Public Health Reform Research Articles

U.S. federal tobacco control policy from 1964 to 2013: Were punctuated and significant public health reforms enacted?

Currently, an academic controversy exists regarding whether U.S. tobacco control policy has been punctuated and rapid, primarily driven by federal policymaking or a combination of federal, state, and local policymaking, and has substantially reduced tobacco consumption. An analysis of U.S. tobacco control policy from 1964 to 2013 indicates federal policy change was not rapid and punctuated and some limited progress occurred in improving the public health. Asserting all U.S. tobacco control policy is purportedly punctuated because of federal tobacco control efforts also ignores discretionary policy output and outcome legislation and regulations operating solely at the state or local levels of government. Analyses of punctuated policy change trends must include operationalized policy outputs and outcomes grounded in scholarly historical and scientific research that analyzes all key policy issues such as clean indoor air linked to a general policy area, like tobacco control, to determine whether punctuation has occurred or not. In the case of federal, but not state tobacco policy, punctuation did not occur. Instead, there were some moderate and incremental advances in tobacco control contradicted by federal tobacco consumption and support policies.

Libro Blu as a mobile app to improve cancer care.

e18190 Background: When ASCO published Top Five List to improve cancer care in 2012, we applied the same principles to build local guidelines, resulting in first edition of our “Libro Blu” (Blue Book), named after a similar tool previously adopted by the Swiss institution IOSI. In 2015 a reform of Lombardy public health, with the establishment of ASST-VAL, covering a huge area with 5 hospitals, brought a further need for harmonization of our work; moreover, the increasing appearance of high cost drugs and the simultaneous restrictions in public health budget required a more rational expense. Methods: After first edition in 2012, Libro Blu underwent periodic updates. In 2015 a major revision took place; besides up-to-date guidelines in the management of specific cancers, edited by Oncology, Hematology and Radiation Therapy specialists, attention was paid to supportive care, with consultants from many other fields. All recommendations in Libro Blu derive from Italian and international guidelines, adapted to our local reality after multidisciplinary discussion, and have been approved after a final joint review. Results: The implementation of Libro Blu resulted in a more consistent application of treatment protocols in ASST-VAL, ensuring all patients the same standard of care, and allowed to raise the level of both specific cancer treatment and supportive care. Furthermore, guidelines for a rational use of drugs allowed to reduce costs in our institution. After one year, 2015 edition of Libro Blu was submitted for review by a number of Italian oncologists from other institutions. Following this review, we used the updated version of Libro Blu to build, with unconditional support from Eli Lilly, a mobile app that will soon be available for download. Conclusions: Libro Blu established a common standard of care in a broad area and allowed a cost reduction that is particularly relevant at this moment, with cancer care facing the appearance of many high cost drugs along with a spending review that involves the Italian health system. The review from other Italian oncologists ensured the adherence of Libro Blu to national guidelines and to state-of-the-art clinical practice. Finally, the mobile app will make consultation easier and will allow to share this tool across all Italian institutions.

When paradigms change in public health: what changes in history?

This conceptual essay investigates the idea of paradigmatic rupture and its implications in historical interpretations of public/collective health, where the dimensions of politics and science intermingle. The polysemic and pre-conceptual nature of "paradigm" is clarified, taking account of the conceptual implications, while reaffirming their semantic usefulness. Essential and cumulative ruptures are discussed and applied to the confrontation of the epistemic rupture brought about by district health centers and the goals of the public health reform movement. The difficulty of the collective health paradigm in maintaining its discursive independence is presented, such that the global spread of the discursive matrix of health centers by the Rockefeller Foundation still constitutes the most recent holistic paradigmatic rupture in Brazilian public health.

Vancouver Coastal Health's Second Generation Health Strategy: A need for a reboot?

