Public Health Objectives Research Articles

Use of the WHO Nutrient Profile Model for Food Marketing Regulation in Germany: Feasibility and Public Health Implications

Introduction: Exposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM). Germany’s Federal Ministry of Food and Agriculture plans to use this model in proposed new food marketing legislation, but it has not yet been tested in Germany. The present study therefore assesses the feasibility and implications of implementing the WHO NPM in Germany. Methods: We applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market drawn from Open Food Facts, a publicly available product database. We calculated the share of products permitted for marketing to children based on the WHO NPM, both under current market conditions and for several hypothetical reformulation scenarios. We also assessed effects of adaptations to and practical challenges in applying the WHO NPM. Results: The median share of products permitted for marketing to children across the model’s 22 product categories was 20% (interquartile range (IQR) 3–59%) and increased to 38% (IQR 11–73%) with model adaptations for fruit juice and milk proposed by the German government. With targeted reformulation (assuming a 30% reduction in fat, sugar, sodium, and/or energy), the share of products permitted for marketing to children increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt and cream, ready-made and convenience foods, and savoury plant-based foods) but changed less in the remaining categories. Practical challenges included the ascertainment of the trans-fatty acid content of products, among others. Conclusion: The application of the WHO NPM in Germany was found to be feasible. Its use in the proposed legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges could be addressed with appropriate adaptations and procedural provisions.

Alcohol licensing legislation and licensing system in South-West Nigeria: Implications to regulate physical availability of alcohol.

The proliferation of alcohol outlets has led to increased physical availability of alcohol, harmful alcohol consumption and related harm in Nigeria. This study explored alcohol licensing legislations and licensing systems across local government councils (LGC) in South-West, Nigeria. Twenty-four LGCs across three states participated in the study. Data were generated from: (i) documents containing LGC liquor licensing legislations; and (ii) semi-structured interviews conducted with 50 LGC officials (16 legislative council clerks and 34 finance officers [director of finance, rate officers and revenue collectors]) were thematically analysed using NVivo. Nine of the sampled LGC enacted liquor licence bylaws. These mostly specified categories of liquor licences issued and licensing fees. None of the liquor licence bylaw contained regulations for controlling physical availability of alcohol and outlet density. Finance officials were licensing officers and there were no licensing committees across the LGCs. The LGC officials were unanimous in stating that generating revenue from licensing fees was the main objective for licensing alcohol outlets. The LGCs licensed alcohol outlets indiscriminately and failed to regulate outlet density. The absence of regulations for controlling outlet density has implications for physical availability of alcohol in Nigeria. Our findings strongly suggest the need to develop national liquor licensing legislation with public health objectives and implementing regulations for controlling temporal and spatial availability of alcohol. Each LGC should inaugurate a licensing committee with clearly defined roles and responsibilities for licensing stakeholders such as LGC health officials, law enforcement agencies and community members.

The state of community health practice in the Czech Republic: Saste Roma project

Abstract A central public health objectives of the Czech government is to reduce health inequalities for community members living in deprived areas of Czechia, where Roma are the most frequent inhabitants. This is achieved through Community Health Workers (CHWs) and subsidies for NGOs. However, they often lack the necessary training in health promotion. Developing more systematic intervention tools could help tackle this challenge, thus improving community health practices and decreasing the burden on the health system. The Saste Roma project responded to the lack of systematic community health practices. It aimed to improve secondary prevention in Roma by developing several interventional tools. Socio-culturally appropriate printed materials are to be used by CHW, as well as by doctors and community members; e-learning is intended for implementation as a part of the school curriculum. These tools have the potential to lower the burden on the health care system to improve community health as they act as communication channels between health professionals and the community. The development of the above tools was carried out with the help of governmental and non-governmental organizations, CHWs, and community members. During the development of the project, some shortcomings of Czech community health services were identified. They include the low competence of CHW, the unwillingness of different sectors to cooperate, refusal of schools to participate due to poor school attendance and workload from other projects. Thus, despite the large government investments in the policy of reducing health inequality, at the local level, it often does not work as it was officially stated. Moreover, despite a 20-year Roma-oriented policy, no evaluation has yet been carried out. Intervention tools from the Saste Roma project can be a first step to get community health practice more systematic in Czechia. The Randomized-control-trial to evaluate the efficacy of developed tools will follow.

