Public Health Service Delivery Research Articles

Linking Inuit Knowledge and Public Health for Improved Child and Youth Oral Health in NunatuKavut.

The oral health of Inuit children in Canada has been identified as a public health crisis. Although efforts are being made to identify and address ways to deal with this crisis, current policy and program approaches are largely entrenched within the prevailing paradigm of dental science to the exclusion of Indigenous people's understandings of health. This article reports qualitative findings of a larger study aimed at identifying, understanding, and addressing rates of oral disease among children living in NunatuKavut, a cluster of small, coastal Inuit communities located in southern Labrador, Canada. Through 18 focus groups with youth (n = 86), caregivers (n = 22), and interviews with key informant (n = 13), this study begins to elucidate southern Inuit understandings of oral health. Theorized using Two-Eyed Seeing, an Indigenous approach to balancing both Indigenous and non-Indigenous understandings of the world, the findings reported here reveal 3 themes, each of which is crosscut by historical and contemporary dimensions: 1) (w)holistic conceptualizations of health are essential to good oral health, 2) achieving optimal oral health is prohibitive for Inuit communities, and 3) community-engaged oral health service delivery is needed. Our recommendations have implications for improved oral public health service delivery for Inuit communities, in that the inclusion of Inuit perspectives on oral health should form an instrumental element of oral public health service delivery. Knowledge Transfer Statement: The results of this study may be used by clinicians and oral health educators to inform approaches to oral health service delivery within the context of Indigenous communities. It may also be used by policymakers to recognize how historical and contemporary issues of colonization relate to the formation of oral health-related policies.

Health needs and priorities of Syrian refugees in camps and urban settings in Jordan: perspectives of refugees and health care providers.

The United Nations has declared the Syrian refugee crisis to be the biggest humanitarian emergency of our era. Neighbouring countries, such as Jordan, strain to meet the health needs of Syrian refugees in addition to their own citizens given limited resources. This study aimed to determine the perspectives of Syrian refugees in Jordan, Jordanian health care providers and other stakeholders in addressing the public health issues of the refugee crisis. Qualitative and quantitative methodologies were used to explore Syrian refugee health needs and services in camp and urban settings in Jordan. Focus group discussions and key informant interviews were used to identify needs, challenges and potential solutions to providing quality health care to refugees. By-person factor analysis divided refugee participants into 4 unique respondent types and compared priorities for interventions. Focus group discussions and key informant interviews revealed a many different problems. Cost, limited resources, changing policies, livelihoods and poor health literacy impeded delivery of public and clinical health services. Respondent Type 1 emphasized the importance of policy changes to improve Syrian refugee health. Type 2 highlighted access to fresh foods and recreational activities for children. For Type 3, poor quality drinking-water was the primary concern, and Type 4 believed the lack of good, free education for Syrian children exacerbated their mental health problems. Syrian refugees identified cost as the main barrier to health care access. Both refugees and health care providers emphasized the importance of directing more resources to chronic diseases and mental health.

Educating the Public Health Workforce: A Scoping Review.

The aim of this scoping review was to identify and characterize the recent literature pertaining to the education of the public health workforce worldwide. The importance of preparing a public health workforce with sufficient capacity and appropriate capabilities has been recognized by major organizations around the world (1). Champions for public health note that a suitably educated workforce is essential to the delivery of public health services, including emergency response to biological, manmade, and natural disasters, within countries and across the globe. No single repository offers a comprehensive compilation of who is teaching public health, to whom, and for what end. Moreover, no international consensus prevails on what higher education should entail or what pedagogy is optimal for providing the necessary education. Although health agencies, public or private, might project workforce needs, the higher level of education remains the sole responsibility of higher education institutions. The long-term goal of this study is to describe approaches to the education of the public health workforce around the world by identifying the peer-reviewed literature, published primarily by academicians involved in educating those who will perform public health functions. This paper reports on the first phase of the study: identifying and categorizing papers published in peer-reviewed literature between 2000 and 2015.

Correction: Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia?

[This corrects the article DOI: 10.1371/journal.pone.0187311.].

