Insomnia, Medicalization, and Expert Knowledge.

Historians have clearly articulated the ways in which sleeplessness has long been part of the human condition. As an object of medical expertise and public health intervention, however, insomnia is a much more recent invention, having gained its status as a pathology during the 1870s. But while insomnia has attracted considerable and concerted attention from public health authorities allied with sleep medicine specialists, this phenomenon is not well explained by classical medicalization theory, in part because it is the sleepless sufferers, not the medical experts, who typically have the authority to diagnose insomnia. The dynamics of insomnia's history are better described as those of a boundary object, around which concepts and practices of biomedicine and psychology coalesce to frame contemporary notions of self-medicalization and self-experiment.

Continuous positive airway pressure (CPAP) intolerance remains a persistent problem for many obstructive sleep apnea patients. Clinicians and researchers continue to search for other effective treatment modalities given the well-documented sequelae associated with untreated obstructive sleep apnea. A multidisciplinary "Alternatives to CPAP program" (ALT) can facilitate systematic evaluation of non-CPAP therapies appropriate for an individual patient. We review successful strategies and barriers encountered during implementation of an ALT at our institution. Creation of similar programs in private practice and academic settings can help medical, dental, and surgical sleep medicine specialists coordinate evaluation and treatment of CPAP-intolerant patients.

Public Health Genomics: the essential part for good governance in public health.

Is Public Health Ethical?

Ecological mental health promotion - The case of suicide prevention: 21st century mental health analogues for 'clean water', 'improved sanitation', and 'vaccines'.

Jaffe and Hope provide an insightful analysis of the ethics implicit in public health interventions. According to them, public health interventions are traditionally divided into two categories: (i) interventions that are beneficial to the recipients [and wider society] (for example, vaccinations); and (ii) interventions that are required to prevent such serious harm to the general population that coercive measures by the state is justified and regulated through public health law (for example, isolation and quarantine). Using the proposed provision of anti-retroviral treatment to all HIV-infected individuals, regardless of the degree of their immune suppression, as proposed by Granich et al. (2009), as an example, Jaffe and Hope argue that such a measure constitutes a third category of public health interventions (hereinafter referred to as ‘category 3′ public health interventions) as they are neither unequivocally in the best interests of the recipients nor given within a clear legal framework designed for imposing restrictions on individuals who are a danger to public health. In addressing the issue of whether there are any widely accepted ethical models within medicine that allow some people to be given an intervention that, on balance, risks more harm than good for the sake of benefit to others (i.e., category 3 measures), Jaffe and Hope argue that ‘the ethical framework and standards that have been, and continue to be, developed in the context of medical research provide a useful model for public health’, and base their proposed ethical framework, thereon. In their view, category 3 public health interventions can ethically proceed if they meet six “necessary conditions”. While Jaffe and Hope’s proposed framework is a welcome addition to the relatively nascent field of public health ethics, it is not clear why they omitted alluding to, and appraising the appropriateness of, pioneering public health ethics frameworks, such as those proposed in the last decade by Kass (2001), Childress et al (2002), Upshur (2002), and Gostin (2003), in relation to category 3 public health interventions / measures. Although they cite Gostin’s 2002 seminal work on public health law, their inexplicable omission to discuss existing public health ethics frameworks gives the impression that Jaffe and Hope are either unaware of the existence of such proposed frameworks (which seems unlikely), or that they believe that such frameworks are inappropriate evaluative models for category 3 public health measures. The latter would be puzzling given the apparent similarities between all the proposed frameworks, to date, theirs included. If they believe the latter is applicable, the onus was/is on Jaffe and Hope to adduce relevant arguments to justify why this is so. Otherwise they risk seemingly reinventing the wheel. While there are distinct differences between Jaffe and Hope’s framework and those that preceded it (for example, none of the earlier public health ethics frameworks regards an informed consent process as a necessary condition to implementing a public health measure), there are striking similarities too. For example, Jaffe and Hope’s third necessary condition (the public health benefit cannot be produced by an alternative means that is ethically preferable) is akin to Childress et al.’s Least Infringement principle, Kass’ Burden Minimisation / Alternative Approaches principle, and Upshur’s Least Restrictive or Coercive Means principle. Similarly, Jaffe and Hope’s fourth proposed necessary condition (the public health benefit is such as to justify the risk of harm to participants) is akin to Childress et al’s Necessity principle, Kass and Gostin’s respective Effectiveness principles, and Upshur’s Harm principle. Likewise, Jaffe and Hope’s sixth necessary condition (the public health measure is scrutinized by some properly constituted and appropriate independent body) is akin to Childress et al’s Public Justification principle, Kass’ notion of procedural justice outlined in her principle of fair balancing of burdens and benefits, and similar in sentiment to Upshur’s Transparency principle (although all three latter frameworks also differ in that they do not make reference to Norm Daniel’s Accountability for Reasonableness model). Given these overall similarities, it is not clear if / how Jaffe and Hope’s proposed “necessary conditions” differ, or are meant to differ, from the proposed “principles” enunciated in proposed frameworks of Kass, Childress et al, Upshur, and Gostin. Arguing that there is a distinction between a “necessary condition” and a “principle” is unsustainable as the latter could easily be phrased as a “necessary condition”. For example, Upshur’s proposed public health ethics framework posits the principle of Reciprocity (which has no parallel in Jaffe and Hope’s model, although it would be very useful if incorporated). Rebranded as a “necessary condition” could see the principle of Reciprocity phrased as follows: “Those affected by a proposed intervention/measure should be adequately compensated and/or offered viable alternative interventions of equal or superior efficacy, if such alternate interventions exist”. Using Granich et al’s HIV treatment proposal as an example, the principle of Reciprocity would require public health authorities to prospectively put in place mechanisms that ensure that recipients who have adverse reaction to first-line ARVS are immediately switched to second-line therapies, at state expense. Furthermore, those who experience severe adverse reactions as a result of their treatment regimen must be fairly compensated. While Jaffe and Hope’s proposed framework is a valuable addition to current literature on public health ethics, it would be helpful to see a follow-up manuscript from them wherein they reconcile or distinguish their proposed public health ethics framework with/from those that have preceded it. This will strengthen not just their proposed framework, but also the field of public health ethics.