Use of the WHO Nutrient Profile Model in Germany: feasibility and public health implications

Abstract Background Exposure to marketing for foods high in sugar, salt, and fat is considered a key risk factor for childhood obesity. To support efforts to limit such marketing, the World Health Organization Regional Office for Europe has developed a nutrient profile model (WHO NPM), published as second edition in March 2023. The German government plans to use this model in new food marketing legislation, but it has not yet been tested in Germany. Methods We applied the WHO NPM to a random sample of 660 food and beverage products across 22 product categories on the German market from Open Food Facts, a product database. We calculated the share of products permitted for marketing to children under current market conditions and for hypothetical reformulation scenarios. We assessed practical challenges in applying the WHO NPM and the effects of model adaptations. Results The median share of products permitted for marketing to children across the 22 categories was 20% (interquartile range (IQR) 3-59%) and increased to 38% (IQR 11-73%) with model adaptations proposed by the German government. With targeted reformulation (i.e. a 30% reduction in fat, sugar, sodium, and/or energy) the share increased substantially (defined as a relative increase by at least 50%) in several product categories (including bread, processed meat, yogurt, convenience foods, and savoury plant-based foods), but changed less in others. Practical challenges included the ascertainment of the trans-fatty acid content of products, among others. Conclusions The application of the WHO NPM in Germany was found to be feasible. Its use in the proposed legislation on food marketing in Germany seems likely to serve its intended public health objective of limiting marketing in a targeted manner specifically for less healthy products. It seems plausible that it may incentivise reformulation in some product categories. Practical challenges could be addressed with adaptations and procedural provisions. Key messages • The practical application of the WHO Europe Nutrient Profile Model 2023 edition to a random sample of food and beverage products on the German market was found to be feasible. • With targeted reformulation, the share of products permitted for marketing to children under the WHO Europe Nutrient Profile Model increases substantially.

Liquid biopsy for early detection of hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is a highly prevalent and lethal cancer globally. Over 90% of HCC cases arise in the context of liver cirrhosis, and the severity of the underlying liver disease or advanced tumor stage at diagnosis significantly limits treatment options. Early diagnosis is crucial, and all guidelines stress the importance of screening protocols for HCC early detection as a public health objective. As serum biomarkers are not optimal for early diagnosis, liquid biopsy has emerged as a promising tool for diagnosis, prognostication, and patients' stratification for personalized therapy in various solid tumors, including HCC. While circulating tumor cells (CTCs) are better suited for personalized therapy and prognosis, cell-free DNA (cfDNA) and extracellular vesicle-based technologies show potential for early diagnosis, HCC screening, and surveillance protocols. Evaluating the added value of liquid biopsy genetic and epigenetic biomarkers for HCC screening is a key goal in translational research. Somatic mutations commonly found in HCC can be investigated in cfDNA and plasma exosomes as genetic biomarkers. Unique methylation patterns in cfDNA or cfDNA fragmentome features have been suggested as innovative tools for early HCC detection. Likewise, extracellular vesicle cargo biomarkers such as miRNAs and long non-coding RNAs may serve as potential biomarkers for early HCC detection. This review will explore recent findings on the utility of liquid biopsy for early HCC diagnosis. Combining liquid biopsy methods with traditional serological biomarkers could improve the overall diagnostic accuracy for early HCC detection.

Evaluation of Sleep Behavior and the Use of Sleep Aids among Adults Living in Saudi Arabia: A Cross-Sectional Study.