Local governance and management of health care services: A community based case study in rural Odisha

Close to 700 million people live in rural areas where the condition of medical facilities is deplorable. In the context of maternal health and reproductive health care, which are the major concerns of human development goals, the important question is about the reach, accessibility, and affordability of these services to the people living in rural areas. As such the well-being of the villagers depends to a great extent on the efficacy of the gram panchayat. In view of the importance of health as a critical input for human development, the present case study aims to look at the different ways the gram panchyat members’ function and involve in areas of health, hygiene and sanitation. A case study of three villages under female and male headed panchayats in Kalahandi district of Orissa is undertaken to understand the involvement of local self-government in the management and delivery of public health services.

Palliative Care, Suffering, Death Trajectory: A View of End-of-Life Care (EOL) Related Issues in Sub-Saharan Africa (SSA)

Palliative care in the sub-Saharan Africa (SSA) region despite some progress made since the first hospice was opened in Zimbabwe in 1979, still lags far behind that of countries with developed economies, and relatively suffers from not being wholly included into mainstream public health service delivery in SSA. The situation is made worse due to relatively poor and pervasive socio-politico-economic factors and the challenge of the changing and increasing non-communicable disease epidemiology in SSA countries. This situation results in a tension between scarce resources and service needs/provision which prevails in a good number of SSA countries. In large part the situation where palliative care, end of life and the death trajectory converge in SSA countries currently portrays one of scarcity of resources and suffering for those ill SSA patients who need the services. This article is an overview of the current situation as pertains to palliative care services in the SSA region and some of the factors that contribute to or perpetuate the current state of palliative care delivery in SSA countries.

Capacity Building of Private Sector Workforce for Public Health Services in India: Scope and Challenges.

Indian health sector is a complex admixture of public and private providers, but several lacunae of public health service delivery system in terms of human resource, access, and quality have resulted in unprecedented growth of private sector. Although seamless delivery of services at rural and urban areas, timely approach, and improved information technology system are the strength of the private sector, this package comes at the cost of high out-of-pocket expenditure. Mobilization of private sector health workforce by their capacity building in terms of orientation toward public health services is one of the available solutions to move toward wider coverage of public health services. However, numerous challenges need to be addressed before realization of this vision.

Improving Contraceptive Access, Use, and Method Mix by Task Sharing Implanon Insertion to Frontline Health Workers: The Experience of the Integrated Family Health Program in Ethiopia.

In 2009, the Ethiopian Federal Ministry of Health launched an Implanon scale-up program with the goal of improving the availability of long-acting reversible contraceptive (LARC) methods at the community level. The Integrated Family Health Program (IFHP) supported the ministry to train Health Extension Workers (HEWs), a cadre of frontline health workers, on Implanon insertion. Prior to this task-sharing initiative, HEWs were only permitted to provide short-acting contraceptive methods; Implanon insertion services were only available at higher-level health facilities, such as health centers and above. To train HEWs on Implanon insertion, IFHP followed a phase-based approach, which consisted of a learning phase (July to September 2009) that transitioned into a scale-up phase (December 2009 to December 2015). Training began with a series of service delivery-based training of trainers (TOT) sessions for clinical care providers selected from health centers followed by rollout trainings on Implanon insertion for HEWs selected from health posts. Immediately after the Implanon rollout trainings, each trained HEW was provided with consumables and Implanon implants to enable them to initiate the Implanon services at their respective health post. To reinforce knowledge and skills, we conducted mentoring visits and performance review meetings. From July 2009 to September 2015, 98 TOT sessions trained 2,328 clinicians and 320 rollout trainings reached 8,436 HEWs. A total of 1,382,318 women received contraceptive services through any IFHP-supported service delivery point, 1,273,990 of whom received an Implanon implant. The IFHP approach proved to be a successful model for increasing access to contraceptive methods in the community, and the program supported the integration of Implanon services into the existing public health service delivery system.

