Table of Contents
Viewpoint Article in Health Policy
Rethinking maternal healthcare for the 21st century in the United States
Author: Vishwani PERSAUD-SHARMA1
1 Doctor of Nursing Practice; Board Certified Nurse Practitioner; Biomedical Engineer, University of Miami, School of Nursing and Health Studies, Miami, Florida, USA.
To date, the United States (U.S.) maternal mortality rate (MMR) is almost 30% higher than that of its global counterparts. With disproportionate maternal morbidities and mortalities across the U.S., the people look to governmental legislation to remedy the steadily rising cases of maternal and infant demise across various states. Health outcomes like postpartum hemorrhage, hypertension, and maternal infection during pregnancy are now important causes of maternal death across the U.S., conditions that were once sustainably treated and, therefore, preventable. Though maternal surveillance and legislation imparted by the Affordable Care Act (ACA) stipulated minor governance of maternal healthcare, indeed, rising maternal death tolls counter its effectiveness, showing disparate discrepancies across ethnicities. Comparative global country analysis reveals effective methods that need to be communicated in U.S. legislation for maternal care standardization and sustenance. States like California also offer tangible evidence of legislative change and maternal and infant outcome success. This paper provides an overview of the maternal and infant crisis in the U.S., provides insight into the current state of maternal surveillance and the ACA, compares the pros and cons of effective maternal healthcare in global countries, and offers a tangible solution to correct the maternal healthcare crisis in the United States of America.
Keywords: America; care; crisis; healthcare, maternal healthcare; morbidity; mortality; United States; USA; maternal mortality rate.
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Viewpoint in Medical and Public Health
Implicit bias among health care providers and its influence on African Americans – A critical analysis
Author: Khushboo PATEL1
1 M.A., Research Associate, Boston University, Boston, MA, USA.
The present article reviews implicit bias among health care providers and its influence on African Americans in the United States and provides critical analysis of the Implicit Association Test (IAT), a commonly used measure to assess implicit bias. Empirical evidence confirms the widespread presence of implicit bias among health care providers in the United States. African Americans have typically reported a lack of communication, misdiagnoses, and inadequate treatment from their health care providers. It is also revealed that health care providers are likely to favor White patients over Black patients and view Black patients as less cooperative. All the studies discussed in the present article make use of the Implicit Association Test (IAT) in order to measure implicit bias. Due to some loopholes of the measure, the article aimed to provide future directions in order to overcome the limitations of the existing research on implicit bias by proposing alternate methodological considerations.
Keywords: African Americans; Implicit Association Test; implicit bias; health care professionals.
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Viewpoint Article in Healthcare Policy
Healthcare access, quality of care and efficiency as healthcare performance measures: A Canadian health service view
Authors: Yamin Tauseef JAHANGIR1,2, Elena NEITERMAN3, Craig R. JANES4, Samantha B. MEYER5
1 PhD, School of Public Health and Health Systems, University of Waterloo, Ontario, N2L 3G1, Canada
2 Lecturer, Department of Public Health, North South University, Dhaka 1229, Bangladesh
3 PhD, Continuing Lecturer, School of Public Health and Health Systems, University of Waterloo, Ontario, N2L 3G1, Canada
4 PhD, Professor; Director, School of Public Health and Health Systems, University of Waterloo, Ontario, N2L 3G1, Canada
5 PhD, Associate Professor, School of Public Health and Health Systems, University of Waterloo, Ontario, N2L 3G1, Canada
While most performance judgements are value-relative, in health systems reform it is important to focus on intermediate performance measures like healthcare access, quality of care and efficiency in healthcare on health status of population, the satisfaction of patients, and the degree to which services are made equitable. However, to date these concepts are not well-defined, remain fairly ambiguous and, consequently, are also not well-measured. Therefore, such concepts do not provide sufficient information to inform changes to the health system that may improve population level outcomes related to structural factors. Our paper established an argument and from our viewpoints we provide a more conceptual clarification on how these three intermediate variables may shape assessments in health system performance, while drawing from the Canadian healthcare system performance gaps and placing them as evidence. We found an immediate need for patient-centred outcome measures in service and clinical quality instead of surrogate outcome measures, need for improved measures on the rate of service utilization such as in terms of service-orientation and patient satisfaction, and a need for more robust approach in measuring allocative efficiency in healthcare to be the key areas of strengthening performance assessments. These intermediate variables can play an important role in Canadian policy and also would have dominant roles in legislative agenda and outcome, which can be both responsive and influential.