A negative attitude toward sleep has greatly affected sleep habits. In addition to contributing to physical and metabolic disorders, poor sleep quality may cause emotional disturbances. This study aimed to measure sleep behavior and factors contributing to poor sleep quality in the Madinah region, Saudi Arabia. We also assessed whether the use of sleeping aids improved peoples sleep. Three hundred and ninety-nine adults in the Madinah region of Saudi Arabia participated in this cross-sectional study. Three data domains were collected using an online questionnaire between 30 January and 26 April 2022. In the first domain, the characteristics of participants were discussed. In the second domain, questions about sleep behavior were asked. In the third domain, we examined the types, frequency, and impact of sleep aid use. Out of the 399 participants, 154 (38.59%) reported sleep problems. A total of 64.94% of the 154 participants blamed stress as the leading cause of their sleep disorders, and 74.68% of those with sleep problems reported reduced productivity. Among those who reported having sleep problems, 46.10% used sleep aids, with Panadol night (antihistamine) being the most used, 49.30%, followed by Melatonin at 39.44%. Sleep quality improved by 67.6% among those who used sleep aids. A total of 71.8% of the participants think it is not safe to use sleep aids in the long term. Our findings suggest that sleep problems are a prevalent concern in Madinah, Saudi Arabia, and even though the use of sleep aids improved sleep quality, it should be considered an emerging and important public health objective in Saudi Arabia. Further studies are needed to evaluate sleep quality and the level of sleep aid usage among other Saudi Arabian regions.

Mobile Apps Aimed at Preventing and Handling Unintentional Injuries in Children Aged

Despite various global health crises, the prevention and handling of unintentional childhood injuries remains an important public health objective. Although several systematic reviews have examined the effectiveness of different child injury prevention measures, these reviews did not address the evaluation of mobile communication intervention tools. Whether and how mobile apps were evaluated provides information on the extent to which communication theories, models, and evidence-based knowledge were considered. Previous studies have shown that the effectiveness of mobile apps increases when theories and evidence are considered during their development. This systematic review aimed to identify research on mobile apps dealing with the prevention and handling of unintentional injuries in children and examine the theoretical and methodological approaches thereof. In addition, this review analyzed the different needs of various target groups of the mobile apps described in the articles. In total, 8 electronic databases, ranging from interdisciplinary to medical and technical as well as social sciences databases, were searched for original research articles or brief reports in peer-reviewed journals or conference proceedings. Moreover, this review encompassed a systematic scan of articles published in the BMJ journal Injury Prevention. These steps were followed by a snowball search based on the literature references in the articles identified through the initial screening. The articles had to be written in English or German, published between 2008 and 2021, and evaluate mobile apps dealing with the prevention and handling of unintentional child injuries. The identified 5 studies were analyzed by 5 independent researchers using an inductive approach. Furthermore, the quality of the studies was assessed using the Mixed Methods Appraisal Tool. A total of 5 articles were included and assessed with regard to overall quality of theoretical and methodological foundations, assessed variables, the focal app's architecture, and the needs of the study participants. The overall study quality was moderate, although part of this classification was due to a lack of details reported in the studies. Each study examined 1 mobile app aimed at parents and other caregivers. Each study assessed at least 1 usability- or user experience-related variable, whereas the needs of the included study participants were detailed in only 20% (1/5) of the cases. However, none of the studies referred to theories such as the Technology Acceptance Model during the development of the apps. The future development and evaluation of apps dealing with the prevention and handling of child injuries should combine insights into existing models on user experience and usability with established theories on mobile information behavior. This theory-based approach will increase the validity of such evaluation studies.

Bulgarian general population attitude to mandatory COVID-19 vaccination: A nationwide cross-sectional study

BackgroundThe issue of mandatory COVID-19 vaccination, entwined with citizens' rights and autonomy, impacts vaccine uptake and trust in health authorities. This study centers on Bulgaria, aiming to uncover attitudes towards obligatory COVID-19 vaccination. MethodsEmploying an online questionnaire, we conducted a cross-sectional survey involving 1433 adults in Bulgaria between April and May 2022. Analysis of responses from 1200 participants illuminated perspectives on mandatory COVID-19 vaccination. ResultsAmong respondents, 38.6% supported or were uncertain about mandatory vaccination, while 61.4% opposed it. Binary logistic regression, utilizing demographic predictors, unveiled that younger age groups, particularly those aged 18–25, demonstrated diminished odds of supporting mandatory vaccination. Those with apprehensions about contracting the virus (OR 2.98, 95% CI 1.65–5.39), perceiving minimal vaccine risks (OR 3.86, 95% CI 1.80–8.26), acknowledging vaccine benefits for health protection (OR 3.86, 95% CI 1.80–8.26), and pandemic containment (OR 3.34, 95% CI 1.16–9.60) were more prone to endorse mandatory vaccination. Trust in general practitioners and pharmaceutical companies also emerged as influential factors. ConclusionThe study portrays a diverse sentiment within Bulgaria's population concerning compulsory COVID-19 vaccination. It underscores the importance of conveying accurate, evidence-based information while upholding individual autonomy. National health authorities should harmonize methodical vaccination initiatives with health promotion interventions targeted at the general population and healthcare professionals. Such an approach can facilitate well-informed choices and contribute to public health objectives.

