiovascular disease. Methods: The intervention mapping (IM) protocol was used in the planning and design of WOW. Focus group discussions and interviews with employees and managers identified the importance of addressing risk factors for CVD at the worksite. Based on the employees' preference for individual counselling, and previous evidence of the effectiveness of this approach in the worksite setting, we decided to use motivational interviewing as part of the intervention strategy. Thus, as a cluster-randomised, controlled control trial, employees at increased risk for CVD (N = 928) will be assigned to a control or an intervention group, based on company random allocation. The sessions will include motivational interviewing techniques, comprised of two face-to-face and four telephonic sessions, with the primary aim to increase habitual levels of PA. Measures will take place at baseline, 6 and 12 months. Secondary outcomes include changes in nutritional habits, serum cholesterol and glucose concentrations, blood pressure and BMI. In addition, healthcare expenditure and absenteeism will be measured for the economic evaluation. Analysis of variance will be performed to determine whether there were significant changes in physical activity habits in the intervention and control groups at 6 and 12 months. Discussion: The formative work on which this intervention is based suggests that the strategy of targeting employees at increased risk for CVD is preferred. Importantly, this study extends the work of a previous, similar study, Health Under Construction, in a different setting. Finally, this study will allow an economic evaluation of the intervention that will be an important outcome for health care funders, who ultimately will be responsible for implementation of such an intervention. [ABSTRACT FROM AUTHOR]

Background: The governments and citizens of the developed nations are increasingly called upon to contribute financially to health initiatives outside their borders. Although international development assistance for health has grown rapidly over the last two decades, austerity measures related to the 2008 and 2011 global financial crises may impact negatively on aid expenditures. The competition between national priorities and foreign aid commitments raises important ethical questions for donor nations. This paper aims to foster individual reflection and public debate on donor responsibilities for global health. Methods: We undertook a critical review of contemporary accounts of justice. We selected theories that: (i) articulate important and widely held moral intuitions; (ii) have had extensive impact on debates about global justice; (iii) represent diverse approaches to moral reasoning; and (iv) present distinct stances on the normative importance of national borders. Due to space limitations we limit the discussion to four frameworks. Results: Consequentialist, relational, human rights, and social contract approaches were considered. Responsibilities to provide international assistance were seen as significant by all four theories and place limits on the scope of acceptable national autonomy. Among the range of potential aid foci, interventions for health enjoyed consistent prominence. The four theories concur that there are important ethical responsibilities to support initiatives to improve the health of the worst off worldwide, but offer different rationales for intervention and suggest different implicit limits on responsibilities. Conclusions: Despite significant theoretical disagreements, four influential accounts of justice offer important reasons to support many current initiatives to promote global health. Ethical argumentation can complement pragmatic reasons to support global health interventions and provide an important foundation to strengthen collective action. [ABSTRACT FROM AUTHOR]

The authors reflect on the foundation of the "Environmental Health" journal, highlighting the publication of over 100 articles last 2011. They note that the journal web site receives over 60,000 unique visitors each month and the steady growth suggests that the number will soon exceed 100,000 monthly. They urge prospective authors to highlight the findings that are new or different together with the implications for future research and in terms of prevention of environmental hazards.

Background: Shared decision-making and patients' choice of interventions are areas of increasing importance, not least seen in the light of the fact that chronic conditions are increasing, interventions considered important for public health, and still non-acceptance of especially risk-reducing treatments of cardiovascular diseases (CVD) is prevalent. A better understanding of patients' medication-taking behavior is needed and may be reached by studying the reasons why people accept or decline medication recommendations. The aim of this paper was to identify factors that may influence people's decisions and reasoning for accepting or declining a cardiovascularpreventive medication offer.Methods: From a random sample of 4,000 people aged 40-59 years in a Danish population, 1,169 participants were asked to imagine being at increased risk of cardiovascular disease and being offered a preventive medication.After receiving 'complete' information about effectiveness of the medication they were asked whether they would accept medication. Finally, they were asked about reasons for the decision.Results: A total of 725 (67%) of 1,082 participants accepted the medication offer. Even quite large effects of medication (up to 8 percentage points absolute risk reduction) had a smaller impact on acceptance to medication than personal experience with cardiovascular disease. Furthermore, increasing age of the participant and living with a partner were significantly associated with acceptance. Some 45% of the respondents accepting justified their choice as being for health reasons, and they were more likely to be women, live alone, have higher income and higher education levels. Among those who did not accept the medication offer, 56% indicated that they would rather prefer to change lifestyle.Conclusions: Medication effectiveness seems to have a moderate influence on people's decisions to accept preventive medication, while factors such as personal experience with cardiovascular disease may have an equally strong or stronger influence, indicating that practitioners could do well to carefully identify the reasons for their patients' treatment decisions. [ABSTRACT FROM AUTHOR]