Keywords: Canada; healthcare and policy; healthcare access; healthcare outcome indicators;
quality of care.
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Original Article in Public Health
Correlates of trail usage for physical activities in rural Appalachia, USA
Authors: Louisa A. SUMMERS1, Ram LAKHAN2, Peter H. HACKBERT3
1 Ph.D., Professor, Department of Health and Human Performance, Berea College, Berea, USA
2 Dr.PH, Assistant Professor, Department of Health and Human Performance, Berea College, Berea, USA
3 PhD, Professor, Department of General Studies, Berea College, Berea, USA
Introduction: Physical inactivity is associated with several negative consequences. Trails in USA have been seen as useful part of build environment in facilitating physical activities for all people. Understanding of the role of sociodemographic and environmental aspects with trail usage can guide interventional plan for trails in Berea, USA.
Purpose: This study aims to examine the correlates of trail usage for physical activities in rural Appalachia.
Methods: It is a cross-sectional research design. Data for three years, 2017, 2018 and 2019 was collected. Parametric test including t-test was applied to observe differences in physical activities minutes per week for gender and analysis for variance for ethnicity, education, income, and overall health. Independent median test was used in observing difference with year and simple regression for age.
Results: Physical activities on trails were found associated with education and overall health for winter (P < 0.05). Age was found associated with more physical activity per week during winter. Physical activities were not found different with gender, ethnicity, and income during summer and winter (P > 0.05) in the same year while comparing between three year from 2017 to 2019, physical activities per minute were found significantly different for both seasons (P < 0.05).
Conclusion: Findings suggest that winter and age are positively associated with physical activities in Berea trails. Education and overall health also have impact on this behavior. Findings of this study may be very useful in developing promotional activities for younger people and summer time.
Keywords: Appalachia; physical activity; public health; trails.
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Original Artcile in Healthcare Policy
The influence of Federal Regulations and community health indicators on community benefit spending by private nonprofit hospital in some States of the US: A retrospective longitudinal correlational study
Authors: Wael ELRAYES1, David PALM2, Fernando WILSON3, Hongmei WANG4, Jane MEZA5, Robin HIGH6, Valerie PACINO7
1 MBBCh, PhD, MS, FACHE, Assistant Professor, Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
2 PhD, Associate Professor, Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
3PhD, Associate Professor, Matheson Center for Health Care Studies, University of Utah, 295 Chipeta Way, Salt Lake City, USA.
4 PhD, Associate Professor, Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
5 PhD, Professor, Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
6 MBA, MA, Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
7 MPH, Department of Health Services Research and Administration, College of Public Health, University of Nebraska Medical Center, Nebraska, USA.
Introduction: In the United States, private nonprofit hospitals are exempt from federal, state, and local taxes in exchange for providing community benefits. Federal legislation in 2007 and 2010 established a standard reporting format that allowed researchers to examine community benefit spending patterns by private nonprofit hospitals, though this continues to be an understudied subject. The aim of this study was to assess whether the recent federal regulations and community health indicators influenced community benefit spending by private nonprofit hospitals in seven US states.
Methods: A retrospective longitudinal study was used to estimate the relationship between county-level community health indicators in one year and levels of spending on community health improvement initiatives in the consecutive year for 223 urban and rural counties in seven US states. A generalized linear mixed model with lagged community health indicators and included multiple covariates was used.
Results: Only two of the fourteen community health indicators included in the analytical model were significantly associated with spending on community health improvement initiatives. The ratio of population to primary care physicians was positively associated with spending (P < 0.0001), while adult smoking was negatively associated with spending on these activities (P = 0.003).
Discussion: Major variations exist in spending on community health improvement initiatives between counties in the same state and across different states. States with the highest health needs spent the least, while those with lowest health needs spent the most. The remarkable fluctuation in spending over the three years of the study could not be explained by a matching variability in the community health needs. Additional research should examine what factors influence the spending decisions by private nonprofit hospitals on community health improvement activities.