Population-level, patient-reported outcomes: a case study regarding a public health intervention that involves patients with life-limiting illnesses.

Dying and death are public health concerns, but little is known about public health interventions that target populations living with life-limiting illnesses. This gap makes it difficult to identify best-practice public health interventions for this population and to achieve public health objectives. The study aimed to describe a public health intervention that intends to improve population-level outcomes using point-of-care and patient-reported outcomes. A case study approach, informed by the Organization for Economic Co-operation and Development's (OECD) Best-Practice Public Health Framework, was used to describe coverage, effectiveness, and equity using mixed methods. Data from 2012 to 2022 were analyzed. Over the 10-year period, the number of deaths recorded in the programme (n = 16,358 to 32,421, +98.2%) as well as the percentage of the population that might benefit from palliative care increased (14.8% to 25.1%). The median age of those admitted for care (74 to 77 years) and the proportion of services participating in the programme located in outer regional and remote areas of Australia increased (2012: 59; 2022: 94; +5.4%). The access by patients that experience the greatest socioeconomic disadvantage decreased (2012: 18.2% n = 4,918; 2022: 15.9% n = 9,525). Improvements in relation to moderate distress related to pain were identified (2012: 63% n = 8,751, 2022: 69% n = 13,700), and one in five instances of severe distress related to pain did not improve (2012: 20% n = 781; 2022: 19% n = 635). Population-level, patient-reported outcome data are useful and necessary in addressing public health objectives in populations with life-limiting illnesses. Our application of the OECD's Best-Practice Public Health Framework has helped to identify and describe a national intervention that may be transferred to other settings to address health promotion objectives. This may help improve the targeting of treatments to improve pain and issues related to equity.

Comparison and clarification of public health and public health nursing competencies: A report of the Committee on Public Health Nursing (2017-2018)

Objectives The Committee on Public Health Nursing (2017-2018) of the Japanese Society of Public Health aimed to elucidate the competencies of public health and public health nursing to provide basic materials for public health, public health nursing education, practice, and research.Methods We studied the core competencies of public health professionals and public health nursing in the United States and examined similarities to and differences from those in Japan.Results The United States and Japan shared similar public health and public health nursing competencies in that they targeted populations, identified health problems, and clarified health challenges for effective actions. However, differences were noted in the understanding of target groups, perspectives for identifying health problems and overcoming health challenges, and conceptualization of individuals in populations. In public health, the target population practiced clear boundaries, such as residing in certain geographical areas and ethnic groups, among others. In health challenges, the top-down approach was employed to resolve health problems in certain populations. The individual was recognized as a part of a population composed of a certain group. In public health nursing, target population (e.g., from individuals/families to groups/communities/social groups) were understood in a continuous and multilayered manner. Individual/family health problems were associated with the characteristics of groups, communities, and social groups that encompass the continuum. Moreover, health challenges were addressed in a manner oriented toward the transformation of social groups as a whole. Public health nursing competencies in both countries, which share many similarities, were developed to achieve the objectives of public health. In the United States, the competencies and skills considered necessary, such as analytical/assessment and cultural competency skills, were clearly expressed and constructed in line with the core competencies of public health professionals. However, in Japan, skills and abilities necessary as competencies in public health nursing mentioned above were not specified.Conclusion Elucidating the core competencies of public health professionals in Japan is essential to develop human resources that can contribute to effective practices in public health and public health nursing. Toward this end, skills and abilities necessary as competencies in public health nursing in Japan, which were not previously verbalized, should be described in detail.