Market mechanisms for newborn health in Nepal

BackgroundIn Nepal, hypothermia is a major risk factor for newborn survival, but the country’s public health care sector has insufficient capacity to improve newborn survival given the burden imposed by distance to health facilities and cost. Low-cost technology to provide newborn thermal care in resource-limited environments exists, but lacks effective distribution channels.This study aims to develop a private sector distribution model for dedicated newborn thermal care technology to ensure equitable access to thermal protection and ultimately improve newborn health in Nepal.MethodsWe conducted a document analysis of newborn health policy in Nepal and a scoping literature review of approaches to newborn hypothermia in the region, followed by qualitative interviews with key stakeholders of newborn health in Nepal.ResultsCurrent solutions addressing newborn hypothermia range from high-technology, high-cost incubators to low-cost behavioral interventions such as skin-to-skin care. However, none of these interventions are currently implemented at scale. A distribution model that provides incentives for community health volunteers and existing public health services in Nepal can deliver existing low-cost infant warmers to disadvantaged mothers where and when needed. Newborn technology can serve as an adjunct to skin-to-skin care and potentially create demand for newborn care practices.ConclusionHarnessing market forces could promote public health by raising awareness of newborn challenges, such as newborn hypothermia, and triggering demand for appropriate health technology and related health promotion behaviors. Market approaches to promoting public health have been somewhat neglected, especially in economically disadvantaged and vulnerable populations, and deserve greater attention in Nepal and other settings with limited public health service delivery capacity.

Does proximity of women to facilities with better choice of contraceptives affect their contraceptive utilization in rural Ethiopia?

BackgroundThere is limited evidence of the linkage between contraceptive use, the range of methods available and level of contraceptive stocks at health facilities and distance to facility in developing countries. The present analysis aims at examining the influence of contraceptive method availability and distance to the nearby facilities on modern contraceptive utilization among married women in rural areas in Ethiopia using geo-referenced data.MethodsWe used data from the first round of surveys of the Performance Monitoring & Accountability 2020 project in Ethiopia (PMA2020/Ethiopia-2014). The survey was conducted in a sample of 200 enumeration areas (EAs) where for each EA, 35 households and up to 3 public or private health service delivery points (SDPs) were selected. The main outcome variable was individual use of a contraceptive method for married women in rural Ethiopia. Correlates of interest include distance to nearby health facilities, range of contraceptives available in facilities, household wealth index, and the woman’s educational status, age, and parity and whether she recently visited a health facility. This analysis primarily focuses on stock provision at public SDPs.ResultsOverall complete information was collected from 1763 married rural women ages 15–49 years and 198 SDPs in rural areas (97.1% public). Most rural women (93.9%) live within 5 kilometers of their nearest health post while a much lower proportion (52.2%) live within the same distance to the nearest health centers and hospital (0.8%), respectively. The main sources of modern contraceptive methods for married rural women were health posts (48.8%) and health centers (39.0%). The mean number of the types of contraceptive methods offered by hospitals, health centers and health posts was 6.2, 5.4 and 3.7 respectively. Modern contraceptive use (mCPR) among rural married women was 27.3% (95% CI: 25.3, 29.5). The percentage of rural married women who use modern contraceptives decreased as distance from the nearest SDP increased; 41.2%, 27.5%, 22.0%, and 22.6% of women living less than 2 kilometers, 2 to 3.9kilometers, 4 to 5.9 kilometers and 6 or more kilometers, respectively (p-value<0.01). Additionally, women who live close to facilities that offer a wider range of contraceptive methods were significantly more likely to use modern contraceptives. The mCPR ranged from 42.3% among women who live within 2 kilometers of facilities offering 3 or more methods to 22.5% among women living more than 6 kilometers away from the nearest facility with the same number (3 or more methods) available after adjusting for observed covariates.ConclusionsAlthough the majority of the Ethiopian population lives within a relatively close distance to lower level facilities (health posts), the number and range of methods available (method choice) and proximity are independently associated with contraceptive utilization. By demonstrating the extent to which objective measures of distance (of relatively small magnitude) explain variation in contraceptive use among rural women, the study fills an important planning gap for family planning programs operating in resource limited settings.

