Implementation Of Public Health Interventions Research Articles

Signal Detection Analysis of Factors Associated With Diabetes Among Semirural Mexican American Adults

Signal detection analysis was used to evaluate a combination of sociodemographic, acculturation, mental health, health care, and chronic disease risk factors potentially associated with diabetes in a sample of 4,505 semirural Mexican American adults. Overall, 8.9% of adults had been diagnosed with diabetes. The analysis resulted in 12 mutually exclusive groups, with diabetes prevalence ranging from 1.8% to 44.1%. Three groups were at the highest risk (34.5%-44.1% diabetic) and accounted for almost half of those with diabetes. Each of these groups was distinguished by their middle to older ages and presence of one or more chronic conditions (high blood pressure, high cholesterol, obesity, and/or poor mental health) in addition to diabetes. The differing composition of the groups identified by the signal detection analysis has important implications for the design and implementation of public health interventions and health care treatment programs for Mexican Americans with diabetes.

The Global Enteric Multicenter Study (GEMS) of Diarrheal Disease in Infants and Young Children in Developing Countries: Epidemiologic and Clinical Methods of the Case/Control Study

Background. Diarrhea is a leading cause of illness and death among children aged <5 years in developing countries. This paper describes the clinical and epidemiological methods used to conduct the Global Enteric Multicenter Study (GEMS), a 3-year, prospective, age-stratified, case/control study to estimate the population-based burden, microbiologic etiology, and adverse clinical consequences of acute moderate-to-severe diarrhea (MSD) among a censused population of children aged 0–59 months seeking care at health centers in sub-Saharan Africa and South Asia.Methods. GEMS was conducted at 7 field sites, each serving a population whose demography and healthcare utilization practices for childhood diarrhea were documented. We aimed to enroll 220 MSD cases per year from selected health centers serving each site in each of 3 age strata (0–11, 12–23, and 24–59 months), along with 1–3 matched community controls. Cases and controls supplied clinical, epidemiologic, and anthropometric data at enrollment and again approximately 60 days later, and provided enrollment stool specimens for identification and characterization of potential diarrheal pathogens. Verbal autopsy was performed if a child died. Analytic strategies will calculate the fraction of MSD attributable to each pathogen and the incidence, financial costs, nutritional consequences, and case fatality overall and by pathogen.Conclusions. When completed, GEMS will provide estimates of the incidence, etiology, and outcomes of MSD among infants and young children in sub-Saharan Africa and South Asia. This information can guide development and implementation of public health interventions to diminish morbidity and mortality from diarrheal diseases.

Environmental correlates of crimean-congo haemorrhagic fever incidence in Bulgaria

BackgroundCrimean-Congo Haemorrhagic Fever (CCHF) is a zoonotic viral disease transmitted by ixodid tick bites, mainly of Hyalomma spp., or through contact with blood/tissues from infected people or animals. CCHF is endemic in the Balkan area, including Bulgaria, where it causes both sporadic cases and community outbreaks.MethodsWe described trends of CCHF in Bulgaria between 1997 and 2009 and investigated the associations between CCHF incidence and a selection of environmental factors using a zero-inflated modelling approach.ResultsA total of 159 CCHF cases (38 women and 121 men) were identified between 1997 and 2009. The incidence was 0.13 cases per 100,000 population/year with a fatality rate of 26%. An epidemic peak was detected close to the Turkish border in the summer of 2002. Most cases were reported between April and September. Increasing mean temperature, Normalized Difference Vegetation Index (NDVI), savannah-type land coverage or habitat fragmentation increased significantly the incidence of CCHF in the CCHF-affected areas. Similar to that observed in Turkey, we found that areas with warmer temperatures in the autumn prior to the case-reporting year had an increased probability of reporting zero CCHF cases.ConclusionsWe identified environmental correlates of CCHF incidence in Bulgaria that may support the prospective implementation of public health interventions.

Public Health Interventions to Reduce Inequalities: What Do We Know Works?

This commentary focuses on the notion of "what works" to reduce health inequalities. It begins by noting the need for and presence of a wide range of methodologies and approaches internationally. It then argues that it is useful to map out these contributions and those in the present Supplement against a set of principles (Macintyre, 2007) to guide the selection and implementation of public health interventions explicitly aiming to reduce health inequalities. The chosen principles derive largely from efforts to reduce steep and persistent Scottish health inequalities by social class. The commentary summarizes Macintyre's analysis of the main characteristics of public health interventions. It then notes that the present Supplement provides clear examples of population-health interventions and their health impacts that are inequality-reducing. The suggested approach and principles align with calls for the use of structural changes in the environment, early-life interventions, reductions in preventive-care barriers, and a harm-reduction philosophy. The commentary concludes that there remains much to learn and to do in order for public health intervention research to clearly demonstrate how to effectively reduce health inequalities in a lasting manner.