Keywords: Affordable Care Act; health expenditures; healthcare policy; patient protection; public health; USA.
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Original Article in Public Health
Using Facebook Ads to promote blood pressure checks among African Americans in the United States: A descriptive study
Authors: Katherine J POLAK1, Jessica LC SAPP2, Jennifer L SEDILLO3
1 MPH, Alumna, American Public University System, School of Health Sciences, Public Health Program, Charles Town, WV, United States.
2 DrPH, MPH, Associate Professor, American Public University System, School of Health Sciences, Public Health Program, Charles Town, WV, United States.
3 PhD, Associate Professor, American Public University System, School of Health Sciences, Public Health Program, Charles Town, WV, United States.
Introduction: Although hypertension is common in the United States, the African American community is disproportionately affected by high blood pressure. The purpose of this study was to evaluate the use of Facebook ads and posts for an online health campaign to promote blood pressure checks among African Americans in the United States.
Methods: The Measure Your Pressure (MYP) health campaign administered from May 2019 to August 2019 included Facebook advertisements, Facebook posts, and an online blog article. The Facebook advertisements included learn more ads, like page ads, and a web-based survey ad. These ads were delivered to two target audiences: 1) individuals at least 18 years old and located in the U.S., and 2) individuals at least 18 years old, located in the U.S., with special interest or behavior in African American culture, and multicultural affinity: African American (US). A web-based survey was used to ask Facebook users’ opinions about the MYP Survey ad. To compare the ads between the general and interest groups, t-tests were used to analyze the reach, impressions, results, and cost per result.
Results: There were 7 Facebook ads which reached 79,812 people. There were 121,683 impressions and 2,057 clicks. When comparing the ads between the general audience and interest groups, there was no significant difference for reach (P = 0.377), impressions (P = 0.427), results (P = 0.356), or cost per result (P = 0.484). There were 11 Facebook posts published which reached 2,171 users. Out of the 386 clicks received from the MYP Survey ad, there were only 11 that completed the web-based survey.
Conclusion: This study shows that it may be possible to indirectly reach larger portions of at-risk individuals with Facebook, but there is no significant difference between ad performance of target audiences using interest groups and general groups. Facebook does not make race demographics available to advertisers, so it is difficult to discern if the population of Facebook users reached were part of the African American community.
Keywords: Advertising as topic; African Americans; blood pressure; internet; social media.
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Original Article in Public Health
The effect of preconception housing and living conditions on primary infertility among couples in Gaza Strip, Palestine: A case-control study
Authors: Amal DHAIR1, Yehia ABED2
1 MPH, Deputy Head Health Center, Health Department, UNRWA, Gaza Strip, Palestine
2 Prof, Faculty of Public Health, Al-Quds University, Gaza Strip, Palestine
Introduction: The aim of this study was to address the relationship between housing and living conditions that couples might experience before and after marriage and primary infertility in Gaza Strip, Palestine.
Methods: A case-control study of 160 infertile couples matched residentially with 160 fertile ones was performed in Gaza Strip, Palestine. Infertile couples were chosen from list of patients registered in five fertility centers from 2016 to 2018. Data was collected through a self-administered questionnaire and analyzed through SPSS program version 22 by using descriptive analysis, cross-tabulation, and binary logistic regression.
Results: A positive association between using private vendors as a source of drinking water before marriage and primary infertility (P < 0.001) was demonstrated in females and males. Being a refugee (P = 0.036), living near borders (P = 0.011), living in extended families (P = 0.021), paying for rents (P = 0.029), and using septic porous sewer tanks (P = 0.020) provided a positive significant relationship after marriage. Odds of drinking water from rooming tanks before marriage was seven times risk in females (95% Confidential Interval [CI] 1.44 to 32.52, P = 0.020) mostly ovulatory and idiopathic causes, using septic sewer porous tanks held three times risk (95% CI 1.33 to 6.92, P = 0.008) mostly obstructive and ovulatory causes in males and females, respectively and living in extended families held twice risk (95% CI, 1.20-3.56, P = 0.009) mostly nonobstructive causes in males and ovulatory and endometrial causes in females.
Conclusion: Our findings provided evidence for the effect of inadequate living conditions on the fertility status of both women and men which opens the gate for further in-depth randomized trials.