Vision for change in practice: a pilot study of recovery oriented mental health services

Managing the integrated delivery of better public health services and working with community assets to improve health outcomes Introduction: Policy dictates a move toward recovery oriented services for people with severe mental health difficulties, yet there is a lack of analysis regarding facilitation of this type of support in Ireland. Practice change: REFOCUS was a pilot project implementing recovery oriented services within the Irish mental health day services. It utilised peer support and individualized care planning to encourage and foster engagement with the community and to guide the service user (SU) towards adopting a positive and forward looking perspective to their lives. SU’s were facilitated to access mainstream employment and social and leisure opportunities. Participating SU and staff availed of co designed recovery led training programme. Some staff were reconfigured to become Individualised Planning Facilitators, Community Connectors and Individual Placement and Support Employment specialists. Aim and theory of change: The evaluation aimed to appraise the impact of implementing recovery focused day services by exploring and measuring the experiences of service users, peer support workers and mental health staff participating in the initiative. SU outcomes were measured qualitatively and quantitatively against CHIME (connectedness, hope and optimism about the future, identity, meaning in life and empowerment) domains of recovery at two time points. Staff beliefs, attitudes and judgements as well as PSW’s experiences were also explored. Population & stakeholders: The evaluation included 35 SU with serious mental health difficulties, 14 health service staff and 7 peer support workers. REFOCUS was a 3 year Genio Trust funded joint initiative between the Irish Health Service Executive and RehabCare. Timeline: This longitudinal study measured outcomes at two time points over a 3 year period. Highlights: At T2 93% of SU judgements measured by INSPIRE agreed peer support workers aided their recovery and SUs agreed they had experienced 82% of the positive personal recovery aspects measured by the QPR. SU met needs as measured by CANSAS remained constant from T1 to T2. At time 2 majority of staff (83%) believed that REFOCUS offered a good way to provide mental health services and 61% felt supported by the HSE in implementing recovery oriented changes Both staff and service user’s identified peer support to be uniquely supportive of a service user’s individual recovery, helping service user’s to feel more positive, confident and independent. Sustainability: Although many staff felt recovery orientated services involved more of a struggle in the short term, long term gains in service user independence, they felt, were worth the extra effort. Some mentioned an increase in job satisfaction from watching service user’s gain hope, confidence and independence from their experiences. Transferability: Staff and service user’s both found peer support to be a positive aspect of REFOCUS and felt with the development of training and guidelines for the role, could be an important improvement to service provider practice. This evaluation has demonstrated that a day service that supports recovery could continue to meet the needs of a service user while also improving their functioning and quality of life which could potentially reduce the level of dependency on health service resources. Results may aid understanding and guide future recovery oriented practices

Trends in levels of self-reported psychological distress among individuals who seek psychiatric services over eight years: a comparison between age groups in three population surveys in Stockholm County

BackgroundPsychiatric service use has increased in Sweden and in other developed countries, particularly among young people. Possible explanations include lower threshold for help-seeking among young people, but evidence is scarce.MethodsWe analysed the 2002, 2006 and 2010 Stockholm public health surveys for changes in the mean level of psychological distress among adult users of psychiatric in- and outpatient services in four age groups: 18–24, 25–44, 45–64 and ≥65 years. Psychological distress was measured via the 12-item General Health Questionnaire (GHQ-12), using the Likert scoring method 0–1–2-3. In- and out-patient psychiatric service use within 6 months from the surveys was obtained from registers.ResultsThe mean level of distress among young adults 18–24 years who utilize psychiatric services decreased between 2002 (mean GHQ-12 score, 95% confidence interval 20.5, 18.1–23.0) and 2010 (16.2, 14.6–17.7), while it remained fairly stable in older age groups. Results were similar in sex-stratified analyses, although the decrease was statistically significant only among young women 18–24 years. At the end of the follow-up, the level of distress among patients was similar for all age-groups.ConclusionsThere were no differences between age groups in the level of distress when seeking care at the end of the follow-up period, supporting that there is no age-specific over- or under-consumption of psychiatric care in later years. However, the lowered threshold for help-seeking among young adults over time might have contributed to increases in psychiatric service use in the young age group. Public health policy and service delivery planning should consider the needs of the widening group of young users of psychiatric services.