Considering ethics in community eye health planning: perspectives from an existing model

Despite the widespread acceptance of the principles of the Alma Ata Declaration of 1978 and the subsequent amendments, health for all has remained a distant dream in many parts of the developing world. Concerns such as the economic efficiency of health systems and their reach and coverage have dominated discussions of public health, with ethics remaining at best a shadowy set of assumptions or at worst completely ignored. Similarly, questions of ethics have been taken for granted and rarely addressed directly in the design of public health models across sectors and are rarely explicitly addressed. This paper uses the experience of the L V Prasad Eye Institute's (LVPEI) pyramidal model of eye healthcare delivery to explore ethical issues in the design and implementation of public health interventions. The LVPEI model evolved over time from its beginnings as a tertiary care centre to a network that spans all levels of eye care service delivery from the community through primary and secondary levels. A previously published analytical framework is applied to this model and the utility of this framework as well as the ethics of the LVPEI model are interrogated. An analytical and prescriptive framework is then evolved that could be used to build in and evaluate ethics in other public health delivery models.

Determinants of Exposure to Second-Hand Tobacco Smoke (SHS) among Current Non-Smoking In-School Adolescents (aged 11–18 years) in South Africa: Results from the 2008 GYTS Study

The aim of this study was to estimate the prevalence and identify correlates of second-hand tobacco smoke (SHS) among 6,412 current non-smoking school-going adolescents (aged 11 to 18 years) in South Africa. A cross-sectional study was carried out in 2008 in South Africa within the framework of the Global Youth Tobacco Survey. Overall, 25.7% of students were exposed to SHS at home, 34.2% outside of the home and 18.3% were exposed to SHS at home and outside of the home. Parental and close friends smoking status, allowing someone to smoke around you and perception that passive smoking was harmful were significant determinants of adolescent’s exposure to both SHS at home and outside of the home. Identified factors can inform the implementation of public health interventions in order to reduce passive smoking among adolescents.

Reflecting on HIV disclosure laws in the context of unsafe sex and the harm-reduction strategy

In this article, we locate two discourses regarding the incidences of bareback sex practices. First, there is the greater reliance on safe sex practices, including going beyond condemnation of risky behaviour. Second, there is a disciplinary discourse of law and punishment. In the first instance, there is the promotion of the use of alternative (non-invasive) sex practices and condom use. In the second, there are highly selective and punitive disclosure laws specifically directed at unprotected sexual activity and other forms of risky or illicit behaviours that involve the transference of blood or other secretions. We believe, however, that a heightened understanding of the motivations behind unsafe sex is necessary to promote the implementation of public health interventions that will be better adapted to the reality of this population. There is, then, an urgent need to begin reflecting on the type of preventive strategies needed. To this effect, the aim of the current article is to initiate some reflections as well as a dialogue on the compatibility between the practice of bareback sex and a health risk reduction approach.

Persistence, Replacement, and Rapid Clonal Expansion of Meningococcal Carriage Isolates in a 2008 University Student Cohort

A study of meningococcal carriage dynamics was performed with a cohort of 190 first-year students recruited from six residential halls at Nottingham University, United Kingdom. Pharyngeal swabs were obtained on four occasions between November 2008 and May 2009. Direct plating and culture on selective media were succeeded by identification and characterization of meningococci using PCR-based methodologies. Three serogroup Y clones and one serogroup 29E clone were highly prevalent in particular residential halls in November 2008, which is indicative of rapid clonal expansion since the start of the academic year. Persistent carriage of the same meningococcal strain for at least 5 to 6 months was observed in 45% of carriers, with infrequent evidence of antigenic variation in PorA. Sequential carriage of heterologous meningococcal strains occurred in 36% of carriers and involved strains with different capsules and antigenic variants of PorA and FetA in 83% of the cases. These clonal replacement strains also exhibited frequent differences in the presence and antigenic structures of two other surface proteins, NadA and HmbR. This study highlights the low level of antigenic variation associated with persistent carriage but, conversely, the importance of alterations in the repertoire of antigenic variants for sequential carriage of meningococcal strains. Rapid clonal expansion of potentially pathogenic strains in residential halls has implications for the implementation of public health interventions in university populations.