In this commentary, we consider the motivations and implications of Vancouver Coastal Health's place-based population health strategy called the Downtown Eastside Second Generation Health Strategy (2GHS) in light of a broader historical view of shifting values in population and public health and structural health reforms in Canada over the past three decades. We argue that the tone and content of the 2GHS signals a shift towards a neoliberal clientelist model of health that treats people as patients and the DTES as a site of clinical encounter rather than as a community in its own right. In its clinical emphasis, the 2GHS fails to recognize the political dimension of health and well-being in the DTES, a community that faces compounding health risks associated with colonialism, gentrification, human displacement, the criminalization of poverty, sex work, and the street economy. Furthermore, we suggest that in its emphasis on allocating funding based on a rationalist model of health system access, the 2GHS undermines well-established insights and best practices from community-driven health initiatives. Our aim is to provide a provocation that will encourage public health policy-makers to embrace community-based leadership as well as the broader structural health determinants that are at the root of the current circumstances of people in the DTES and other marginalized communities in Canada.

S60 - Libro Blu: a tool to coordinate Oncology practice and to rationalise resource employment

Background: AOVV was born in 2003, covering a huge area with 4 hospitals, each working autonomously until then. The reform of Lombardy public health in 2015 changed the AOVV in ASST-VAL, including one more hospital. Such a broad area, with the conglomeration of different experiences, brought a need for harmonization of therapeutic choices to ensure all patients the same standard of care. Moreover, the increasing appearance of high cost drugs and the simultaneous restrictions in public health budget resulted in a need for a more rational allocation of expense. In this context, we took inspiration, and used its name, from “Libro Blu”, a tool previously adopted by IOSI. Material and methods: Our effort to coordinate Oncology practice resulted in the first edition of our “Libro Blu” in 2012. After periodic updates, in 2015 a major revision took place. Besides the updates in care of specific cancers, carried out by Oncology, Hematology and Radiation Therapy specialists, much attention has been paid to supportive care, involving consultants from Internal Medicine, Geriatrics, Endocrinology, Cardiology, Palliative Care and Psycho-Oncology. Recommendations in “Libro Blu” derive from Italian and international guidelines; after a thorough discussion in multidisciplinary meetings, they have been adapted to the specific needs of our local reality and approved after a final revision. Results: The implementation of “Libro Blu” resulted in a more consistent application of treatment protocols in our institution, ensuring all residents the same standard of care; notably, the facilitation of multidisciplinary discussions during this process allowed to raise the level of our cancer care, focusing both on treatment of the disease and on patients' needs in supportive care. Furthermore, establishing institutional guidelines for a rational use of high cost drugs allowed to reduce costs by about 400000 €/year. Conclusions: “Libro Blu” has allowed to establish a homogeneous standard of care in a broad area in which health professionals were previously working autonomously. The cost reduction deriving from our guidelines is particularly relevant in this moment, with Oncology facing the appearance of many high cost drugs in the context of a spending review that also involves the Italian health system. We think that “Libro Blu”, with the implementation of guidelines adapted to the specific needs of a local institution, could be reproduced in fields other than Oncology and in other local realities.

‘Relieving gloomy and objectless lives’. The landscape of Caterham Imbecile Asylum

From the mid-eighteenth century the lunatic asylum landscape has been recognised as playing a key role in the health of patients. This article explores the landscape of a different type of nineteenth-century institution, Caterham Imbecile Asylum, one of the first state imbecile asylums. Built following the public health reforms of the 1860s, Caterham was a long-stay institution, and thus developed a particular institutional geography, due to the nature of its patients and its remit. This article will examine how the landscape of Caterham, its location, its grounds and its wider environment, were used as part of the asylum regime to provide a therapeutic landscape, and relieve the formerly gloomy, monotonous and objectless lives of its patients.

A Qualitative Study of Violence Against Women after the Recent Disasters of Iran.