Linking pharmacists to the delivery of public health services

ObjectiveTo describe components fundamental to the process of linking pharmacy to the delivery of public health services in a sustainable way. SummaryPharmacists deliver public health services with varying frequency. A literature review was conducted to create a set of fundamental links necessary for pharmacists to deliver public health services in a sustainable way. The service needed to be in alignment with public health priorities, be incorporated in the pharmacy curriculum, have postgraduate training opportunities, have a policy or legal platform supporting the service, and have a business model for financial sustainability. Immunization delivery was identified as an exemplary public health service delivered by pharmacists. Additional services evaluated were tobacco cessation counseling, transitions of care, hypertension screening, and substance abuse counseling. ConclusionPharmacists are well positioned to provide public health services. Although pharmacists can offer these services, their delivery is variable because of unclearly defined links in the process necessary for their implementation. This article identifies actionable steps to establish sustainable methods for community pharmacists to deliver public health services.

Intention to Use a Mobile-Based Information Technology Solution for Tuberculosis Treatment Monitoring – Applying a UTAUT Model

There are 2.2 million cases of tuberculosis (TB) in India, with an economic burden of $3 billion per year. Efficient monitoring of TB treatment is critical and the Indian Government's current reliance on a pen and paper system for monitoring patients' adherence to treatment is neither effective nor scalable. Employing the unified theory of acceptance and use of technology model (UTAUT) as its theoretical foundation, this study investigates the factors influencing the acceptance and use of a mobile-based IT solution for TB treatment monitoring. Data was collected from a survey of healthcare professionals working in TB treatment clinics and analysed using partial least squares structural equation modelling. Four constructs in the UTAUT model, effort expectancy (EE), facilitating conditions (FC), performance expectancy (PE) and social influence (SI) --- were found to significantly and positively influence healthcare professionals' behavioral intention to use the proposed mobile-based IT solution, and explained 56% of the variance. Importantly, our study validates the predictive capabilities of the UTAUT model in public health service delivery context in a developing country.

Syndromic Surveillance of Mental and Substance Use Disorders: A Validation Study Using Emergency Department Chief Complaints.

This study evaluated whether emergency department (ED) patient presentations for problems related to mental and substance use disorders could be validly monitored by a syndromic surveillance system that uses chief complaints to identify mental disorders. The study used syndromic surveillance data on 146,315 ED visits to participating Fresno County, California, hospitals between January 1 and December 31, 2013. Free-text patient chief complaints are automatically classified into syndromes based on the developer's algorithms. Agreement was assessed between the algorithm's syndrome classification of mental health and substance abuse (MHSA) disorders and ICD-9-CM discharge diagnostic codes. Diagnosis and ED utilization patterns among patients with at least one visit with an MHSA syndrome classification were also examined. Approximately 8% of ED visits during the study period received an MHSA syndrome classification. Overall agreement between MHSA syndrome classification and psychiatric- or substance use-related ICD-9 discharge diagnoses was high (κ=.92, 95% confidence interval=.91-.92). Sensitivity (100%) and specificity (98.6%) of the MHSA syndrome classification were also very high. MHSA syndrome-classified patients exhibited high levels of health care and morbidity burden compared with other patients. ED chief complaints can be utilized to reliably and validly ascertain the incidence of patient presentations for mental and substance use disorders in contexts in which discharge diagnoses are not routinely available. Wider adoption of MHSA-related syndrome algorithms by syndromic surveillance systems could be valuable for public mental health surveillance, service delivery, and resource planning efforts.

After-action review of the 2009-10 H1N1 Influenza Outbreak Response: Ohio's Public Health System's performance.

In early 2009, H1N1 influenza was identified within the human population. Centers for Disease Control and Prevention (CDC) officials responded with focused assessment, policy development, and assurances. The response was mobilized through efforts including procurement of adequate vaccine supply, local area span of control, materials acquisition, and facilities and resource identification. Qualitative evaluation of the assurance functions specific to the system's ability to assure safe and healthy conditions are reported. The methodology mirrors the Homeland Security Exercise and Evaluation Program used to assess system capability. Findings demonstrate the effectiveness of community responsive disease prevention efforts in partnership with the public health systems mission to unify traditional public sector systems, for-profit systems, and local area systems was accomplished. As a result of this response pharmaceutical industries, healthcare providers, healthcare agencies, police/safety, colleges, and health and human service agencies were united. Findings demonstrate the effectiveness of community response strategies utilizing feedback from system stakeholders. After-action review processes are critical in all-hazards preparedness. This analysis of local health district response to the H1N1 influenza outbreak informs future public health service delivery. Results provide a synthesis of local health department's emergency response strategies, challenges encountered, and future-focused emergency response strategy implementation. A synthesis is provided as to policy and practice developments which have emerged over the past seven years with regard to lessons learned from the 2009-10 H1N1 influenza outbreak and response.

