Applying the WHO recommendations on health-sector response to violence against women to assess the Spanish health system. A mixed methods approach

This methodological note describes the development and application of a mixed-methods protocol to assess the responsiveness of Spanish health systems to violence against women in Spain, based on the World Health Organization (WHO) recommendations.     

Physically active lifestyles for all Americans: A call to action for non-profit organizations

Many nonprofit organizations and non-governmental organizations (NGOs) are strategically poised to encourage and facilitate healthier lifestyles. Non-profit organizations can play leadership roles in improving physical levels among all Americans.     

Potential of pharmacists to help reduce the burden of poorly managed cardiovascular risk

Introduction: Rural areas require better use of existing health professionals to ensure capacity to deliver improved cardiovascular outcomes. Community pharmacists (CPs) are accessible to most communities and can potentially undertake expanded roles in prevention of cardiovascular disease (CVD). Objective: This study aims to establish frequency of contact with general practitioners (GPs) and CPs by patients at high risk of CVD or with inadequately controlled CVD risk factors. Design, setting and participants: Population survey using randomly selected individuals from the Wimmera region electoral roll and incorporating a physical health check and self‐administered health questionnaire. Overall, 1500 were invited to participate. Results: The participation rate was 51% when ineligible individuals were excluded. Nine out of 10 participants visited one or both types of practitioner in the previous 12 months. Substantially more participants visited GPs compared with CPs (88.5% versus 66.8%). With the exception of excess alcohol intake, the median number of opportunities to intervene for every inadequately controlled CVD risk factor and among high risk patient groups at least doubled for the professions combined when compared with GP visits alone. Conclusion: Opportunities exist to intervene more frequently with target groups by engaging CPs more effectively but would require a significant attitude shift towards CPs. Mechanisms for greater pharmacist integration into primary care teams should be investigated.     

Rural community pharmacy: a feasible site for a health promotion and screening service for cardiovascular risk factors

ABSTRACT: A pharmacist-delivered health promotion and screening service for cardiovascular risk factors in rural community pharmacy was implemented in the Upper Hunter Valley, New South Wales (NSW). We describe the development of the service and profile 204 participants at their initial screening. A standardised clinical protocol guided the pharmacist through delivery of the service. The mean age of participants was 44 years ( SD ± 13 ). Over half (54%) had a Body Mass Index (BMI) > 25, 54% had cholesterol > 5.0 mmol L^-1 and 18% a systolicBP > 140 mmHg and/or diastolicBP > 90 mmHg. Most (80%) received lifestyle information (dietary, exercise or smoking cessation). One third required referral to a general practitioner. Provision of the service through community pharmacy increased the community's access to screening, 28% reported that they had never had their cholesterol measured. Since this new service was able to identify, educate and refer people at risk of cardiovascular disease in a rural community, we recommend a broader adoption through rural pharmacies.     

Improvements in biometric health measures among individuals with intellectual disabilities: A controlled evaluation of the Fit 5 program

BackgroundIndividuals with intellectual disabilities (ID) have poorer health statuses compared to the general population. Actions are needed to address health disparities and promote healthy lifestyles among individuals with ID. Moreover, studies that consider program settings for this population are needed.ObjectiveThe Special Olympics health program, Fit 5, was evaluated to assess effectiveness in improving health measures for individuals with ID. The settings of programs’ implementation were also considered.MethodsFour Special Olympics basketball teams participated as an intervention group, and three teams as a control group, in a study of the Fit 5 program that was implemented during, and as part of, a regular 8-week basketball season. Resting heart rate (RHR) and blood pressure, and height and weight to calculate Body Mass Index (BMI), were measured before and after the program. Differences in pre- and post-measures were compared between the two groups with paired samples t-tests and ANCOVA.ResultsParticipants in the intervention group had significantly greater improvements in resting systolic and diastolic blood pressures (p = 0.02 and 0.03, respectively) and RHR (p = 0.003). BMI increased for both groups; however, the increase in the intervention group was significantly less (p = 0.006). The Special Olympics setting was considered familiar and supportive and effectively reached individuals with ID.ConclusionThe Fit 5 program positively impacts RHR and blood pressure, and could help reduce extents of BMI increases, in individuals with ID when implemented in a common setting. Further investigation of the impact of Fit 5 and similar programs in additional settings is warranted.     