Introduction Violence against women (VAW) is one of the most widespread violations of human rights and a major barrier to achieving gender equality. Violence against women is increased in disaster-stricken communities. Violence experiences, cases, and lessons-learned concerning Iran's disasters have not been investigated, documented, or shared so far. To fill this knowledge gap, this qualitative study aimed to explore types of VAW and girls after the recent quakes and floods in Iran. Problem The objective for this study was exploring the manifestations of VAW after the natural disasters in Iran. A qualitative approach was used for this study. Data were collected by in-depth, unstructured interviews and field observations in three affected regions of Iran, including East Azerbaijan, Bushehr, and Mazandaran. A total of 15 participants, eight damaged women as well as seven key informants, were interviewed. A content analysis using Graneheim approach was performed for analyzing transcribed interviews. Two main themes were extracted from data, including domestic violence and violence within community. The first theme included three categories: physical, psychological, and sexual violence. Psychological violence and sexual harassment were two categories of violence within the community concept. Different types of violence emerged from the present research that can be anticipated and integrated into future disaster medicine plans, public health reforms, and national rules of Iran. Improving women's knowledge on their rights to have a life without violence, and participation of both women and men in violence reduction projects, can be considered in all disaster management phases. Sohrabizadeh S . A qualitative study of violence against women after the recent disasters of Iran. Prehosp Disaster Med. 2016;31(4):407-412.

Laudato Si', Civic Studies, and the Future of Democracy

Abstract Pope Francis authored Laudato Si' as a statement on climate change, and it has provoked intense discussion and debate on climate around the world. The statement's contributions to the topic are most welcome.1 Yet few have noted the encyclical's resources for addressing a more general crisis in the contemporary world, a crisis of democracy understood as collective agency.2 This crisis erodes human capacities to address a multitude of challenges, from climate change to sectarian warfare, from economic and racial inequalities to public health and educational reform. In this essay, I argue that the encyclical has significant contributions to make not only for analyzing the crisis but also for catalyzing a democratic awakening. The encyclical, from this vantage, complements the field of civic studies.

Public health systems under attack in Canada: Evidence on public health system performance challenges arbitrary reform.

Public health is currently being weakened in several Canadian jurisdictions. Unprecedented and arbitrary cuts to the public health budget in Quebec in 2015 were a striking example of this. In order to support public health leaders and citizens in their capacity to advocate for evidence-informed public health reforms, we propose a knowledge synthesis of elements of public health systems that are significantly associated with improved performance. Research consistently and significantly associates four elements of public health systems with improved productivity: 1) increased financial resources, 2) increased staffing per capita, 3) population size between 50,000 and 500,000, and 4) specific evidence-based organizational and administrative features. Furthermore, increased financial resources and increased staffing per capita are significantly associated with improved population health outcomes. We contend that any effort at optimization of public health systems should at least be guided by these four evidence-informed factors. Canada already has existing capacity in carrying out public health systems and services research. Further advancement of our academic and professional expertise on public health systems will allow Canadian public health jurisdictions to be inspired by the best public health models and become stronger advocates for public health's resources, interventions and outcomes when they need to be celebrated or defended.

The Limits of Public Health Reform in Urban America

The Limits of Public Health Reform in Urban America

A study of the influential factors for health inequality

Using a national dataset, this study investigates the inequalities in physical functional status, depressive symptoms, and self-rated health among groups of people with different socioeconomic status (SES) through the use of multilevel regression models. The results reveal that as age increases, differences in physical functional status among people with different SES expand and no significant differences in depressive symptoms are found. However, general conclusions on the trend of differences in self-rated health cannot be made. In wealthy regions, the differences in the three health indicators among people with different SES shrink, but these differences expand in poor regions. Finally, this study advocates that the emphasis of the structural reform of medical treatment and public health should be elderly with low SES who resides in poor regions.