Keywords: Gaza Strip; housing; living conditions; primary infertility.
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Original Article in Global Public Health
Survival status and determinants of under-five mortality in Sudan: Evidence from the Multiple Indicator Cluster Survey 2014
Authors: Huda Mohamed Mukhtar AHMED1, Hiba Abbas Omer ELKARIB2,
Mutaz Fikri Mohamed Osman DIGNA3
1 PhD, Associate Professor Department of Econometrics and Social Statistics, Faculty of Economic and Social Studies, University of Khartoum, Visiting Scholar, University of Toledo, Ohio, USA
2 MD, Faculty of Medicine, University of Khartoum, Sudan
3 MD, Faculty of Medicine, University of Khartoum, Sudan.
Introduction: Under-five mortality in Sudan declined in the last decade, but the reduction was well below the goal set by the Sudan Health Sector Strategic Plan developed for 2012-2016. This study investigated the risk factors of under-five mortality in Sudan.
Methods: Data by the Multiple Indicator Cluster Survey conducted in 2014 by the Central Bureau of Statistics (CBS) and the Federal Ministry of Health, Sudan, were collected. Non-parametric methods such as Kaplan–Meier survival function and log-rank were used to assess the effect of socioeconomic and demographic variables on under-five mortality. Cox hazard proportional and frailty models were carried out to examine predictors of under-five mortality.
Results: Our research showed that the risk of death among under-five children vary by states in Sudan. Moreover, Cox proportional and frailty models showed that type of birth (Hazard Ratio (HR) twin birth vs. single birth = 2.7, (95% Confidential Interval [CI] 1.8 to 4.1, P = 0.000), household wealth index (HR rich vs. poor = 0.42, (95% CI 0.20 to 0.87, P = 0.021), previous birth interval less than 2 years (HR Interval < 2 years vs first birth = 2.3, (95% CI 1.6 – 3.4, P = 0.000), and region of residence (HR Northern region vs. Khartoum) = 0.33, (95% CI 0.12 – 0.92, P = 0.035) were statistically significant determinant of under-five mortality in Sudan.
Discussion: Based on our findings, all intervention plans targeted to reduce child mortality in Sudan should consider specific determinants of risk. Furthermore, the Cox proportional model jointly with frailty models could be useful for further studies on determinants of under-five mortality.
Keywords: Cox hazard proportional; frailty model; global health, Sudan; under-five mortality.
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Original Article in Public Health
Testing Multi-Theory Model (MTM) in Predicting Physical Activity Behavior Among Upper Elementary School Children in Northern India
Authors: Poonam KHANNA1, Tejinder Pal SINGH2, Tarundeep SINGH3,
Rekha KAUSHIK4, Manoj SHARMA5
1 Associate Professor, Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
2 P.h.D., Division of Public Health, Department of Family and Preventive Medicine University of Utah, Salt Lake City, USA
3 M.D., Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
4 Associate Professor, Department of Food Science, MMICT&BM(HM), MM(DU),Mullana, Ambala,Haryana, India.
5 Professor, Environmental & Occupational Health, School of Public Health, University of Nevada, Las Vegas, USA
Introduction: Physical inactivity in children is a precursor to childhood obesity, which is a major public health concern due to its increasing prevalence over the years. Aim of this study was to predict physical activity (PA) behavior among upper elementary school children from Northern India through Multi -Theory Model (MTM).
Methods: The Multi-Theory Model (MTM) was used to predict PA behavior among 214 upper elementary school children in District Ambala, Haryana, India. A 38-item Physical Activity (PA) questionnaire was used to assess the constructs of MTM. Significant predictors of PA behaviour change (i.e., initiation and sustenance) were assessed by using stepwise multiple regression.
Results: Our findings showed that the mean for the intention to initiate engaging in 60 minutes of physical activity every day in the upcoming week was 2.14 units (SD = 1.23, possible range 0-4 units). The initiation model explained 12.5% variance in the intention to start PA behavior change. Sustenance model explained 5.3% of the variance in the intention for the sustenance of 60 minutes of PA every day. Examining the sustenance model, two constructs of emotional transformation (β = 0.169, P = 0.012) and practice for change (β = 0.177, P = 0.008) were significant predictors.