Abstract B6: Social marketing intervention to increase HPV vaccine utilization among Hispanic girls: Preliminary data

Abstract Incidence and mortality rates from cervical cancer are higher in Hispanic women compared to non-Hispanic white women. The recently approved HPV (human papillomavirus) vaccine has been proven effective in preventing 70% cervical cancer cases (those caused by two types of high-risk HPV). This translational research study draws on Rogers’ Diffusion of Innovation theory to address the need to hasten the pace of diffusion of this new vaccine, especially among populations with high rates of cervical cancer. An academic-community partnership employed the methodology of community-based prevention marketing (CBPM) to develop a culturally appropriate, multilevel intervention aimed at increasing the utilization of the HPV (human papillomavirus) vaccine against cervical cancer among Hispanic girls. CBPM combines social marketing theories and techniques with community-based participatory research (CBPR) approaches for the development and implementation of public health interventions aimed at producing behavior change. In this presentation we will present the social marketing plan used in the intervention and preliminary data. The intervention uses a combination of Spanish-language media-radio, newspaper and printed brochures-to disseminate the messages throughout the community. A trained lay health promoter (promotora de salud) at Progreso Community Center receives phone calls to answer general questions about the vaccine and eligibility requirements for the VFC program, refers patients to appropriate locations to obtain the vaccine, and provides follow-up reminders. We present baseline intervention data on rates of HPV vaccine utilization by race/ethnicity and preliminary data on responses to the media campaign. The study contributes valuable knowledge about culturally and linguistically appropriate social marketing strategies for HPV vaccine use among Hispanics. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):B6.

Regional and age-specific patterns of pandemic H1N1 influenza virus seroprevalence inferred from vaccine clinical trials, August-October 2009

The extent of the H1N1 pandemic has been estimated from case counts and deaths but the proportion of exposed populations with inapparent infections has not been described in detail. We analysed haemagglutination-inhibition (HI) antibody titres of pre-vaccination sera from pandemic vaccine trials conducted in six countries on four continents to provide an indication of A/CA/07/2009(H1N1)-like influenza seroprevalence in those populations. Among 7,962 subjects, ranging in age from 12 months to over 60 years, the proportions with HI antibody titres > or =40 to the H1N1pnd virus in the period from August to October 2009 were, by country: Costa Rica 26.4%, United States (US) 22.5%, Switzerland 16.9%, Germany 12.6%, Belgium 10.1%, and Japan 5.9%. Age-specific seropositivity rates in the samples were higher in children and adolescents in Costa Rica and in the US than in Europe and in Japan. The low proportion of seropositive children in Europe and Japan suggests that little local viral transmission had occurred in those regions even as late as September and October 2009, while in the US and Costa Rica, the greater proportion of previously infected children and young adults suggested that a significant number of asymptomatic infections had occurred during the first pandemic wave. Nevertheless, in all locations, the majority of the population remained susceptible to the pandemic virus at the beginning of the influenza season in the northern hemisphere, justifying the implementation of public health interventions.

Spotlight on measles 2010: Preliminary report of an ongoing measles outbreak in a subpopulation with low vaccination coverage in Berlin, Germany, January-March 2010

Since early January 2010, Berlin has been experiencing a measles outbreak with 62 cases as of 31 March. The index case acquired the infection in India. In recent years, measles incidence in Berlin has been lower than the German average and vaccination coverage in school children has increased since 2001. However, this outbreak involves schools and kindergartens with low vaccination coverage and parents with critical attitudes towards vaccination, which makes the implementation of public health interventions challenging.

The Role of Behavioral Science Theory in Development and Implementation of Public Health Interventions

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Pharmaceutical and chemical pediatric poisoning in Kuwait: a retrospective survey.

Past studies of pediatric poisoning in Kuwait have suggested differences at hospital level which could impact on the implementation of public health interventions. The objective was to compare pediatric poisoning admissions at general hospitals in Kuwait. Retrospective survey of all pediatric poisoning cases at the six general hospitals from January 2004 to December 2005. Case data were documented using ICD-10 criteria and the poisoning severity score. Aggregated data was also obtained from five private hospitals. 978 children were admitted in public hospitals over 2004 and 2005 (no fatalities) being 1.8% and 1.6% of all pediatric admissions (private hospitals admitted 293 cases). The majority of the poisoning cases came from Jahra hospital (>35%), the median age was 2.3 yrs, 93% of cases were under 6 yrs old and 71% were Kuwaiti. Two thirds of cases involved pharmaceuticals although this varied between hospitals with a tendency for more severe cases with chemical poisoning (p=0.011). Kerosene was an important problem at Jahra hospital (34.7% of chemical exposures). Non-opioid analgesics constituted 22.3% of medication exposures with hormones and drugs affecting the autonomic nervous system also common with some difference in pattern between institutions. Case demographics do not vary significantly between the hospitals but there are differences in the nature of toxic agents to which children are exposed suggesting that preventive and educational programs could be targeted to specific areas for maximal effect particularly with regard to household chemical and kerosene exposures.