Background: Emerging public health threats often originate in resource-limited countries. In recognition of this fact, the World Health Organization issued revised International Health Regulations in 2005, which call for significantly increased reporting and response capabilities for all signatory nations. Electronic biosurveillance systems can improve the timeliness of public health data collection, aid in the early detection of and response to disease outbreaks, and enhance situational awareness. Methods: As components of its Suite for Automated Global bioSurveillance (SAGES) program, The Johns Hopkins University Applied Physics Laboratory developed two open-source, electronic biosurveillance systems for use in resource-limited settings. OpenESSENCE provides web-based data entry, analysis, and reporting. ESSENCE Desktop Edition provides similar capabilities for settings without internet access. Both systems may be configured to collect data using locally available cell phone technologies. Results: ESSENCE Desktop Edition has been deployed for two years in the Republic of the Philippines. Local health clinics have rapidly adopted the new technology to provide daily reporting, thus eliminating the two-to-three week data lag of the previous paper-based system. Conclusions: OpenESSENCE and ESSENCE Desktop Edition are two open-source software products with the capability of significantly improving disease surveillance in a wide range of resource-limited settings. These products, and other emerging surveillance technologies, can assist resource-limited countries compliance with the revised International Health Regulations. [ABSTRACT FROM AUTHOR]

Background: Refugees experience multiple health and social needs. This requires an integrated approach to care in the countries of resettlement, including Canada. Perhaps, interactive eHealth tools could build bridges between medical and social care in a timely manner. The authors developed and piloted a multi-risk Computer-assisted Psychosocial Risk Assessment (CaPRA) tool for Afghan refugees visiting a community health center. The iPad based CaPRA survey was completed by the patients in their own language before seeing the medical practitioner. The computer then generated individualized feedback for the patient and provider with suggestions about available services. Methods: A pilot randomized trial was conducted with adult Afghan refugees who could read Dari/Farsi or English language. Consenting patients were randomly assigned to the CaPRA (intervention) or usual care (control) group. All patients completed a paper-pencil exit survey. The primary outcome was patient intention to see a psychosocial counselor. The secondary outcomes were patient acceptance of the tool and visit satisfaction. Results: Out of 199 approached patients, 64 were eligible and 50 consented and one withdrew (CaPRA = 25; usual care = 24). On average, participants were 37.6 years of age and had lived 3.4 years in Canada. Seventy-two percent of participants in CaPRA group had intention to visit a psychosocial counselor, compared to 46 % in usual care group [X2 (1)=3.47, p = 0.06]. On a 5-point scale, CaPRA group participants agreed with the benefits of the tool (mean = 4) and were 'unsure' about possible barriers to interact with the clinicians (mean = 2.8) or to privacy of information (mean = 2.8) in CaPRA mediated visits. On a 5-point scale, the two groups were alike in patient satisfaction (mean = 4.3). Conclusion: The studied eHealth tool offers a promising model to integrate medical and social care to address the health and settlement needs of refugees. The tool's potential is discussed in relation to implications for healthcare practice. The study should be replicated with a larger sample to generalize the results while controlling for potential confounders. [ABSTRACT FROM AUTHOR]