The Swedish coeliac disease epidemic with a prevailing twofold higher risk in girls compared to boys may reflect gender specific risk factors

In the mid 1980s the incidence of coeliac disease in Swedish children below 2 years of age increased threefold within a few years, and after a 10-year high incidence period returned equally rapidly to the previous level. Analysing the epidemic with respect to any change in female to male ratio over time, or shift in age at diagnosis, may increase the understanding of coeliac disease aetiology. In a population-based incidence study of childhood coeliac disease, 2151 cases (811 boys/1340 girls) were diagnosed from 1973 to 1997. Incidence rates and relative risks (RRs) were calculated by gender, age at diagnosis and calendar time. Cumulative incidences by age and gender were calculated for different birth cohorts. A twofold higher risk (RR: 1.9, 95% confidence interval (CI) 1.7–2.1) for coeliac disease in girls as compared to boys prevailed throughout the epidemic. Further, during the post-epidemic period there was an upward shift in age at diagnosis. So far, however, a majority of the cases diagnosed at older ages belong to birth cohorts of the epidemic period, i.e. cohorts that already had a high coeliac disease risk before 2 years of age. Our results suggest that girls as compared to boys may be genetically more vulnerable to environmental exposures influencing the immunological processes towards coeliac disease. Further, an increased risk for coeliac disease during the first years of life due to, for example, unfavourable infant dietary habits, may result in an increased total childhood risk for coeliac disease. A longer follow-up, even into adulthood, is needed to determine whether or not the lifetime risk has changed.     

Animal–human connections, “one health,” and the syndemic approach to prevention

A syndemic involves two or more afflictions that, by interacting synergistically, contribute to excess burdens of disease. A syndemic approach to prevention, meanwhile, focuses on connections among health-related problems, considers those connections when developing health policies, and aligns with forces for social change. In this short report, we expand the syndemic concept to acknowledge the extent to which animal health connects with human health and, with reference to existing publications, we demonstrate the pertinence of this expanded definition for a syndemic approach to prevention. Our demonstration assumes practical importance in relation to the concept of ‘one health’, which many prominent veterinary and human health scientists have recently endorsed as a sound basis for redressing human diseases, animal diseases, and environmental degradation worldwide. While social scientists have mostly ignored animal health, few ‘one health’ proponents have emphasized social conditions or involved social scientists. By explicitly accommodating animal–human connections in our expanded conceptualization of a syndemic, we hope to help create a space in which human health, veterinary, and social scientists may learn from one another, collaborate in research, and cooperate to clear the way for innovations in prevention.     

A comparison of the association between socioeconomic position and cardiovascular disease risk factors in three age cohorts of Australian women: findings from the Australian Longitudinal Study on Women's Health

OBJECTIVES: To assess the associations between three measurements of socioeconomic position (SEP) -- education, occupation and ability to cope on available income -- and cardiovascular risk factors in three age cohorts of Australian women. METHODS: Cross-sectional analysis of three cohorts of Australian women aged 18-23, 45-50 and 70-75 years. RESULTS: In general, for all exposures and in all three cohorts, the odds of each adverse risk factor (smoking, obesity and physical inactivity) were lower in the most advantaged compared with the least advantaged. Within each of the three cohorts, the effects of each measurement of SEP on the outcomes were similar. There were, however, some notable between-cohort differences. The most marked differences were those with smoking. For women aged 70-75 (older), those with the highest educational attainment were more likely to have ever smoked than those with the lowest level of attainment. However, for the other two cohorts, this association was reversed, with a stronger association between low levels of education and ever smoking among those aged 18-23 (younger) than those aged 45-50 (mid-age). Similarly, for older women, those in the most skilled occupational classes were most likely to have ever smoked, with opposite findings for mid-age women. Education was also differently associated with physical inactivity across the three cohorts. Older women who were most educated were least likely to be physically inactive, whereas among the younger and mid-age cohorts there was little or no effect of education on physical inactivity. CONCLUSION: These findings demonstrate the dynamic nature of the association between SEP and some health outcomes. Our findings do not appear to confirm previous suggestions that prestige-based measurements of SEP are more strongly associated with health-related behaviours than measurements that reflect material and psychosocial resources.     

Places and health: a qualitative study to explore how older women living alone perceive the social and physical dimensions of their neighbourhoods

There is growing interest in the impact that neighbourhood environment might have on the health of older people. Although the number of older Australian women, particularly those living alone, is projected to increase in coming decades, their experiences of neighbourhood have not been exclusively examined. The aims of this paper are: (1) to explore, from the perspective of these women, the social and physical dimensions of neighbourhoods and (2) to investigate variation in these accounts according to whether women lived in areas of higher or lower socioeconomic status. Twenty women aged between 75 and 93 years, residing in metropolitan Adelaide, South Australia (SA), participated in a series of two in-depth interviews. Women's perceptions of their neighbourhood, and accounts of every-day activities in the community were analysed to determine how both social and physical aspects of neighbourhood might relate to health and wellbeing. Findings suggest that a reciprocal and trusting relationship with neighbours underpinned older women's sense of satisfaction with, and feeling of security within, the neighbourhood. Other factors such as living in close proximity to services and existing social networks were also seen as important. Women's stories demonstrated that they were able to draw on both existing social networks and neighbours to sustain their independence and social connection within the community. Women living in more disadvantaged areas were more conscious of social disconnection in their neighbourhoods, and to the way that traffic noise and pollution detracted from their neighbourhood environment. These findings indicate that, for older women living alone, trusting and reciprocal relationships with neighbours are likely to form an important part of their broader social support network and should be recognised in relation to the process of maintaining the health of older women living in the community.     

