Background: Pregnant women are exposed to endocrine disrupting chemicals (EDCs) through prolonged contact with personal care products, food containers and plastics. Gestational exposure to EDCs may be associated with changes in birth weight and fetal growth, placing children at risk for negative outcomes later in life. Objective: To examine the association between gestational exposure to four EDC classes (phthalates, polychlorinated biphenyls (PCBs), polyfluorinated compounds (PFCs) and polybrominated diphenyl ethers (PBDEs)) and infant birth weight. Methods: Using data from the Health Outcomes and Measures of Environment (HOME) study, 2003-2006 (n=387), we used Bayesian Hierarchical Linear Regression Modeling (BHLM) to examine the associations between four EDC classes and birth weight. Results: Colinearity among the chemical concentrations was severe with correlations as large as 0.98. In BHLM analyses that shrunk the beta coefficients towards the class-specific mean. We found that no individual metabolites from any of the four EDC classes were associated with birth weight. In the BHLM, the parameter μβ was the average beta coefficient within a chemical class (e.g. phthalates) in relation to birth weight. For a 10-fold increase in chemical concentration, the μβ values were respectively, 0.89g for phthalates, -1.48g for PCBs, -15.8g for PFCs and -2.14 for PBDEs. In order to put these effect sizes in context, we examined the relative impact of chemical exposure on birth weight versus the effect of poverty on birth weight, based on a Bayesian analysis of four socioeconomic (SES) indicators: low income, low education, no private health insurance, and unemployment. For SES, the estimated value of μβ was -63.1g. Thus poverty had a larger association with lower birth weight than gestational chemical exposure as measured by a multiplicative factor of x121 for phthalates, x193 for PCBs, x36.1 for PFCs, and x157 for PBDEs. Conclusion: Gestational exposure to phthalates, PCBs, PFCs or PBDE had only small associations with differences in birth weight among the HOME study participants. In particular, the average association between gestational EDC exposure and birth weight is approximately 36.1 to 193 times smaller than the effect of poverty on birth weight. While no μβ values attained significance, three were negative. PFCs and phthalates have the greatest associations with birth weight (one negative, one positive). The phthalate and PFC EDC classes, taken within the context of SES, should be considered for closer study.
In 2009, Mexico passed a national drug policy reform decriminalizing the possession of small amounts of certain drugs for personal use with the aim of diverting drug-dependent individuals from prison and towards addiction treatment. However, the public health approach codified by the reform has not yet led to a meaningful change in local police practices nor contributed to the meaningful scale-up of harm reduction and addiction treatment services in many Mexican cities. Specifically, in Tijuana, Baja California, there continues to be a variety of local level barriers – including arbitrary police behaviours – that hinder the ability of people who inject drugs (PWID) from accessing vital harm reduction services. This has implications for the growing HIV epidemic in Mexico’s northern border region, given that access to harm reduction interventions has been shown to effectively reduce the risk of HIV infection among PWID. In contrast to the largely enforcement-based local response seen in Tijuana, the municipal Four Pillars approach implemented in Vancouver, Canada in 2001 was passed as a public-health oriented response to the rising prevalence of HIV/AIDS among PWID in the Downtown Eastside of Vancouver. Centered on the balancing of four approaches – harm reduction, treatment, prevention and enforcement – the Four Pillars approach in Vancouver has led to a well-resourced local harm reduction and addiction treatment system. This local emphasis on harm reduction contrasts with the Canadian Conservative federal government’s opposition to harm reduction approaches. However, police-public health partnerships along with strong political support have led to the substantial scale up of harm reduction services as well as the reduction of HIV/AIDS among PWID in Vancouver, unlike what has been observed in Tijuana. This commentary therefore aims to assess the discrepancies between federal policy and local responses to drug-related harms in order to fully understand the impact and implications of national drug policies in shaping local response to drug related harms among populations of PWID. Through a comparison of the drug policy landscape in two cities linked by a large North American drug trafficking route - Tijuana, Mexico and Vancouver, Canada, - this commentary suggests that drug policy reform in and of itself will have little impact at the local level unless it is appropriately resourced and meaningfully supported by key stakeholders.