Advancing the Science of Delivery

Applying critical realism to the COVID-19 pandemic to improve management of future public health crises.

In the UK and globally, pharmacy professionals (pharmacists and pharmacy technicians) contribute to the delivery of local and national public or population health interventions. The existing literature on pharmaceutical public health predominantly focuses on micro-level activities, primarily describing community pharmacies delivering public health interventions to individuals. There is little-known evidence on pharmacy professionals' involvement in delivering public health interventions at meso- (e.g., organisational) and macro (national/policy) levels, nor to what extent pharmacy professionals have specialist/advanced roles within public health practice. This study specifically explored pharmacy professionals' specialist/advanced roles within public health as well as the opportunities and barriers to career development. The analyses of this mixed-methods study makes a series of important recommendations for future action. This study included two independent cross-sectional electronic surveys for pharmacy professionals and public health professionals, a call for evidence, and two workshops to develop recommendations. Pharmacy professionals (n = 128) and public health professionals (n = 54) across the UK participated in the surveys. Most of the Pharmacy Professionals respondents were female (70%), pharmacists (85%), working in primary (33%) or secondary (25%) care settings, mainly based in England (75%), and most (63%) lacked formal public health qualifications although they were involved in a diverse range of public health interventions. The public health professionals were mostly females (67%), practicing in England (58%). Both professional groups identified opportunities and barriers to pharmacy professionals' involvement in public health. Almost half of the public health professionals respondents (44%) stated that they had a pharmacy professional working as part of their current public health teams. Eighty-seven percent of public health professional respondents (45/52) agreed that having pharmacists or pharmacy technicians specialising in public health would be beneficial or very beneficial. Most of the documents, reports, and case histories provided through the call for evidence were unpublished. The workshops generated 94 recommendation statements, highlighting collaboration and the need to acknowledge pharmacy professionals' contributions to public health. The recommendations for strategic action at meso- and macro-levels included three main themes: adopting a national strategic approach to pharmaceutical public health, including improving commissioning; formalising pharmaceutical public health workforce development; and promoting further evidence-based pharmaceutical public health research and development.

Preventive Strategy Against Infectious Diarrhea—A Holistic Approach

"SHARE. CARE. CURE." – A EUROPEAN REFERENCE NETWORK FOR RARE INFECTIOUS DISEASES

As documented by countless numbers of articles in the lay and medical media, there is a contentious debate over health care reform occurring in our society. There is no doubt that such a public discussion, albeit sometimes rancorous, is the signature of a healthy democracy. Nevertheless, throughout much of the discussion, there does seem to be some consensus that there are large numbers of Americans without access to health care because of lack of insurance coverage, and that this number is increasing. Furthermore, most law and policy makers believe that it should be decreased, if not eliminated, even if they cannot agree upon the means by which this should be accomplished. One of the cornerstones of most current policy initiatives is that greater access be placed on preventative medical care, and that the primary care physician be the vehicle by which this is achieved. Consequently, there has been substantial effort placed on increasing the number of physicians graduating from US medical schools both by starting new institutions and by increasing class sizes among existing schools. According to the American Association of Medical Colleges, the first year enrollment in US medical schools rose 2% in 2009 vs. 2008, both by the opening of 4 new medical schools and a 7% or more increase in class size among 12 existing schools.1 However, to date, there has been substantially less effort to address the workforce issues related to graduate medical education (GME) that will be engendered by the increase in medical school graduates and the need for more primary care physicians. In fact, given the increase in medical school graduates, it is projected that there will soon be more graduates than available residency positions! Almost all GME in this country is financed by payments made to teaching hospitals through the Medicare program. However, the number of federally funded GME positions is capped by statute. Although it is generally agreed that more primary care physicians are needed, only ∼36% of these positions are in primary care specialties (Internal Medicine, Pediatrics and Family Medicine).2 Federal policy makers have been heretofore reticent about mandating the specialty distribution of GME positions. However, it would not take much imagination to envision a federal initiative to realign the specialty distribution of these positions to promote the training of primary care physicians. Thus, without any increase in the total number of GME positions, a game of “musical chairs” among the subspecialties will ensue. At the current time, there are 70 Sleep Medicine programs around the country with 140 filled positions. As a small field, we will be left scrambling to compete for funding among much larger specialties such as cardiology (2396 positions) or neurology (1877 positions).2 What will be our strategy to at least maintain, if possibly even to increase the number of GME positions that we have? I submit that as a field, we will need to demonstrate the added value of having a cadre of Sleep Medicine specialists available to treat and consult on difficult to manage patients with various sleep disorders or those with uncommon sleep disorders. It is unrealistic to imagine that Sleep Medicine specialists will be the primary caregivers for the large number of patients with sleep problems given the number of such patients and the number of practicing Sleep Medicine specialists. To date, there have been few studies that have shown that patient outcomes are better with input from Sleep Medicine specialists. Those that have been performed have confirmed that patients receive better care from Sleep Medicine specialists or accredited sleep centers,3,4 but it is unlikely that public policy will be developed based on such limited data. Therefore, our field needs more evidence both to demonstrate better patient outcomes and to emphasize the cost effectiveness of our services. This will be one of our greatest challenges. Otherwise, the field of Sleep Medicine will be increasingly marginalized in the march towards more primary care physicians and fewer specialists.