UNDERSTANDING THE DIGITAL NARRATIVE OF HEALTH COMMUNICATION

The digital media has come a long way in promoting participatory communication. From not limiting itself to social interactions alone, the digital medium has become a medium of raising social awareness, promoting entrepreneurship, and creating a steady web on public domain. This has resulted into a forum of self-reliance on knowledge accessibility.This forum has become a steady source of information even in the face of extreme crises. Understanding the need for reliable communication on health in the last pandemic in terms of health, the digital media took an innovative stance through app-based interaction and led to steady discussion on the prevention, improvement, and remedial approaches of the health crises. Health communication makes was for effective public health objectives that could be both promotion as well as assistance towards individual and collective change thereby minimizing health disparities. Digital media here plays a crucial role.The research here will be undertaken to understand the applicability of apps through interviews with health experts and case studies of health apps that are in function. This will be enhanced and elaborated with the aid of different communication models applicable in case of digital media and health communication that can address different health crises.

Understanding the impact of disease and vaccine mechanisms on the importance of optimal vaccine allocation.

Vaccination is an important epidemic intervention strategy. However, it is generally unclear how the outcomes of different vaccine strategies change depending on population characteristics, vaccine mechanisms and allocation objective. In this paper we develop a conceptual mathematical model to simulate strategies for pre-epidemic vaccination. We extend the SEIR model to incorporate a range of vaccine mechanisms and disease characteristics. We then compare the outcomes of optimal and suboptimal vaccination strategies for three public health objectives (total infections, total symptomatic infections and total deaths) using numerical optimisation. Our comparison shows that the difference in outcomes between vaccinating optimally and suboptimally depends on vaccine mechanisms, disease characteristics, and objective considered. Our modelling finds vaccines that impact transmission produce better outcomes as transmission is reduced for all strategies. For vaccines that impact the likelihood of symptomatic disease or dying due to infection, the improvement in outcome as we decrease these variables is dependent on the strategy implemented. Through a principled model-based process, this work highlights the importance of designing effective vaccine allocation strategies. We conclude that efficient allocation of resources can be just as crucial to the success of a vaccination strategy as the vaccine effectiveness and/or amount of vaccines available.

Multiple models for outbreak decision support in the face of uncertainty

Policymakers must make management decisions despite incomplete knowledge and conflicting model projections. Little guidance exists for the rapid, representative, and unbiased collection of policy-relevant scientific input from independent modeling teams. Integrating approaches from decision analysis, expert judgment, and model aggregation, we convened multiple modeling teams to evaluate COVID-19 reopening strategies for a mid-sized United States county early in the pandemic. Projections from seventeen distinct models were inconsistent in magnitude but highly consistent in ranking interventions. The 6-mo-ahead aggregate projections were well in line with observed outbreaks in mid-sized US counties. The aggregate results showed that up to half the population could be infected with full workplace reopening, while workplace restrictions reduced median cumulative infections by 82%. Rankings of interventions were consistent across public health objectives, but there was a strong trade-off between public health outcomes and duration of workplace closures, and no win-win intermediate reopening strategies were identified. Between-model variation was high; the aggregate results thus provide valuable risk quantification for decision making. This approach can be applied to the evaluation of management interventions in any setting where models are used to inform decision making. This case study demonstrated the utility of our approach and was one of several multimodel efforts that laid the groundwork for the COVID-19 Scenario Modeling Hub, which has provided multiple rounds of real-time scenario projections for situational awareness and decision making to the Centers for Disease Control and Prevention since December 2020.

Child Health Implications of Plastic Waste Reduction in West Africa

Rapidly growing, unregulated plastic litter has created a multitude of environmental and economic problems in developing countries. The problems are particularly serious for single use plastic (SUP) products that cannot be recycled. While the case for plastic waste reduction is clear, it may conflict with public health and other social objectives. Using Demographic and Health Survey (DHS) data from Ghana and Nigeria, this paper considers the potential for health damage from waste reduction policies that reduce household use of SUP drinking-water containers. The econometric analysis provides strong evidence that SUP containers significantly reduce child mortality and incidence of diarrhea, after controlling for other, widely cited determinants in the literature. By implication, general measures to reduce plastic use may also increase childhood illness and death. The study demonstrates how plastic-waste reduction policies should not be assessed in isolation from their public health implications for poor households and suggests countervailing measures that can be taken to address the SUP waste problem. The study can be replicated in any of the 73 countries where DHS data include the use of plastic containers as household water sources.

