Strong Public Health Research Articles

Web-based training and supervision for LGBT-affirmative mental health practice: A randomized controlled trial

Abstract Background Lesbian, gay, bisexual, and transgender (LGBT) individuals in most countries remain stigmatized, requiring culturally sensitive mental health care to foster coping and resilience. This trial tested the efficacy of an LGBT-affirmative mental health training for psychologists and psychiatrists in Romania, where such resources are scarce. The trial compared in-person and web-based training modalities. Methods Participants were randomized to a 2-day training either in-person (n = 56) or via web by viewing the live-streamed training (n = 54), and assessed pre- and 5-, 10- and 15-months post-training, with optional monthly web-based supervision (n = 47) after the first follow-up. Generalized linear mixed models were conducted to assess for change across time. Results The sample (M age=34.98) was mostly female (88%) and heterosexual (84%). Trainees, regardless of in-person or web-based attendance, reported significant decreases from baseline to 15-month follow-up in explicitly (b = 0.21, 95% CI 0.06 − 0.37, p < 0.01) and implicitly (b = 0.26, 95% CI 0.10 − 0.41, p < 0.001) assessed homonegativity, and significant increases in LGBT-affirmative clinical skills (b = -1.19, 95% CI -1.41− -1.00, p < 0.001), beliefs (b = -0.17, 95% CI -0.31 − -0.03, p < 0.05) and behavior (b = -1.17, 95% CI -1.72 − -0.61, p < 0.05). Conclusions Training in LGBT-affirmative mental health can change provider attitudes and practice in high-stigma countries. The fact that web-based trainings were equally efficacious as in-person trainings suggests that such education can have widespread reach. As LGBT individuals represent one of the highest-risk global populations for mental health problems driven by stigma, findings hold strong public health potential. Future research should assess the impact of such trainings across high-need settings and include patient outcomes.

299. “Where the Rubber Meets the Road”: Stakeholders’ Perspectives about the Current State of HCV Care Delivery in Massachusetts Jails

BackgroundHCV is highly prevalent in criminal-justice involved populations (CJIP). Nationally, the operationalization of guideline-driven HCV care (including testing and treatment) for CJIP has been challenging, prompting this study to understand barriers and facilitators.MethodsWe used purposeful sampling strategies to recruit key stakeholders including people who are incarcerated, clinicians providing care in jail, clinicians providing care outside of jail, corrections administrators, and representatives of industry, public health and public policy. Semi-structured interviews were performed in Spanish or English, based on preference of participant. Written notes were used to capture details from interviews in jails and interviews outside of jail were recorded. People interviewed outside of jail were offered a stipend. Interviews were coded and analyzed with a compare and consensus approach.ResultsOf 120 people, 49 (41%) people agreed to be interviewed in each of the stakeholder categories including 21 men who were incarcerated (mean age 32 [IQR 25, 39], 60% non-White). Barriers to HCV care delivery included (1) Fragmented healthcare delivery because of transient nature of CJIP (2) Frustration and disempowerment experienced by people incarcerated in jail and (3) Heterogeneous views on stakeholders responsible for providing and financing HCV care in jails. Facilitators to HCV care delivery included (1) Incarcerated population’s interested in HCV care for public and personal health and (2) An existing strong public health infrastructure in place supporting HIV care delivery.ConclusionUnderstanding various stakeholders’ views of barriers to HCV care in jails is a necessary first step to building improved care pathways. Mutual recognition may help to focus limited administrative and fiscal resources on HCV care for this transient population. Disclosures All authors: No reported disclosures.