Public health in the emergency department: overcoming barriers to implementation and dissemination.

This article is the outcome of a consensus building workshop entitled, "Overcoming Barriers to Implementation and Dissemination" convened at the 2009 Academic Emergency Medicine Consensus Conference, ''Public Health in the ED: Surveillance, Screening, and Intervention." The participants were asked to address potential methods for overcoming barriers to the dissemination and implementation in the emergency department (ED) of evidenced-based practices to improve public health. The panel discussed three broad areas of interest including methods for disseminating evidence-based practices, barriers encountered during the process of implementation, and the importance of involvement in activities outside the ED including engagement in policy development and improvement. Four recommendations were discussed in detail and consensus was reached. The recommendations included 1) researchers and advocates should disseminate findings through multiple forums beyond peer-reviewed publications when an ED-based public health intervention has enough evidence to support integration into the routine practice of emergency care; 2) local barriers to implementation of public health interventions should be recognized and well understood from multiple perspectives prior to implementation; 3) innovation must be put into place and adapted based on local institutional context and culture as barriers and the best methods for overcoming them will vary across institutions; and 4) use of legislation, regulation, and incentives outside of the ED should support and strengthen ED-based interventions. For each area of interest, research dimensions to extend the current understanding of methods for effectively and efficiently implementing evidence-based public health interventions in the ED were discussed and consensus was achieved.

ETHICAL ANALYSIS IN PUBLIC HEALTH PRACTICE: A MULTI-SECTORAL MIXED-METHODS STUDY

Rationale: All decisions in public health practice involve implicit value judgements, and many involve explicit reference to ethical principles. Despite the increased awareness, interest and literature in Public Health Ethics in the past decade, there remains little understanding of what public health practitioners or trainees mean by ethics, what meta-ethical foundations shape their approach to ethical dilemmas, and what prior training in ethics they have had or wish to have. This study aims to answer some of these questions and will serve as the basis for the development of resources to aid public health decision-making. Method: Qualitative and quantitative data were collected from public health practitioners by means of paper and web-based surveys, as well as structured interviews. Data was coded and analysed using SPSS 15. Results: 16/20 trainees, 70/150 Canadian practitioners, and 508/2058 American practitioners responded to the survey; 10 interviews were conducted. There was remarkable heterogeneity of responses regarding prioritization of values and meta-ethical justification of ethical norms. Respondents reported little training in ethics and considerable in enhancing their skills. Conflict between ethical imperatives and the law were a prominent feature of American, but not Canadian respondents. Conclusions: Public Health practitioners hold a variety of disparate views regarding ethics in public health. These translate into different understandings of the goals and means of public health, with far reaching implications in all spheres of practice. A Public Health Ethical Reflection tool was developed to enhance ethical awareness in goal setting, planning and implementation of public health interventions.

Hepatitis B virus infection and immunization status in a new generation of injection drug users in San Francisco

Hepatitis B virus (HBV) infection is common among injection drug users (IDU). Younger IDU, however, may be less susceptible to infection due to the implementation of public health interventions, such as universal immunization programs and syringe exchange programs. To investigate the current epidemiology of HBV infection and control among a new generation of drug users in the United States, we conducted interviews and examined HBV serologic markers in a cross-section of street-recruited IDU under age 30 in San Francisco, CA. Of the 831 persons studied, 21% showed serologic evidence of current or past infection; 22% had isolated antibodies to hepatitis B surface antigen consistent with vaccine-mediated immunity; and 56% had no HBV markers. In multivariate analyses, HBV infection was associated with drug use behaviour in heterosexual males; sexual behaviour in males who have sex with males; and both drug use and sexual behaviour in females. Vaccine-mediated immunity was independently associated with female sex and younger age. In conclusion, HBV transmission persists among young IDU in San Francisco. Few young injectors show evidence of successful immunization and the majority remains susceptible to disease. Until the broad effects of universal vaccination are seen, targeted and innovative approaches to immunizing young IDU in the US are needed to prevent a substantial number of new HBV infections.