‘The Little Brother of the Ottoman State’: Ottoman technocrats in Kabul and Afghanistan's development in the Ottoman imagination, 1908–23

AbstractBy charting the activities of Ottoman experts in Afghanistan from 1908–23, this article demonstrates how their arrival precipitated a series of state-building practices rooted in the particular historical experience of Ottoman reform projects. The country thus became the object of an Ottomanmission civilisatriceand the beneficiary, in the eyes of certain figures within the Ottoman Committee of Union and Progress, of an avowedly Ottoman-Turkish modernity. Sharing this conviction were members of the Afghan royal family and its chief ministers, especially Maḥmūd Ṭarzī, who first invited the Ottoman advisers to Kabul. The provision of Ottoman technical assistance took a variety of forms, but is most evident in military, educational, and public health reforms enacted in Kabul in this period. Through the study of previously unexamined Ottoman, Afghan, and British sources, the aim here is to incorporate these events into discussions of Ottoman informal empire, Afghan developmentalism, and pan-Islam.

Europeanisation of health systems: a qualitative study of domestic actors in a small state.

BackgroundHealth systems are not considered to be significantly influenced by European Union (EU) policies given the subsidiarity principle. Yet, recent developments including the patients’ rights and cross-border directive (2011/24 EU), as well as measures taken following the financial crisis, appear to be increasing the EU’s influence on health systems. The aim of this study is to explore how health system Europeanisation is perceived by domestic stakeholders within a small state.MethodsA qualitative study was conducted in the Maltese health system using 33 semi-structured interviews. Inductive analysis was carried out with codes and themes being generated from the data.ResultsEU membership brought significant public health reforms, transformation in the regulation of medicines and development of specialised training for doctors. Health services financing and delivery were primarily unaffected. Stakeholders positively perceived improvements to the policy-making process, networking opportunities and capacity building as important benefits. However, the administrative burden and the EU’s tendency to adopt a ‘one size fits all’ approach posed considerable challenges. The lack of power and visibility for health policy at the EU level is a major disappointment. A strong desire exists for the EU to exercise a more effective role in ensuring access to affordable medicines and preventing non-communicable diseases. However, the EU’s interference with core health system values is strongly resisted.ConclusionsOverall domestic stakeholders have a positive outlook regarding their health system Europeanisation experience. Whilst welcoming further policy developments at the EU level, they believe that improved consideration must be given to the specificities of small health systems.

The Public Health of Village Private Life: Reform and Resistance in Early Twentieth Century Rural China

In the 1920s and 1930s, elite reformers ventured into the Chinese countryside, eager to bring new health practices to rural people in order to strengthen the nation. In rural Ding County (Dingxian), an organization called the Mass Education Movement crafted a program of public health reform that took the rural home and family as the central reform targets. Through examinations of midwifery, family planning, home design, and infant and child healthcare, this article plumbs the interstices between reformers’ visions of and plans for reforming village family life and the expectations and desires of villagers. Health modernizers drew strict lines between “traditional” China, where they believed matters of family health were kept behind closed doors, and the new China they were working toward, where individual and family health was subject to public scrutiny. However, the varied reactions of rural people to their proposals—accepting some, rejecting others—highlights that rural people’s concerns rested not on issues of secrecy or privacy but on questions of power, expertise, and efficacy. The reformers’ persistent focus on what they saw as villagers’ superstitious and traditional notions of privacy as barriers to change meant that they disregarded village internal politics and power dynamics and, ultimately, limited the effectiveness of their reforms.