Patterns of self-medication with antibiotics in Maputo City: a qualitative study

BackgroundMozambique classifies but does not yet enforce antibiotics as prescription-only-medicine (POM) allowing the public access to a variety of antibiotics that otherwise are provided on prescription. This contributes to the growing practice of self-medication with antibiotics (SMA) which systematically exposes individuals to the risk of developing antibiotic resistance, antibiotic side effects and increases the health service costs and morbidity. This study aimed at describing the patterns of SMA among Maputo city pharmacy customers.MethodsA qualitative study conducted between October 2018 and March 2019 was developed with thirty-two pharmacy customers and seventeen pharmacists. Using convenience sampling, customers were recruited after buying antibiotics without prescription from nine private pharmacies. Of the thirty-two participants, twenty participated in in-depth interviews and twelve in two focus groups discussions (FGD) with six participants each. Purposive sampling and a snowball technique were used to recruit pharmacists. The transcripts were coded and analyzed using latent content analysis. Nvivo 11 was used to store and retrieve the data. The COREQ (Tong, 2007) checklist for interviews and FGD was performed.ResultsCustomers admitted practices of SMA, pharmacists admitted dispensing a variety of antibiotics without prescription. Non-prescribed antibiotics (NPA) were obtained through five different patterns including; using the generic name, describing the physical appearance and using empty package, describing symptoms or health problem to pharmacists, using old prescriptions and sharing antibiotics with family, friends, and neighbors.ConclusionDifferent patterns of SMA are contributing to the indiscriminate use of antibiotics among customers. The NPA utilization is perceived as an expression of self-care where participants experience self-perceived symptoms and indulge in self-treatment as a method of caring for themselves. Moreover, antibiotics are mostly used to treat diseases that do not necessarily need antibiotics. Strong and effective public health education and promotion initiatives should be implemented to discourage inappropriate utilization of antibiotics and SMA practices.

Containing a measles outbreak in Minnesota, 2017: methods and challenges.

We report on a measles outbreak largely occurring in Minnesota's under-vaccinated Somali community in the spring of 2017. The outbreak was already into its third generation when the first two cases were confirmed, and rapid public health actions were needed. The aim of our response was to quickly end transmission and contain the outbreak. The state public health department performed laboratory testing on suspect cases and activated an Incident Command staffed by subject matter experts that was operational within 2 h of case confirmation. Epidemiologic interviews identified exposures in settings where risk of transmission was high, that is, healthcare, childcare, and school settings. Vaccination status of exposed persons was assessed, and postexposure prophylaxis (PEP) was offered, if applicable. Exposed persons who did not receive PEP were excluded from childcare centers or schools for 21 days. An accelerated statewide measles, mumps, and rubella (MMR) recommendation was made for Somali Minnesota children and children in affected outbreak counties. Partnerships with the Somali Minnesota community were deepened, building off outreach work done with the community since 2008. Public health identified 75 measles cases from 30 March to 25 August 2017: 43% were female, 81% Somali Minnesotan, 91% unvaccinated, and 28% hospitalized. The median age of cases was 2 years (range: 3 months-57 years). Most transmission (78%) occurred in childcare centers and households. A secondary attack rate of 91% was calculated for unvaccinated household contacts. Over 51,000 doses of MMR were administered during the outbreak above expected baseline. At least 8490 individuals were exposed to measles; 155 individuals received PEP; and over 500 persons were excluded from childcare and school. State and key public health partners spent an estimated $2.3 million on response. This outbreak demonstrates the necessity of immediate, targeted disease control actions and strong public health, healthcare, and community partnerships to end a measles outbreak.

Elizabeth Seton: American Saint

Elizabeth Ann Bayley Seton (1774–1821) was the first American-born Roman Catholic saint. Privately educated in New York City, Seton grew up in comfortable circumstances, educated and doted upon by socially prominent and religiously attuned parents. Her father, a son of French Huguenots, was a notable physician and professor of anatomy active in New York public health, while her mother grew up in the family of an Anglican priest and pastor of a Staten Island church. Groomed for a life in society, Seton married an ambitious young merchant at age twenty but later was widowed with five children at age thirty-one. After the crisis of her husband's failed business and death, Seton subsequently converted to Roman Catholicism and became a high-profile Catholic leader, eventually launching a notable private academy and convent in Emmitsburg, Maryland. Seton's activities in public service began in the 1790s with her involvement in the New York Society for the Relief of Poor Widows with Small Children, which had been founded by the Scottish evangelical leader Isabella Graham. As a benefactor of indigent white women in New York, Graham's society provided for Seton—then a young mother herself—an early model for a benevolent organization professionally staffed and financially managed exclusively by women. Along with the strong influence and public health activism of her father, Dr. Richard Bayley, a physician devoted to scientific management of contagious diseases such as yellow fever, the Graham society for indigent women helped influence Seton's later work for the Catholic and public interest via her founding and leadership of the American Sisters of Charity, the first U.S.-based order of Roman Catholic nuns.