加强“将健康融入所有政策”的实施:基于现实主义的解释性案例研究

目前,世界各国普遍采取跨部门行动解决健康的宏观社会和经济决定因素。"将健康融入所有政策(Hi AP)"是各国采取跨部门行动的策略之一,它以广义的健康决定因素而非单纯的卫生服务为目标,在决策过程中系统解决健康问题。近几十年来出现了很多关于Hi AP的案例,但这些案例成功或失败的原因并未得到系统的研究,这就导致以证据为基础的有关促进或阻碍Hi AP策略实施的相关因素的研究较少。本文基于现实主义视角,采用解释性案例研究,分析了不同地区Hi AP策略的实施情况。本研究在提出概念性框架的基础上,分析了与Hi AP可持续实施有关的背景、社会机制及结果,并利用相关文献以及从关键知情人访谈中得到的证据,寻找相关的模式和主题对现象加以解释。最后,通过对瑞典和加拿大魁北克实施卫生影响力评估的情况进行比较,揭示了Hi AP成功实施的经验。此方法能够帮助研究者对某一地区内成功实施Hi AP的社会机制和背景因素的大量证据信息加以审核并做三角测量,还可用于分析其他形式的部门间行动,以减少不同背景、不同地区之间的卫生不公平性现象。     

The interplay of structure and agency in health promotion: integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice

The recent debate in public health about the "inequality paradox" mirrors a long-standing dispute between proponents of structuralist approaches and advocates of action theory. Both views are genuine perspectives of health promotion, but so far they have not been adequately linked by health promotion theory. Using Anthony Giddens's concepts of structure and agency seems promising, but his theory has a number of shortcomings that need to be amended if it is to be applied successfully to health promotion. After briefly assessing Giddens's theory of structuration, this paper proposes to add to it both the concept of structural change as proposed by William Sewell and the policy dimension as described by Elinor Ostrom in her distinction between "operational" and "collective choice" level. On this basis, a multi-level model of the interaction of structure and agency in health promotion is proposed. This model is then connected to central claims of the Ottawa Charter, i.e. "build healthy public policy", "create supportive environments", "strengthen community actions", and "develop personal skills". A case study from a local-level health promotion project in Germany is used to illustrate the explanatory power of the model, showing how interaction between structure and agency on the operational and on the collective choice level led to the establishment of women-only hours at the municipal indoor swimming pool as well as to increased physical activity levels and improved general self-efficacy among members of the target group.     

Inspiring Healthy Adolescent Choices: A Rationale for and Guide to Strength Promotion in Primary Care

The social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Clinicians can assist in this development by adopting a strength-based approach to adolescent health care, which applies concepts from positive youth development to the medical office setting.     

HIV transmission from husbands to wives in Cambodia: a systematic review of the literature

HIV transmission in Cambodia has declined considerably in recent years, yet new incidents of HIV transmission within marital relationships have increased. Evidence suggests that the cause of this is transmission from HIV-positive men to their HIV-negative spouses. The objective of this paper is to develop an evidence-based model of HIV transmission from husbands to wives in Cambodia in a context of culture and society, drawing from the published literature. A critical analysis of peer reviewed literature, professional papers, policy reports and reference books identified four plausible factors influencing inter-spousal HIV transmission: (1) a hierarchical male-dominated society, (2) husbands' involvement with sex workers, (3) cultural values concerning the ideal Khmer woman and (4) unprotected sex between an HIV-infected husband and his uninfected wife. This evidence-based explanatory model can be used to inform future culturally appropriate HIV-education and prevention programmes.     

An internet-based approach to enhance self-management of chronic low back pain in the Italian-speaking population of Switzerland: results from a pilot study

Summary Objective: To illustrate the development and pilot evaluation of a website designed to enhance self-management of chronic low back pain for the Italian-speaking population of Switzerland. Methods: 20 patients affected by chronic low back pain used a website – specifically created for the project – for a period of five months, under the monitoring of a team of health professionals. Evaluation was carried out by means of a telephone questionnaire administered at baseline and at the end of the intervention, and intermediate online user-testing performed in the fourth month of the intervention. A control group of 15 patients was created to assist the evaluation. Results: Compared to the control group, results from the pilot evaluation suggest a decrease in the intensity of back pain in people with access to the website; an increase in physical activity; a reduction in both medical consultation and the use of painkillers, and a gain in declarative and procedural knowledge. This coincides with a general positive assessment of the website. Conclusion: The study supports the need to test the proposed approach on a wider scale. Submitted: 21 November 2005, Revised: 13 July 2006, 24 February 2007, Accepted: 28 March 2007     