British Columbia’s Opioid Substitution Treatment (formerly Methadone Maintenance Therapy1 ) made a switch in formulation from generic methadone to a proprietary medication called Methadose™ (BC Ministry of Health, 2013) effective February 1 of 2014. The switch to Methadose™ in British Columbia (BC) offers an opportunity to examine the literature about methadone, MMT, and opioids and trace the evolution of policy and practice that inform this substitution therapy. A metanarrative review of the literature demonstrates the evolving perspective on MMT and offers insights to how a society views substance use, as well as future medication changes that affect a particular patient population, especially when that population is comprised of individuals who face structural inequities in mainstream Canadian society
This capstone is a review of national policies and practices in Indonesia to address human resources for health shortages since 2010. A comprehensive search of peerreviewed and grey literature yielded 65 relevant studies/documents. These were evaluated to assess how well or poorly they align with the WHO Global of Practice on the International Recruitment of Health Personnel using an analytical framework developed specifically for the Code. The findings suggest that Indonesia’s policies have been adapted, to address the mobility of health workers, and mechanisms now exist to scale up the production of health workers. However, this review identifies key challenges remaining concerning equitable access, quality of healthcare, and regulation. Recommendations to policy-makers include the need for firmer negotiation of international agreements, stronger rural retention programs, modification of medical education curriculum and admissions criteria, and work with other stakeholders to ensure policy space for health priorities.
The World Health Organization (WHO) estimates that 40 million people are in need of palliative care worldwide, and of these, 37 million of them live in low- and middle-income countries (LMIC). Moreover, 98% of children who are in need of palliative care globally live in LMIC and almost half of them are living in Africa (WHO, 2015). Current palliative care needs are largely unmet and yet the need for palliative care is increasing due to the prevalence of HIV/AIDS, drugresistant tuberculosis, and increasing rates of cancer, chronic conditions and non-communicable diseases (Sternswärd & Clark, 2004; Blinderman, 2009). Kenya is a key region to examine because it is a lower middle-income country, the burden of disease is high, public funding of palliative care is very limited, and yet with the combined efforts of national associations, dedicated healthcare workers, Non-Governmental Organizations and charities, Kenya is one of only three African countries that is approaching full integration of palliative care – ranked alongside several high-income countries worldwide. Several international health and social justice agencies have highlighted that palliative care is a human right and should be recognized as a fundamental component of healthcare (Gwythner, Brennan & Harding, 2009); on the ground, the practice of this principal remains tenuous. In 2010 Human Rights Watch issued various hard-hitting reports on the state of palliative care in Kenya, highlighting a severe lack of governmental investments in palliative care service, particularly for children, and inadequate access or provision of essential palliative care medications such as morphine (Lohman & Amon, 2015). Since then, the 4 Kenyan Ministry of Health, in partnership with the Kenyan Hospices and Palliative Care Association (KEHPCA), has attempted to improve access to pain and palliative care services. Improvements such as including palliative care in the National Patients’ Rights Charter, issuing detailed plans to integrate palliative care into the Kenyan public health system, publishing National Palliative Care Guidelines, and recent purchases of publicly funded opioid analgesic in the form of oral morphine (Ali, 2016). Although there have been great strides in the establishment of palliative care services in Kenya, there are some overarching influential factors that complicate these efforts. There are also some key social justice concerns highlighted in the literature with regards to how inequity and stigma affect the facility of palliative care in Kenya. Through a comprehensive literature review in conjunction with my experiences from my internship with KEHPCA, I will discuss the hallmarks of palliative care in Kenya, the impacts of globalization, the increasing need for integrated services, the stigma and misconceptions that contribute to inequitable access, and finally explore the paradoxical relationship between social justice and this emerging public health issue.
In high HIV prevalence settings, the delivery of HIV prevention, treatment and care services has created an enormous strain on health systems currently struggling to cope with critical shortages of health personnel. In attempts to address this dilemma, task shifting has taken place across sub-Saharan Africa to improve access to testing and treatment, decrease service costs, improve outreach, and ultimately combat the spread of HIV. Within this, task shifting can take many forms. For example, nurses can provide treatments that were previously the responsibility of medical doctors; likewise, lay counsellors can offer voluntary HIV testing, which nurses and practitioners formerly conducted. Within the provision of HIV care delivery, Community Health Workers (CHWs) have played a critical role, as they are individuals who receive basic training to conduct specific services that overburdened staff would otherwise struggle to carry out. However, widespread usage of CHWs within HIV care has not been immune to ethical challenges. For instance, CHWs have often been expected to carry out emotionally- and physically-demanding tasks with inadequate training, supervision and even compensation. Moreover, CHWs have been poorly integrated into formal health systems, which has not only impacted the quality of their work, but has further perpetuated power asymmetries between them and other health worker cadres. By using Tanzania as a case study, the objective of this paper is to examine ethical challenges and propose strategies to potentially resolve them, which emerge within HIV care delivery programs that involve CHWs. In this study, I evaluate these challenges through the lens of Ethical Principlism and more specifically, by focusing on the following ethical principles: respect, justice, beneficence, critical reflection, and confidentiality. As discussed, prioritizing these principles can help to ensure that CHWs receive fair and standardized forms of remuneration, are provided with adequate resources to conduct their work, and have increased power and decision-making within HIV programs. These outcomes can ultimately enable CHWs to help combat the spread of HIV through a means that does not exploit or take their critical role within service delivery for granted.