Program Kehamilan

In 2016, at the beginning of Sustainable Development Goals (SDGs) era, preventable morbidity and mortality rates related to pregnancy remained very high. In the series of reproductive health care, antenatal care (ANC) facilitates important health service functions, including health promotion, premarital and preconception screening, diagnosis, and prevention of disease. Antenatal care in nulliparous women without complications was performed up to 10 times, while in primiparous and multiparous women without complications of pregnancy, ANC examination is recommended to be performed 7 times during the pregnancy period. Premarital screening is an action to prevent health problems in yourself, your spouse or offspring. This examination has several advantages, namely to prevent various diseases in the babies, such as thalassemia, diabetes mellitus, and other diseases. Preconception care aims to prevent and control disease at various stages of life, and a strong public health program is needed which uses a life perspective from infancy through childhood, adolescence and adulthood. Preconception care packages along with evidence-based interventions suggested by the World Health Organization include nutritional conditions; tobacco use; genetic conditions; environmental health; use of vaccines; prevention of interpersonal violence, sexually transmitted infections, drugs use, and Female Genital Mutilation (FGM).

Acute Hepatitis A Infection and Vaccination in the Veterans Health Administration

Acute Hepatitis A Infection and Vaccination in the Veterans Health Administration

Long-Term Effects of Parenting and Adolescent Self-Competence for the Development of Optimism and Neuroticism.

Optimism and neuroticism have strong public health significance; however, their developmental precursors have rarely been identified. This study examined adolescents' self-competence and their parents' parenting practices as developmental origins of optimism and neuroticism in a moderated mediation model. Data were collected when European American adolescents (N = 290, 47% girls) were 14, 18, and 23 years old. Multiple-group path analyses with the nested data revealed that 14-year psychological control and lax behavioral control of both parents predicted lower levels of 18-year adolescence self-competence, which in turn predicted decreased 23-year optimism and increased neuroticism. However, the positive effects of warmth on 18-year optimism were stronger in the context of high maternal and paternal authoritativeness, and the positive effects of warmth on adolescent self-competence was attenuated by maternal authoritarianism. This study identified nuanced effects of parenting on adolescents' competence and personality, which point to important intervention targets to promote positive youth development.

Generation and Selection of a Panel of Pan-Filovirus Single-Chain Antibodies using Cell-Free Ribosome Display.

.Filoviruses, which include ebolaviruses and marburgvirus, can cause outbreaks of highly lethal hemorrhagic fever. This disease causes significant morbidity and mortality in humans and non-human primates, with human fatality rates reaching 90% during some outbreaks. Currently, there is lack of licensed vaccines or antivirals for these viruses. Since early symptoms of filovirus infection mimic more common diseases, there is a strong unmet public health and biodefense need for broad-spectrum filovirus rapid diagnostics. We have generated a panel of mouse single-chain Fv-antibodies (scFvs) to filovirus glycoproteins (GPs) using cell-free ribosome display and determined their cross-reactivity profiles to all known filovirus species. Two scFvs (4-2 and 22-1) were able to detect all known Ebolavirus and Marburgvirus species. This is the first report on ribosome display scFvs that can detect a broad set of filovirus GPs, which demonstrates the potential for use in diagnostics.