Global public health today: connecting the dots

BackgroundGlobal public health today faces new challenges and is impacted by a range of actors from within and outside state boundaries. The diversity of the actors involved has created challenges and a complex environment that requires a new context-tailored global approach. The World Federation of Public Health Associations has embarked on a collaborative consultation with the World Health Organization to encourage a debate on how to adapt public health to its future role in global health.DesignA qualitative study was undertaken. High-level stakeholders from leading universities, multilateral organizations, and other institutions worldwide participated in the study. Inductive content analyses were performed.ResultsStakeholders underscored that global public health today should tackle the political, commercial, economic, social, and environmental determinants of health and social inequalities. A multisectoral and holistic approach should be guaranteed, engaging public health in broad dialogues and a concerted decision-making process. The connection between neoliberal ideology and public health reforms should be taken into account. The WHO must show leadership and play a supervising and technical role. More and better data are required across many programmatic areas of public health. Resources should be allocated in a sustainable and accountable way. Public health professionals need new skills that should be provided by a collaborative global education system. A common framework context-tailored to influence governments has been evaluated as useful.ConclusionsThe study highlighted some of the main public health challenges currently under debate in the global arena, providing interesting ideas. A more inclusive integrated vision of global health in its complexity, shared and advocated for by all stakeholders involved in decision-making processes, is crucial. This vision represents the first step in innovating public health at the global level and should lead to a serious rethinking of education curricula to allow the next generation to engage within political contexts for restructuring global public health.

A Review of Posttraumatic Stress Disorder and Obesity: Exploring the Link.

The incidence of posttraumatic stress disorder (PTSD) and obesity are on the rise, and evidence continues to support the observation that individuals who have symptoms of PTSD are more likely to develop obesity in their lifetime. The incidence of obesity in individuals with PTSD, including war veterans, women, and children exposed to trauma, is not solely attributable to psychotropic medications, but actual pathophysiologic mechanisms have not been fully delineated. Additionally, there are no studies to date demonstrating that obese individuals are predisposed to developing PTSD compared to the general population. This review explores the pathogenic pathways common to both PTSD and obesity, which include inflammation, the renin-angiotensin-aldosterone system, cellular structures, and neuroendocrine activation. A PubMed search for the years 2000-2015 with the keywords PTSD and obesity was performed. There were no language restrictions. More research is needed in human subjects to understand the pathogenic pathways common to both PTSD and obesity and to further clarify the direction of identified associations. Ideally, in the future, clinical interventions targeting these pathways may be able to modify the course of PTSD and obesity. The outcome of studies investigating the utility of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in the treatment of PTSD symptoms will be relevant to control both PTSD and obesity. Importantly, outcomes assessing inflammation, obesity, and cardiac function in the same subjects also should be determined. Research is needed to reveal the multidimensional and intricate relationship between PTSD and obesity. The implications of this research would be essential for treatment, prevention, and potential public health reforms.

Patients’ Opinions on Family Doctor Accessibility in Estonia

Patients’ Opinions on Family Doctor Accessibility in Estonia

Thomas Hodgkin (1798-1866).

Thomas Hodgkin was a diligent, selfless and benevolent man whose name is instantly recognisable in the medical field due to his description of a type of the lymphoma that is named after him, 'Hodgkin's Lymphoma'. Based at Guy's Hospital, London, he created a vast catalogue of specimens in their Medical Museum and facilitated teaching at the establishment. He was dedicated to education, public health and social reform in the 19th century.

Health Reform and Academic Health Centers: Commentary on an Evolving Paradigm.

The Patient Protection and Affordable Care Act (ACA), both directly and indirectly, has had a demonstrable impact on academic health centers. Given the highly cross-subsidized nature of institutional funds flows, the impact of health reform is not limited to the clinical care mission but also extends to the research and education missions of these institutions. This Commentary discusses how public policy and market-based health reforms have played out relative to expectations. The authors identify six formidable challenges facing academic health centers in the post-ACA environment: finding the best mission balance; preparing for the era of no open-ended funding; developing an integrated, interprofessional vision; broadening the institutional perspective; addressing health beyond clinical care; and finding the right leadership for the times. Academic health centers will be well positioned for success if they can focus on 21st-century realities, reengineer their business models, and find transformational leaders to change institutional culture and behavior.

Importance of public health reforms in decreasing pressures on emergency departments across England

Importance of public health reforms in decreasing pressures on emergency departments across England