Background: To compare the effectiveness between conventional (face-to-face) and online public health approaches focused on mental health, self-efficacy of health management and quality of life of older adults.Design and methods: Participants will be 65+ residents of the city of Rijeka and the wider urban area and will be divided into three groups. The first group consists of participants who will be included in the conventional (face-to-face) form of public health intervention, the second group consists of participants who will be involved in online public health intervention and the third group consists of participants from the control group. A total of 450 participants will participate in a pretest-posttest non-equivalent groups design research, with 150 participants per group. A series of questionnaires will be administered to evaluate effect of the interventions on mental health, self-efficacy of health management and quality of life. Results of this research will provide insight into the effectiveness of the electronic way of implementing chronic disease self-management interventions compared to conventional (face-to-face) which can be useful to policy makers and public authorities in the organization and implementation of health policies.Expected impact of the study for public health: This research will contribute to the definition, implementation and adaptation of future public health interventions related to mental health, selfefficacy of health management and quality of life in the context of various epidemiological situations such as the current one caused by the COVID-19 pandemic.Significance for public healthSocial distancing, curfews and quarantine during the COVID-19 pandemic led to a deterioration in mental health, especially in vulnerable population groups. Older adults were and are still greatly impacted by the pandemic in terms of mental health, socialization aspect and loneliness. Therefore, new approaches in public health interventions should be implemented. Innovative public health approaches related to resilience enhancement and chronic disease self-management in combination with modern technologies should be implemented and evaluated. Evidence-based results of this research will provide insight into the effectiveness of the electronic way of implementing public health interventions compared to conventional (face-to-face) which can be a useful tool to policy makers and public authorities in planning and adapting future mindfulness-based and chronic disease self-management interventions.

BackgroundThe limited integration of ethics in nutrition-related public health policies and interventions is one major concern for those who have the task of implementing them. Ethical challenges that are overlooked during the development of such interventions could raise serious ethical issues during their implementation and even after. As a result, these decision makers need technical support and ethical guidance for adaptation of interventions to local (cultural, social, economic, etc.) contexts.AimThe goal of this scoping review is to delineate and “map” the range of ethical issues in nutrition-related public health interventions, as well as the range of the various fields in which they may arise.MethodsA scoping review of empirical research and conceptual literature was conducted following the framework of Arksey and O’Malley. Searches using PubMed with Medical Subject Headings (MeSH) categories and Advanced Search Builder as well as in the Global Health Library were performed. The final sample consists of 169 publications.ResultsThe ethics of public health prevention or treatment of obesity and non-communicable diseases is the most explicitly and frequently discussed subject. In comparison, ethical issues raised by public health interventions in the fields of undernutrition, breastfeeding, vitamin/mineral supplementation and food fortification, food security, food sustainability and food safety are addressed in a lower proportion of the sample. The results illustrate the various natures, types, and scopes of existing public health nutrition-related interventions, and the various ethical issues that may be raised by these interventions, in addition to the numerous and different contexts in which they may be implemented.DiscussionThe ethical issues faced in the development and implementation of nutrition-related public health interventions are varied and cannot be equated with, nor generalized about, when dealing with specific activities in this field. More importantly, these ethical issues cannot be managed without a careful consideration for the complexity of contexts in which nutrition-related interventions are expected to be implemented. These interventions engage a variety of actors with diverse perspectives and interests. We discuss these challenges and also comment on the importance of considering ethical impacts in the monitoring and evaluation of such interventions.ConclusionGeneral ethical frameworks or recommendations–although useful–cannot be expected to provide policy makers, implementators and other public health personnel with sufficient practical ethical guidance as they cannot consider and anticipate the particularities of all specific nutrition-related public health interventions and the complexity of the contexts in which they are implemented. Further research is needed in order to develop more targeted ethical frameworks.

[This corrects the article DOI: 10.1371/journal.pone.0186897.].