E-Oral Health and Teledentistry in Finland - an Overview

Despite universal health coverage and a strong public health system, the oral health profile of Finland falls behind in an international age-matched prevalence of oral diseases. The oral healthcare system is organised and funded mainly by municipalities. Other stakeholders include the Finnish Student Health Service foundation (FSHS), government and private practices, where the Social Insurance Institution of Finland plays a major role in funding. Rise in the treatment need in recent years due to the increasing dentulous ageing population has challenged the healthcare system. Governmental response to the demand is an ongoing social and healthcare reform and increase of oral health professional education since 2004. However, the current and future treatment need is not met only by conventional prevention strategies and physical service provision. Finland has over the years supported a determined policy of building a digital healthcare architecture. This applies also to all fields of oral healthcare: virtual education, digital diagnostics, digital clinical workflow, national electronic patient records, patient-generated data registers, electronic prescriptions, remote consultation, digital service management, as well as research and big data mining. These tools could play an important role in improving national oral health and increasing equity. This is an overview of the above-mentioned fields of e-Oral health and teledentistry in Finland based on current scientific literature, national reports, strategies and legislation.
 
 

In Case You Haven't Heard…

Last week was the annual Rx Drug Abuse and Heroin Summit extravaganza of science, law enforcement and anti‐pharma information in Atlanta. We had to miss it due to scheduling but would have loved to have been there. “This is the best summit ever,” Joseph Garbely, D.O., vice president of medical services and medical director of Caron, told us by phone. He had dinner with Kelly Clark, M.D., immediate past president of the American Society of Addiction Medicine (Garbely is now on the board), and a few other people, including Nora Volkow, M.D., head of the National Institute on Drug Abuse (NIDA), and Robert Dupont, M.D., the first head of NIDA — as networking is a key draw of the event. He did say that treatment in general is underrepresented at the summit. What treatment needs to do more of is to show outcomes, he said. What he learned from this year's summit: “There is an amazing group of people who are committing to forwarding the science and the understanding that addiction is a chronic disease,” he said. “The energy is really positive.” However, we spoke to him before the speech given by President Trump, which was actually boycotted by some attendees. Geoffrey Laredo, formerly senior advisor at NIDA and now a principal at Santa Cruz Strategies, boycotted it, standing outside in the sunshine instead. “I am boycotting,” he said of the speech. “I am very pleased to be at the Rx Drug Abuse and Heroin Summit. Impacting the addiction crisis in the U.S. — including the acute opioid overdose epidemic — still requires all of our hard work and ideas. As you know, I was very involved in this meeting for several years while at NIDA, and I'm glad to see the continued commitment and focus from the public health community. I am very concerned with this White House and its approach to the issue. We hear some good rhetoric and some awful, hurtful rhetoric. We see proposals to slash agency and program budgets that work directly on addiction prevention, treatment and recovery. What we don't see is a truly coordinated plan of the size, focus and scope that could make serious inroads into addiction in the U.S. We are very fortunate that Congress proposed and provided significant research funding to the National Institutes of Health to broaden its work in addiction. The HEALing Communities initiative and several other research efforts will undoubtedly yield results that will save lives.” Andrew Kessler, principal with Slingshot Solutions, had already flown from Atlanta back home to Washington, D.C., and watched the president's speech on the livestream (as did we). “Perhaps my biggest disappointment is that I did not hear the word ‘disease’ even once during the president's remarks,” Kessler told us afterward. “Until he — and those who work with him — understand and accept that addiction and substance use disorders are a disease, progress will be slow. To treat a disease the size and scope of this one, we need a strong public health response — and the bedrock of that response is Medicaid. Mr. Trump spent almost 80 percent of his speech offering his support for law enforcement. We all respect law enforcement, but it would have been nice to hear him offer his support for prevention, treatment and recovery professionals. They make just as many sacrifices, and get almost no recognition.” He added, “The president was effusive in his praise for drug‐sniffing dogs. They probably do a great job. Maybe one day SUD professionals will garner his adulation as well.” Jeff Quamme of the CCB didn't stick around for the speech either. “[Trump's] pattern of turning everything into a campaign stump, personal attack on his political enemies or flat‐out mistruths speaks volumes to me,” he told ADAW.

Legal Feasibility of US Government Policies to Reduce Cancer Risk by Reducing Intake of Processed Meat.