Introduction of Hib vaccine into national immunization programmes: A descriptive analysis of global trends

Despite the demonstration of effectiveness and public health impact of Hib conjugate vaccines, the majority of infants from poorest countries do not yet have access to this safe and effective preventive intervention. This paper provides a descriptive analysis of the main characteristics of countries that have included Hib vaccine in their national immunization programmes before 2006. It highlights the importance of regularly analyzing the process of decision-making involved in implementation of public health interventions, in order to learn from cumulative experience and expedite the introduction of future interventions.

Detection of Neisseria meningitidis DNA from skin lesion biopsy using real-time PCR: usefulness in the aetiological diagnosis of purpura fulminans

The present study evaluated the usefulness of a real-time polymerase chain reaction (rtPCR) assay for the detection of Neisseria meningitidis (Nm) and genogrouping on skin lesion biopsies in patients with purpura fulminans (PF). Retrospective single-centre study. Adult and paediatric intensive care units at the University Hospital of Rouen. All patients admitted between January 2000 and January 2006, with a final diagnosis of PF and for which a skin biopsy and blood cultures were performed, were included. Skin biopsy and blood cultures were used for culture and rtPCR. Thirty-four patients fulfilled the criteria (27 children and 7 adults). Nm rtPCR performed on skin biopsy was positive in 100% (34/34) of cases, compared with only 14.7% (5/34) for skin culture (p=0.0001). rtPCR genogrouping on skin biopsy was positive in 58.8% (20/34) of the cases compared with 14.7% (5/34) for skin culture (p=0.0013). For patients (n=17) in whom rtPCR was performed both on blood and skin biopsy, skin biopsy gave a significantly higher rate of Nm detection [100% (17/17) vs. 58.8% (10/17); p=0.023] and genogroup characterisation [76.5% (13/17) vs. 35.3% (6/17); p=0.045] than blood. We encountered no specimen with culture-positive and rtPCR-negative results (negative predictive value of rtPCR 100%). In suspected PF cases, skin biopsy is more reliable to identify Nm and its genogroup than blood or, probably, CSF, especially when PCR methods are used. This could help the implementation of public health interventions, especially concerning a vaccination policy.

A Hepatitis B Outbreak Associated with Outpatient Chelation Therapy

BACKGROUND/OBJECTIVES: In 2004 a county health department identified two cases of acute hepatitis B among men (age ≥ 70 years) who denied traditional hepatitis risk factors. Interviews linked the men to the same clinical practice, where both had outpatient chelation therapy. In response the health department initiated an epidemiological investigation in February 2005. <b>Objectives</b><ul><li>•To ascertain the existence of an outbreak</li><li>•To determine the etiology of the outbreak</li><li>•To implement preventive public health measures.</li></ul> METHODS: The health department conducted clinic visits to assess compliance with standard infection control practices and conducted a retrospective cohort study consisting of medical record reviews and patient interviews. Patients were screened for hepatitis through serologic survey. Samples from patients with acute (IgM positive) and chronic (HBsAg positive) hepatitis B infections were submitted to CDC for genotyping and nucleic acid sequencing. RESULTS: Violations of standard infection control practices included failure to prepare and store intravenous infusions under aseptic conditions, inconsistent hand hygiene, inconsistent use of personal protection (gloves), and inadequate cleaning of multidose vials prior to use. Of the estimated 253 clinic patients, 106 (42%) patients were tested for hepatitis. A total of 6 acute and 2 chronic hepatitis B cases were identified. The physician had chronic hepatitis and was also positive for the hepatitis B e antigen. All cases had received chelation therapy at the clinic (including the physician). Following the study, an additional chelation patient developed acute hepatitis B, resulting in a total of 9 hepatitis B cases. Five specimens were tested by CDC (including one from the physician), and all five were found to be of the same genotype and serotype which is consistent with a common source or transmission event. CONCLUSIONS: Both epidemiologic and laboratory data support hepatitis B transmission in this clinical practice. The high infectivity of the hepatitis B e antigen positive physician increased the consequences of breaks in infection control. This outbreak is one of the few documented instances linking transmission from a hepatitis B e antigen-positive health care professional to patients. Implementation of public health interventions, (including closing the practice) halted the hepatitis B transmission. More oversight of outpatient clinics may prevent future outbreaks.

Quelles sont les conditions de réussite des interventions en santé publique ?

This article aims to identify the optimal conditions necessary for the implementation of public health interventions. In order to approach this question, the authors relied upon a review of the health promotion literature and on three evaluation reports on the processes undertaken within the framework of French regional health programmes and their British equivalent counter-parts. Based on the synthesis of this work, the article puts forth recommendations for carrying out public health interventions at the national, regional and local level. It concludes by offering some structural proposals for improving health programme implementation.