Background: The contact networks between individuals can have a profound impact on the evolution of an infectious outbreak within a network. The impact of the interaction between contact network and disease dynamics on infection spread has been investigated using both synthetic and empirically gathered micro-contact data, establishing the utility of micro-contact data for epidemiological insight. However, the infection models tied to empirical contact data were highly stylized and were not calibrated or compared against temporally coincident infection rates, or omitted critical non-network based risk factors such as age or vaccination status. Methods: In this paper we present an agent-based simulation model firmly grounded in disease dynamics, incorporating a detailed characterization of the natural history of infection, and 13 weeks worth of micro-contact and participant health and risk factor information gathered during the 2009 H1N1 flu pandemic. Results: We demonstrate that the micro-contact data-based model yields results consistent with the case counts observed in the study population, derive novel metrics based on the logarithm of the time degree for evaluating individual risk based on contact dynamic properties, and present preliminary findings pertaining to the impact of internal network structures on the spread of disease at an individual level. Conclusions: Through the analysis of detailed output of Monte Carlo ensembles of agent based simulations we were able to recreate many possible scenarios of infection transmission using an empirically grounded dynamic contact network, providing a validated and grounded simulation framework and methodology. We confirmed recent findings on the importance of contact dynamics, and extended the analysis to new measures of the relative risk of different contact dynamics. Because exponentially more time spent with others correlates to a linear increase in infection probability, we conclude that network dynamics have an important, but not dominant impact on infection transmission for H1N1 transmission in our study population. [ABSTRACT FROM AUTHOR]

Diabetes is one of the greatest public health challenges to face Australia. It is already Australia's leading cause of kidney failure, blindness (in those under 60 years) and lower limb amputation, and causes significant cardiovascular disease. Australia's diabetes amputation rate is one of the worst in the developed world, and appears to have significantly increased in the last decade, whereas some other diabetes complication rates appear to have decreased. This paper aims to compare the national burden of disease for the four major diabetes-related complications and the availability of government funding to combat these complications, in order to determine where diabetes foot disease ranks in Australia. Our review of relevant national literature indicates foot disease ranks second overall in burden of disease and last in evidenced-based government funding to combat these diabetes complications. This suggests public funding to address foot disease in Australia is disproportionately low when compared to funding dedicated to other diabetes complications. There is ample evidence that appropriate government funding of evidence-based care improves all diabetes complication outcomes and reduces overall costs. Numerous diverse Australian peak bodies have now recommended similar diabetes foot evidence-based strategies that have reduced diabetes amputation rates and associated costs in other developed nations. It would seem intuitive that "it's time" to fund these evidence-based strategies for diabetes foot disease in Australia as well. [ABSTRACT FROM AUTHOR]

Background: Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods: The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004-06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004-2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results: We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions: Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it's essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations. [ABSTRACT FROM AUTHOR]

Background: Universal access is one of the major aims in public health and social care. Services should be provided on the basis of individual needs. However, municipal autonomy and the fragmentation of services may jeopardize universal access and lead to variation between municipalities in the delivery of services. This paper aims to identify patient-level characteristics and municipality-level service patterns that may have an influence on the use and costs of health and social services of frail elderly patients. Methods: Hierarchical analysis was applied to estimate the effects of patient and municipality-level variables on services utilization. Results: The variation in the use of health care services was entirely due to patient-related variables, whereas in the social services, 9% of the variation was explained by the municipality-level and 91% by the patient-level characteristics. Health-related quality of life explained a major part of variation in the costs of health care services. Those who had reported improvement in their health status during the preceding year were more frequent users of social care services. Low informal support, poor functional status and poor instrumental activities of daily living, living at a residential home, and living alone were associated with higher social services expenditure. Conclusions: The results of this study showed municipality-level variation in the utilization of social services, whereas health care services provided for frail elderly people seem to be highly equitable across municipalities. Another important finding was that the utilization of social and health services were connected. Those who reported improvement in their health status during the preceding year were more frequently also using social services. This result suggests that if municipalities continue to limit the provision of support services only for those who are in the highest need, this saving in the social sector may, in the long run, result in increased costs of health care. [ABSTRACT FROM AUTHOR]