The World Health Organization, the World Cancer Research Fund, and the American Cancer Society have each in recent years concluded that processed meats are probable carcinogens. The 2015-2020 Dietary Guidelines for Americans did not separately evaluate health effects of processed meat, although it mentioned lower processed meat intakes among characteristics of healthy diets. We summarized the international scientific literature on meat intake and cancer risk; described the scientific and political processes behind the periodic Dietary Guidelines for Americans; described the US red meat and processed meat industries and the economic structure of government-supported industry initiatives for advertising and promotion; and reviewed and analyzed specific factors and precedents that influence the feasibility of four potential policy approaches to reduce processed meat intake. Based on a review of 800 epidemiological studies, the World Health Organization found sufficient evidence in humans that processed meat is carcinogenic, estimating that each 50-gram increase in daily intake increases the risk of colorectal cancer by 18%. Among the four policy responses we studied, legal feasibility is highest in the US for three policy options: reducing processed meat in school meals and other specific government-sponsored nutrition programs; a local, state, or federal tax on processed meat; and public service announcements on health harms of processed meats by either the government or private sector entities. Legal feasibility is moderate for a fourth policy option, mandatory warning labels, due to outstanding legal questions about the minimum evidence required to support this policy. Political feasibility is influenced by the economic and political power of the meat industries and also depends on decisions in the next round of the Dietary Guidelines for Americans about how to assess and describe the link between processed meat consumption and cancer risk. Public policy initiatives to reduce processed meat intake have a strong scientific and public health justification and are legally feasible, but political feasibility is influenced by the economic and political power of meat industries and also by uncertainty about the likely treatment of processed meat in the 2020-2025 Dietary Guidelines for Americans.

Ayushman Bharat National Health Protection Scheme: an Ethical Analysis.

The Ayushman Bharat (Hindi for "India blessed with a long life") scheme is a government health insurance program that will cover about 100 million poor and vulnerable families in India providing up to INR 0.5 million per family per year for secondary and tertiary care hospitalization services. In addition, it also proposes to establish 150,000 health and wellness centers all over the country providing comprehensive primary health care. The beneficiaries of the hospital insurance scheme can avail health care services from both public and empanelled private health facilities. This scheme is one of the largest government-sponsored health insurance schemes in the world. Previous experience with government-financed health insurance schemes in India has shown that they are inequitable, inefficient, and do not provide financial protection. There is a lack of clarity on the budgetary provisions over the years when the utilization is likely to increase. The Ayushman Bharat scheme in its current form strengthens the "for profit" private health sector, requiring greater emphasis on its regulation. The scheme, which has primary, secondary, and tertiary care components, places a great focus on the secondary and tertiary care services and requires more investment in comprehensive primary health care. The potential problems of "profit-motivated" supplier-induced demand by private health care providers and corrupt practices are possible ethical burdens of the scheme. For the Ayushman Bharat to meet the ethical principle of justice, it should first address universal coverage of comprehensive primary health care and move on to hospital insurance in a progressive manner. The scheme should have provisions to strictly regulate secondary and tertiary care hospitalization in the private health sector to prevent misuse. It is the ethical responsibility of the government to ensure a strong and robust public health system, but the current provisioning of the Ayushman Bharat scheme does not do this and the reasons for this are explained in this paper.

The Cost of Osteoporosis, Osteopenia, and Associated Fractures in Australia in 2017.

Osteoporosis and osteopenia are increasingly prevalent conditions among older adults. Not only do the fractures associated with poor bone health have significant health consequences for the individual, but also their economic impact is placing increasing financial burden on governments and society. This study aimed to determine the direct economic cost of osteoporosis, osteopenia, and fractures among Australians aged 50 years and older in 2017. This study uses previous Australian data on the incidence and prevalence of osteoporosis and osteopenia together with recent Australian data on health service utilization after fracture to provide an estimate of the economic burden of osteoporosis. A bottom-up costing approach was used to determine the average direct health care and non-health care total costs of a fracture, as well as the average community health service costs of managing individuals with osteoporosis or osteopenia. The total direct cost of osteoporosis in Australia in 2017 was estimated to be $3.44 billion (AUD 2017, USD 2.77 billion). Treatment of fractures accounted for 68% of total direct costs, and non-fracture management of osteoporosis accounted for 32%. Hip fractures accounted for the highest proportion (43%) of the total direct cost of fractures, although fractures at "other" sites accounted for 38.5%. Fractures among individuals aged 70 years and older accounted for 74% of the direct costs (55% and 19% in women and men, respectively). Fracture costs in those with osteopenia accounted for 50% of direct fracture treatment costs. This up-to-date cost analysis estimated that costs in 2017 were three times higher than in 2007. These estimates will aid clinicians, policy makers, researchers, and health care organizations to acknowledge the economic importance of reducing osteoporosis-related fractures and associated costs. This provides a strong public health case to promote bone health that will assist in reducing future fracture-related costs. © 2018 American Society for Bone and Mineral Research.