Despite successful efforts made by the South African government to implement youthfriendly services in public clinics, none of these efforts have formally evaluated youth engagement as an integral framework to improve health service delivery to young adults (16-24 years). The youth engagement framework is a participatory research approach, where young people and adults merge their efforts to work towards a common goal while sharing knowledge and power. The objective of our study was to evaluate the effectiveness of the Youth Engagement (YE) approach as part of a larger adolescent HIV cohort study. AYAZAZI (‘knowing themselves’ in the Zulu language) is an interdisciplinary longitudinal cohort study at the Perinatal HIV Research Unit (PHRU) which aims to link HIV socio-behavioural patterns and clinical characteristics among youth age 16-24 years living in Soweto, South Africa. The AYAZAZI study adopted a youth engagement approach where youth (16-24 years) play an active role as research staff members and participants while receiving the guidance and support of adult allies. The AYAZAZI cohort study has a mixed age group on staff, consisting of Adolescents and Young Adults (AYA) (16-24 years) staff, and adult allies (older than 25 years). To evaluate the YE approach in AYAZAZI, we employed two data sources: anonymously written responses submitted via a suggestion box, as well as responses given during face-to-face interviews. The suggestion box was implemented in the youth lounge at the PHRU clinic to assess Adolescents and Young Adults (AYA) research participants’ satisfaction with the AYAZAZI research study. We also conducted face-to-face interviews with 5 (AYA) AYAZAZI research participants (18-24 years), 4 youth AYAZAZI research staff (16-24 years), and 4 AYAZAZI “adult allies” staff (older than 25). Key findings from the youth engagement evaluation included young people feeling valued by staff members, and youth staff having new career aspirations as a result of interacting with adult staff members. Adopting a youth engagement approach created an effective communication space between adults and young people. Taken together, our results suggest that, when given a supportive environment where young people can engage with those of the same age group along with supportive adults, youth are more likely to partake in programs and services intended to benefit them.
Background: Worldwide, mental and substance use disorders (SUD) account for over 183.9 million disability adjusted life years. While interventions do exist they are not readily implemented, especially in low- and middle-income countries, due to a lack of available human resources, monetary resources, stigma, and difficulties in changing practice patterns. Quality Improvement (QI) has been reported in literature to successfully improve health services and systems through small-scale, iterative change cycles. Objectives: This study assessed the impact of the NextGenU.org online blended course in terms of integrating, improving and sustaining mental health services using quality improvement methods in primary health care in Kenya. It also analyzed the experience of participants who completed the NextGenU.org online blended course. Method: A mixed-methods study was conducted, incorporating both qualitative focus groups (FGD) and key informant interviews (KII), and quantitative statistical measures. Data came from the Computer-Based and Alcohol Training Assessment in Kenya (eDATA K), which was implemented in collaboration with the University of British Columbia (UBC) and African Mental Health Foundation (AMHF). FGDs and KIIs were analyzed using NVivo through a constant-comparison method, to identify themes emerging from the data. A second coder analyzed the data to ensure reliability and validity. Quantitative analysis was conducted to analyze the course completion rates. Additionally, the researcher incorporated their own notes from observations made during fieldwork over the course of a 12-week practicum with AMHF to triangulate the results. Results: Overall, 27 screeners and clinicians completed the NextGenU.org online blended course. There were two FGDS and two KIIs conducted in Makueni county during July - September 2015. In terms of the staff’s experience in completing the online course many participants noted strong facilitators such as: the certificates, desire for knowledge, personal motivations, relevant material, and case studies. The limited amount of space, computers, and restrictions on Internet access acted as barriers. Participants perceived their knowledge of QI methods, leadership, and time management to have increased from completing the course. Perceived self-efficacy also increased, as staff believed their ability to be a leader, manage time and deal with errors and mistakes within the workplace improved. There was also a positive shift in stigma associated with SUD. Most importantly, the integration and improvement in mental health services was maintained even though staff discussed common challenges, such as heavy workload and limited time. Some participants reported that some people in management roles should have been more supportive, as their limited involvement acts as a barrier to greater integration of services, while other where thankful of the management support. Conclusion: This is one of the first studies of using QI methods to integrate, improve and sustain mental health services in the primary health care system in Kenya. Based upon the experiences described in the FGDs and KIIs, the blended online course was perceived to be acceptable, feasible and successful. The results indicate that quality improvement continues to be integrated in Makueni overall improving mental health services.