A cross-sectional study using freedom of information requests to evaluate variation in local authority commissioning of community pharmacy public health services in England

ObjectivesThis study aims to provide a national picture of the extent and nature of public health services commissioned by local authorities (LAs) from community pharmacies across England in financial year...

A strategic approach to workforce development for local public health.

In 2009, Peel Public Health set a vision to transform the work of public health from efficient delivery of public health services as defined by provincial mandate to the robust analysis of the health status of the local population and selection and implementation of programming to achieve best health outcomes. A strategic approach to the workforce was a key enabler. PPH is a public health unit in Ontario that serves 1.4 million people. An organization-wide strategic workforce development program was instituted. It is theory-based, evidence-informed and data-driven. A first step was a conceptual framework, followed by interventions in workforce planning, human resources management, and capacity development. The program was built on evidence reviews, theory, and public health core competencies. Interventions spread across the employee work-life span. Capacity development based on the public health core competencies is a main focus, particularly analytical capacity to support decision-making. Employees gain skill and knowledge in comprehensive population health. Leadership evolves as work shifts to the analysis of health status and development of interventions. Effective human resource processes ensure appropriate job design, recruitment and orientation. Analysis of the workforce leads to vigorous employee development to ensure a strong pool of potential leadership successors. Theory, research evidence, and data provide a robust foundation for workforce development. Competencies are important inputs to job descriptions, recruitment, training, and human resource processes. A comprehensive workforce development strategy enables the development of a skilled workforce capable of responding to the needs of the population it serves.

Social Media Technology and Public Health in Ontario: Findings from a Planning Meeting Exploring Current Practices and Future Research Directions.

In the province of Ontario, many of the public health units (PHUs) now possess and use social media as part of their daily health promotion and communication operations. To explore this topic, a planning meeting was held to generate deeper insights toward the use of these forms of technology for preventative services delivery. The planning meeting was held with 50 participants, comprising representatives from 20 of the 36 PHUs in Ontario, interested academics, students and government representatives. A nominal group technique (NGT) was used to build consensus related to future research needs, as related to public health and social media. Participants generated a range of insights around the use of social media, including the need for: leadership buy-in and resource allocation; social media policy and governance structure; performance measurement and evaluation; practices related to engagement with program recipients and addressing the lack of resources faced by many health units. Future research priorities were also generated, related to evaluating the cost-benefit of social media activities and understanding behaviour change implications. Further research is needed to evaluate the functionality, leadership and competency requirements and impact(s) of these new forms of health communication technology within public health service delivery.

Liberia, Ebola and the pitfalls of state-building: Reimagining domestic and diasporic public authority

Using the Ebola outbreak of 2014/2015 in Liberia as a case study, this article demonstrates that by converting ‘private activities and resources’ for public health service delivery, Liberian domestic and diasporic non-government actors effectively broadcasted public authority at meso- and micro-levels previously assumed to be the exclusive domain of government and international institutions. Moving beyond the structural violence and state-building frameworks, I argue that while Liberia's pursuit of a vertical state-building agenda at the behest of international donors unravelled during Ebola, the public health measures employed by non-government Liberian actors were constituted by horizontal nation-building objectives. This refashioned how we think about public authority in post-war states and beyond. The article provides a systematic documentation of how and why Liberians ‘inside’ and ‘outside’ the geographic territory of the post-war state used their individual and collective agency to eradicate Ebola, and why their interventions are important for a larger discussion about the trajectory of post-Ebola recovery. Though it is difficult to prove a causal relationship between the interventions of non-government Liberian actors and the gradual decline in Ebola incidence rates, I underscore important correlations between their public health measures and Ebola eradication.