Factors affecting self-reported chemical intolerance: A five-year follow-up study in Japan

ObjectiveChemical intolerance (CI) has become a strong public health concern in industrialized countries. The Japanese Chemical Intolerance (JCI) study was conducted in January 2012 with a cohort of 7245 adults from population-based sampling as the baseline. The aim of the present study was to investigate the factors involved in the improvement and development of CI from the five-year follow-up study. MethodsFrom the 7245 cohort, 735 persons with CI (case) were identified, and 1750 controls without CI were randomly selected to match gender and age for case and control groups. Self-reported questionnaires were administered to the subjects of the two groups to obtain information on status of CI; medical history; medical, lifestyle, or physical interventions; changes in living situation or occupation; and psychosomatic states. ResultsA total of 909 individuals responded during the follow-up period. After five years, improvement in CI was observed in 67.7% of the case group. Status of CI was reported in 6.7% of the control group. Multiple logistic regression analyses revealed that baseline atopic dermatitis and negative psychosomatic states including irritability, fatigue, anxiety, depressed mood, and somatic symptoms were significantly associated with development of CI in controls. Appropriate physical activity and maintaining a regular lifestyle including diet or sleep during the last three years of the follow-up period were significant factors for improvement of CI in the case group. ConclusionsEnsuring appropriate physical activity and regular lifestyle rather than improving physical environment lead to improvement of CI. Stable psychosomatic state is essential for preventing CI.

State Approaches to Addressing the Overdose Epidemic: Public Health Focus Needed.

States have implemented a variety of legal and policy approaches to address the overdose epidemic. Some approaches, like increasing access to naloxone and connecting overdose survivors with evidence-based treatment, have a strong public health foundation and a compelling evidence base. Others, like increasing reliance on punitive criminal justice approaches, have neither. This article examines law and policy changes that are likely to be effective in reducing overdose-related harm as well as those that are likely to increase it.

Historical reconstruction of the community response, and related epidemiology, of a suspected biological weapon attack in Ningbo, China (1940)

ABSTRACT During World War II, members of the Imperial Japanese Army biological warfare Unit 731 conducted a live test deployment of plague-infected fleas in Ningbo, Zhejiang Province, China. The deployment triggered an outbreak involving 165 cases in downtown Ningbo, 112 of which were fatal (68% case fatality rate). Despite lack of access to effective medical countermeasures, the Ningbo community exhibited a high degree of social cohesion and resilience in the context of effective public health response. These findings support the value of community preparedness and strong public health infrastructure to mitigate the impact of biological weapons.

Facilitators for maternity waiting home utilisation at Attat Hospital: a mixed-methods study based on 45years of experience.