Uneven progress in reducing exposure to violence at home for New Zealand adolescents 2001–2012: a nationally representative cross‐sectional survey series

Objective: To explore trends, and identify risk factors, that may explain changes in adolescent exposure to family violence over time. Methods: Data for this study was drawn from the Youth 2000 series of cross‐sectional surveys, carried out with New Zealand high school students in 2001, 2007 and 2012. Latent class analysis was used to understand different patterns of exposure to multiple risks for witnessing violence at home among adolescents. Results: Across all time periods, there was no change in witnessing emotional violence and a slight decline in witnessing physical violence at home. However, significant differences were noted between 2001 and 2007, and 2007 and 2012, in the proportion of adolescents who reported witnessing emotional and physical violence. Four latent classes were identified in the study sample; these were characterised by respondents' ethnicity, concerns about family relationships, food security and alcohol consumption. For two groups (characterised by food security, positive relationships and lower exposure to physical violence), there was a reduction in the proportion of respondents who witnessed physical violence but an increase in the proportion who witnessed emotional violence between 2001 and 2012. For the two groups characterised by poorer food security and higher exposure to physical violence, there were no changes in witnessing of physical violence in the home. Implications for public health: In addition to strategies directly aimed at violence, policies are needed to address key predictors of violence exposure such as social disparities, financial stress and alcohol use. These social determinants of health cannot be ignored.     

How income and education contribute to risk factors for cardiovascular disease in the elderly in a former Communist country

OBJECTIVES: Careful examination of the risk factors for cardiovascular disease (CVD) may enable clinicians to develop a reasonably preventive programme among the elderly. The main purpose of this paper was to examine the effects of income and education on CVD risk factors in an elderly population who had lived most of their lives in Communist times. METHODS: The CINDI (Countrywide Integrated Non-communicable Diseases Intervention) Programme questionnaire was used to collect data from an elderly (65+ years) population in Lodz, a large industrial city in Poland. The study population (n = 1,461) was selected at random, and the overall response rate was 57.1%. The following risk factors were evaluated: hypertension, obesity, elevated cholesterol, elevated blood sugar and smoking. RESULTS: Hypertension was the most frequently observed CVD risk factor (83.4% of participants) followed by hypercholesterolaemia (70.2%), obesity (30.5%), diabetes (18.4%) and smoking (8.5%). Hypertension and hypercholesterolaemia were related to age (OR=0.91, 95%CI: 0.88-0.95 and OR=0.95, 95%CI: 0.92-0.98, respectively). The younger people in the study population exhibited the highest prevalence of hypertension and hypercholesterolaemia; hypercholesterolaemia was observed more frequently among widowed respondents. Obesity and diabetes were associated with education level (OR=0.52, 95%CI: 0.34-0.79 and OR=0.60, 95%CI: 0.37-0.97, respectively). Younger single males with a lower level of education and income exhibited the highest prevalence of smoking. Multivariate analysis showed that age, education and gender were the best predictors for the cumulative risk factors of CVD. CONCLUSIONS: Education is more strongly associated with CVD risk factors than material status in the elderly. The best predictors of risk factors were age, sex and education. As we gain knowledge about CVD risk factors, we may be able to target preventive services in the elderly population more accurately and effectively, and help older adults make health decisions to reduce risk factors and increase their quality of life.     

An innovative approach to participatory health policy development in Bulgaria: The conception and first achievements of the Partnership for Health

The Bulgarian Partnership for Health was established in 2015 as a new forum for health policy formulation and discussion. The Partnership presents a new approach of structured and sustained stakeholder involvement to overcome the lack of public participation in health policy development and implementation. Constituted as a permanent consultative body to the Council of Ministers, the Partnership engages a wide variety of stakeholders and professionals to shape and improve health policies. The shared governance of the Partnership between the Minister of Health and a patient organisation supports the elaboration of legislative acts based on the stakeholders' collaboration in priority areas. The governance and organisational structure of the Partnership assures capacity building, fast mobilisation of experts, continuity of stakeholder involvement, and increased responsibility in health policy development and implementation. This type of participatory approach may help reconcile initially opposing positions and foster reforms often impeded by political antagonism. Persisting challenges are a rather slow process of policy development and different perceptions of key concepts among the stakeholders. As policy-making in many countries in Eastern Europe suffers from political distrust, the Partnership's approach of involving experts - and not only politicians - could provide inspiration also to other countries, which have struggled with inconsistency of health policies pursued by different governments.