Background: The Responsive Interdisciplinary Child-Community Health Education and Research (RICHER) initiative is an intersectoral and interdisciplinary community outreach primary health care (PHC) model. It is being undertaken in partnership with community based organizations in order to address identified gaps in the continuum of health services delivery for 'at risk' children and their families. As part of a larger study, this paper reports on whether the RICHER initiative is associated with increased: 1) access to health care for children and families with multiple forms of disadvantage and 2) patient-reported empowerment. This study provides the first examination of a model of delivering PHC, using a Social Paediatrics approach. Methods: This was a mixed-methods study, using quantitative and qualitative approaches; it was undertaken in partnership with the community, both organizations and individual providers. Descriptive statistics, including logistic regression of patient survey data (n=86) and thematic analyses of patient interview data (n=7) were analyzed to examine the association between patient experiences with the RICHER initiative and parent-reported empowerment. Results: Respondents found communication with the provider clear, that the provider explained any test results in a way they could understand, and that the provider was compassionate and respectful. Analysis of the survey and in-depth interview data provide evidence that interpersonal communication, particularly the provider's interpersonal style (e.g., being treated as an equal), was very important. Even after controlling for parents' education and ethnicity, the provider's interpersonal style remained positively associated with parent-reported empowerment (p<0.01). Conclusions: This model of PHC delivery is unique in its purposeful and required partnerships between health care providers and community members. This study provides beginning evidence that RICHER can better meet the health and health care needs of people, especially those who are vulnerable due to multiple intersecting social determinants of health. Positive interpersonal communication from providers can play a key role in facilitating situations where individuals have an opportunity to experience success in managing their and their family's health. [ABSTRACT FROM AUTHOR]

Background: There are few reports on the nutritional status of Bhutanese children. The objective of this paper is to summarize results from the 2008 National Nutrition Survey and to describe progress achieved during the last two decades. Methods: A cross-sectional survey of 2376 children aged 6 to 59 months was conducted during November-December 2008 to provide national and regional estimates. A multi-stage cluster sampling method was applied and 40 gewogs/thromdes were selected from each region (Western, Central, Eastern). Guidelines on how to measure length/height and weight followed WHO standardized procedures. Data were analysed for consistency and validation using the software WHO Anthro and the WHO SPSS macro. Underweight, stunting, overweight, wasting and thinness were defined based on the WHO Child Growth Standards. Data from 1986-88 and 1999 national surveys were reanalysed using the WHO standards to describe trends in nutritional status. Results: Nationally, 34.9% Bhutanese preschool children are stunted and 10.4% are underweight. Wasting is 4.7%, with severe wasting close to 2% in rural areas, while overweight affects 4.4% of preschool children. While underweight rates are similar across regions, wasting is substantially more prevalent in the Western region and stunting in the Eastern region. Stunting shows a steep rise during the first two years of life, as high as 40%, and levels off thereafter, while wasting is greatest among children aged 6-24 months and subsequently decreases. The prevalence of stunting fell from 60.9% in 1986-88 to 34.9% in 2008, and underweight declined from 34.0% to 10.4% during same period. The percentage of wasted children dropped from 5.2% in 1986-88 to 2.5% in 1999 but then increased to 4.7% in 2008. Conclusions: There have been major improvements in the nutritional status of Bhutanese children over the past two decades, however, linear growth retardation remains a significant concern. Early identification of growth faltering is essential for improving the effectiveness of public health programs to prevent stunting. Similarly, wasting rates indicate the need for a system to identify children with severe malnutrition in the isolated communities so that they can receive appropriate care. [ABSTRACT FROM AUTHOR]

Background: Best current estimates of neuropathic pain (NeuP) prevalence come from studies using various screening detecting pain with probable neuropathic features; the proportion experiencing significant, long-term NeuP, and the proportion not responding to standard treatment are unknown. These "refractory" cases are the most clinically important to detect, being the most severe, requiring specialist treatment. Methods: We report an international Delphi survey of experts in NeuP, aiming for consensus on the features required to define, for epidemiological research: (1) neuropathic pain; and (2) when NeuP is "refractory". A web-based questionnaire was developed and data collected from three rounds of questionnaires from nineteen experts. Results: There was good consensus on essential inclusion of six items to identify NeuP ("prickling, tingling, pins & needles", "pain evoked by light touch", "electric shocks or shooting pain", "hot or burning" pain, "brush allodynia on self-examination", and "relevant history") and on some items that were non-essential. Consensus was also reached on components of a "refractory NeuP" definition: minimum duration (one year); number of trials of drugs of known effectiveness (four); adequate duration of these trials (three months / maximum tolerated); outcomes of treatment (pain severity, quality of life). Further work needs to validate these proposed criteria in general population research. Conclusions: This paper presents an international consensus on measuring the epidemiology of refractory neuropathic pain. This will be valuable in reaching an agreed estimate of the prevalence of neuropathic pain, and the first estimate of refractory neuropathic pain prevalence. [ABSTRACT FROM AUTHOR]