To describe facilitators for maternity waiting home (MWH) utilisation from the perspectives of MWH users and health staff. Data collection took place over several time frames between March 2014 and January 2018 at Attat Hospital in Ethiopia, using a mixed-methods design. This included seven in-depth interviews with staff and users, three focus group discussions with 28 users and attendants, a structured questionnaire among 244 users, a 2-week observation period and review of annual facility reports. The MWH was built in 1973; consistent records were kept from 1987. Data analysis was done through content analysis, descriptive statistics and data triangulation. The MWH at Attat Hospital has become a well-established intervention for high-risk pregnant women (1987-2017: from 142 users of 777 total attended births [18.3%] to 571 of 3693 [15.5%]; range 142-832 users). From 2008, utilisation stabilised at on average 662 women annually. Between 2014 and 2017, total attended births doubled following government promotion of facility births; MWH utilisation stayed approximately the same. Perceived high quality of care at the health facility was expressed by users to be an important reason for MWH utilisation (114 of 128 MWH users who had previous experience with maternity services at Attat Hospital rated overall services as good). A strong community public health programme and continuous provision of comprehensive emergency obstetric and neonatal care (EmONC) seemed to have contributed to realising community support for the MWH. The qualitative data also revealed that awareness of pregnancy-related complications and supportive husbands (203 of 244 supported the MWH stay financially) were key facilitators. Barriers to utilisation existed (no cooking utensils at the MWH [198/244]; attendant being away from work [190/244]), but users considered these necessary to overcome for the perceived benefit: a healthy mother and baby. Facilitators for MWH utilisation according to users and staff were perceived high-quality EmONC, integrated health services, awareness of pregnancy-related complications and the husband's support in overcoming barriers. If providing high-quality EmONC and integrating health services are prioritised, MWHs have the potential to become an accepted intervention in (rural) communities. Only then can MWHs improve access to EmONC.

Substantial Increase in Compliance with Saturated Fatty Acid Intake Recommendations after One Year Following the American Heart Association Diet.

The American Heart Association (AHA) dietary guidelines recommend 30–35% of energy intake (%E) be from total fat, <7%E from saturated fatty acids (SFA), and <1%E from trans fatty acid (TFA). This study evaluates the effect of AHA dietary counselling on fat intake. Between 2009 and 2014, 119 obese adults with metabolic syndrome (MetS), (71% women, average 52.5 years of age, and 34.9 kg/m2 of body mass index), received individual and group counselling on the AHA diet, over a one-year study period. Each participant attended 2 individual sessions (months 1 and 12) and 12 group sessions, at one-month intervals. At baseline and one-year, we collected three random 24-h diet recalls (two weekdays and one weekend day). Fat intake patterns over time were analyzed using paired-t test and linear mixed-effect models. There was significant variation on SFA and TFA intake per meal, being highest at dinner, in restaurants, and on weekends. Over the one-year study period, daily intake of total fat, SFA, and TFA decreased by 27%, 37% and 41%, respectively (p-value < 0.01, each). Correspondingly, the percentage of participants complying with AHA’s recommendations, increased from 25.2% to 40.2% for total fat (p-value = 0.02); from 2.5% to 20.7% for SFA (p-value < 0.01); and from 45.4% to 62% for TFA (p-value = 0.02). Additionally, SFA intake for all meal types at home decreased significantly (p-value < 0.05, each). AHA dietary counselling significantly increased the compliance with AHA dietary guidelines, with an eightfold increase in compliance in SFA intake. Nonetheless, ~80% of our participants still exceeded the recommended SFA intake. Substantial efforts are needed to encourage low-SFA and low-TFA food preparation at home, with strong public health policies to decrease SFA and TFA in restaurants and prepared foods.

Who Needs Big Health Sector Reforms Anyway? Seychelles’ Road to UHC Provides Lessons for Sub-Saharan Africa and Island Nations

The road to universal health coverage (UHC) needs not be driven by big reforms that include the initiation of health insurance, provider–funder separation, results-based financing, or other large health sector reforms advocated in many countries in sub-Saharan Africa and elsewhere. The Seychelles experience, documented through a series of analytical products like public expenditure reviews and supporting surveys with assistance from the World Bank and World Health Organization (WHO), shows an alternative, more incremental reform road to UHC, with important lessons to the region and other small-population or island nations. Done well, in some countries, a basic supply-side funded, publicly owned and operated, and integrated health system can produce excellent health outcomes in a cost-effective and sustainable way. The article traces some of the factors that facilitated this success in the Seychelles, including high political commitment, strong voice and a downward accountability culture, strong public health functions, and an impressive investment in primary health care. These factors help explain past successes and also provide a good basis for adaptation of health systems to dramatic shifts in the epidemiological and demographic transitions, disease outbreaks, and rising public expectation and demand for high quality of care. Once again, how the Seychelles responds can show the way for other countries in the region and elsewhere regardless of the types of reforms countries engage in.