Learning from Ritual: Covid-19 Public Health Measures and Messaging in Timor-Leste

In this paper, I reflect on the significance of ritual activity directed towards COVID-19 in Timor-Leste. What, if anything, it tells us about East Timorese beliefs and attitudes regarding infectious disease and why understanding the cultural dimensions of infectious disease is critical to public health responses. Timor-Leste recorded its first COVID-19 case on March 21st, 2020. Over the course of the following weeks elders held ritual ceremonies across the country to mobilise the ancestors and ask for their assistance to keep COVID-19 at bay. These ceremonies circulated widely on social media within Timor-Leste and among the East Timorese diaspora. In parallel to this initial flourishing of ritual activity the government swiftly enacted legislation to declare a state of emergency, closing international borders and establishing quarantine centres across the country. In many ways the health authorities’ response to COVID-19 has been exemplary, with low case numbers and 0 deaths throughout 2020. However, since February 2021 COVID-19 cases have increased exponentially, exposing social cleavages based on education, language and socio-economic position. With limited resources, the health authorities, and in particular the Centre for Integrated Crisis Management, have focused on prevention, contact tracing and testing, adhering to WHO guidelines and emphasising ‘best practices. Yet, the response has been criticized for being top-down and heavy handed. For example, certain public health measures, such as mandatory testing and burial protocols, have been poorly communicated to the broader community. The use of bio-medical language and introduction of new terms and concepts has been excessively didactic and lacks local contextualization. For the majority of the population of Timor-Leste, especially those living in rural areas, lived experiences of illness and disease are interpreted primarily through and by customary beliefs and practices. The rituals directed towards COVID-19 demonstrate a clear understanding of the nature of infection, contamination, disease, models of causality and fears around infection. They also reveal local capacities to contain epidemics and the ability to learn with the bio-medical response. The levels of participation observed in COVID-19 rituals online and local support for these initiatives expressed on social media suggests at the very least that health authorities should engage with local communities in a two-way dialogue to discuss beliefs and existing prevention strategies that can assist and support public health objectives and measures.

A SWOT analysis of the complex interdependencies of the Maltese reimbursement processes

BackgroundThe processes that operationalize the evaluation framework for new medicines are implemented to reach the system objectives of public health, financial sustainability, and equitability. However, when the activities and procedures of these processes are misaligned, the objectives of the system may be at risk. ObjectivesTo evaluate the supporting processes for introducing new medicines in public healthcare services in Malta. MethodsWe first reviewed literature on the Maltese reimbursement system and subsequently conducted semi-structured interviews based on the Hutton Framework. Interviewees included policy makers, committee members, procurement staff, medical specialists, pharmacists, and pharmaceutical industry representatives. After validation, we analysed the data with a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis. ResultsMost medicines are assessed for introduction on the Government Formulary List. Exceptional requests fall outside this policy and pass through the Exceptional Medicinal Treatment route. Efficiency, quality, and transparency are major weaknesses across the supporting processes. Taking up responsibility, however, is considered the most important factor in reaching system objectives. Stakeholders tend to shift responsibilities to other processes, start/stop activities that impact the activities of subsequent processes whilst dismissing any contribution to the weaknesses of the system. Consequently, system objectives cannot be reached in an optimum manner. ConclusionsThe Maltese case showed that recommendations for introducing new medicines in the public healthcare setting are influenced beyond the choice of HTA tools and criteria. Earmarked budgets, political steering, delays, and uninformed applicants as well as HTA capacity are impeding on system goals of public health, equity, and sustainability.

Judicial Power and Influence on Population Health.

Policy Points Since its founding, the Supreme Court has played a major role in defining the parameters of governments' public health powers and the scope of individual health-related rights. Although conservative courts have been less favorable to public health objectives, federal courts have, for the most part, advanced public health interests through consensus and adherence to the rule of law. In establishing the current six-three conservative supermajority, the Trump administration and the Senate shifted the Supreme Court dramatically. A majority of Justices, led by Chief Justice Roberts, did shift the Court in a decidedly conservative direction. It did so incrementally, guided by the Chief's intuition that the Institution itself should be preserved, mindful of maintaining public trust and appearing outside the political fray. That has all changed because Roberts' voice no longer holds sway. Five members of the Court have displayed a willingness to overturn even long-held precedent and dismantle public health policy in favor of the Justices' core ideological tenants-notably the extensive reach of the First and Second Amendments and a parsimonious view of executive and administrative action. Public health is vulnerable to judicial rulings in this new conservative era. This includes classic public health powers in infectious disease control as well as reproductive rights; lesbian, gay, bisexual, trans, queer or questioning, and others (LGBTQ+) rights; firearm safety; immigration; and climate change. Congress has the power to curb the most extreme actions of the Court while still adhering to the vital ideal of a nonpolitical branch. That does not require Congress itself to overreach (such as by "packing" the Supreme Court, as Franklin Delaeno Roosevelt once proposed). Congress could, however, 1) disempower lower federal judges from issuing injunctions that apply nationwide, 2) limit the Supreme Court's so-called shadow docket, 3) alter the way that presidents appoint federal judges, and 4) set reasonable term limits for federal judges and Supreme Court Justices.

The Unbearable Cost of Drug Development

The Unbearable Cost of Drug Development

The National Healthy People Initiative:: History, Significance, and Embracing the 2030 Oral Health Objectives.

Since 1979, the U.S. Department of Health and Human Services has worked with multiple subject matter experts and the public to develop and issue a set of ambitious, measurable objectives known as "Healthy People." These objectives are aimed at improving the health of the nation issued at the start of each decade, and feature specific targets to be achieved at the end of the decade. The fifth iteration, Healthy People 2030, consists 358 measurable public health objectives associated with evidence-based interventions. Oral health is represented by 11 specific objectives aimed at reducing dental caries in children and adolescents, reducing untreated decay and periodontal disease in adults, and promoting evidence-based prevention strategies, including community water fluoridation, dental sealants, oral cancer screenings, and, most importantly, increasing access to dental services. In fact, access to the oral health care system for children, adolescents, and adults is identified as a Healthy People 2030 Leading Health Indicator - a high-priority Healthy People 2030 objective selected to drive action toward improving health and well-being - for the second straight decade. With the continued promotion of multidirectional integration of oral health and overall health across multiple disciplines, many - including policymakers, oral health professionals, other healthcare professionals, dental and public health organizations, and community advocates - have a role in affecting the outcome of the Healthy People 2030 oral health objectives.

Does the implementation of pay-for-performance indicators improve the quality of healthcare? First results in France.

Pay-for-performance (P4P) models are intended to promote quality of care in both hospitals and primary care settings. They are considered as a means of changing medical practices, particularly in primary care. The first objective of this study was to assess how performance indicators changed over time, measured through "Remuneration on Public Health Objectives" (ROSP) scores, between 2017 and 2020 in a large French region (Grand Est region), and to compare this evolution in the rural vs. urban areas of the region. The second objective was to focus on the area with the least improvement in ROSP scores and to investigate whether the scores and the available sociodemographic characteristics of the area were associated. First, we measured the evolution over time of P4P indicators (i.e., ROSP scores) obtained from the regional health insurance system, for GP practices in the Grand Est region between 2017 and 2020. We then compared the scores between the Aube Department and the rest of the region (urban areas). To address the second objective, we focused on the area found to have the least improvement in indicators to investigate whether there was a relationship between ROSP score and sociodemographic characteristics. More than 40,000 scores were collected. We observed an overall improvement in scores over the study period. The urban area (Grand Est region minus the Aube) scored better than the rural area (Aube) for chronic disease management [median 0.91 (0.84-0.95) vs. 0.90(0.79-0.94), p < 0.001] and prevention [median 0.36 (0.22-0.45) vs. 0.33 (0.17-0.43), p < 0.001], but not for efficiency, where the rural area (Aube) performed better [median 0.67(0.56-0.74) vs. 0.69 (0.57-0.75 in the rest of the Grand Est region, p = 0.004]. In the rural area, we found no significant association between ROSP scores and sociodemographic characteristics, except for extreme rurality in some sub-areas. At the regional level, the overall improvement in scores observed between 2017 and 2020 suggests that the implementation of ROSP indicators have improved the quality of care, particularly in urban areas. These results also suggest that efforts should be focused on rural areas, which already had the lowest scores at the start of the P4P program.