Discussion and Conclusion: In conclusion, MTM is a useful framework to design interventions to promote physical activity among upper elementary school children in India. More empirical work needs to be undertaken in India, using randomized controlled trials that operationalize expanded form of this model.
Keywords: Children; health behaviour; India; Multi Theory Model; physical activity.
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Original Article in Public Health Policy
Testing the Multi-Theory Model for initiation and sustenance of smoking cessation at Kathmandu Metropolitan City, Nepal: A cross-sectional study
Authors: Sumitra SHARMA1, Umesh R. ARYAL2, Manoj SHARMA3
1 PhD candidate, Faculty of Health, Queensland University of Technology, Brisbane, Australia
2 PhD, Senior Researcher, Public Health and Environmental Research Center, Kathmandu, Nepal
3 PhD, Professor, Environmental and Occupational Health School of Public Health, University of Nevada, Las Vegas, NV, USA
Introduction: Smoking and use of other tobacco products are a global public health threat. The objective of the study was to predict the initiation and sustenance of smoking cessation (SC) by applying the multi-theory model (MTM) of health behavior change.
Methods: In a cross-sectional study, the face-to-face interview was conducted by visiting different public places and coffee shops in Kathmandu Metropolitan, Nepal. A 30-item valid and reliable MTM-based survey instrument was administered to the participants who smoked cigarettes. Stepwise multiple regressions were conducted to explain SC behavior. The entire value of the Cronbach alpha coefficient (α) of the subscales and the scale was 0.91 which is excellent internal consistency.
Results: A total of 132 participants completed the study (93.6%). The median age of participants was 35.53 years and 75% of them were males. The median number of cigarettes smoked per day was 7. Behavioral confidence (β = 0.06, P = 0.02) and changes in the physical environment (β = 0.11, P = 0.01) were significant predictors for the initiation of SC. Next, emotional transformation (β = 0.25, P < 0.001) was a significant predictor for sustenance for SC.
Conclusion: MTM has the usefulness to assess both the initiation and sustenance behavior of SC. Potential solutions using MTM constructs should be developed in future interventions to change behavior of SC.
Keywords: Initiation; Multi-theory Model; smoking cessation; sustenance.
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Case Report in Community Health and Ophtalmology
Retained multiple contact lenses in a vulnerable dementia patient
Authors: Rohit SHARMA1, Zuhair SHARIF2
1 MBBS MS MRCSEd (Royal College of surgeons Edinburgh) FRCOphth (Royal College of Ophthalmologists, London), Assistant Professor (Hony) University of Nottingham. Consultant Ophthalmic Surgeon, University Hospitals Derby and Burton, United Kingdom
2 MBBS, University Hospitals Derby & Burton, London, United Kingdom
We report a case of an 85-year-old female nursing home resident with a background of dementia, who presented to the eye casualty clinic complaining of an 8-month history of a painful red eye and reduced vision. Treated ‘on and off’ by various doctors and healthcare professionals with antibiotic drops for eight months with no improvement. Eversion of the upper eye lid revealed an infected foreign body which turned out to be multiple contact lenses stacked on top of each other. Further history taking from her son suggested that the contact lenses were possibly left in for 3 years or longer when he noticed carers stopped replacing them at the care home. Patients with dementia are vulnerable adults and are at an increased risk of intentional or unintentional abuse and neglect. Careful care and attention should be given when taking a history and examining a patient with dementia. The case also highlights the importance of upper lid eversion as part of a thorough eye examination especially in patients who might have difficulty providing a history of a misplaced contact lens. This is the first such case to the best of our knowledge of retained contact lenses in a dementia patient. Patients with dementia should be advised against contact lens wear. Also the need for careful mandatory documentation in the clinical notes and communications to the general practitioner or care home about the insertion and removal of contact lenses with dates and name of professional perfoming this.
Keywords: Contact lenses; carers; dementia; eyelid; foreign bodies.
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Case Report in Obstetrics and Emergency Medicine
A case report of atrial enlargement and transitory electrocardiographic changes during labour
Authors: Antonio VILLA1, Donatella RODEGHER2, Valeria BARBERA2, Carlo TURRI3
1 M.D., Department of Internal Medicine, ASST Fatebenefratelli-Sacco, Milan, Italy.
2 M.D., Department of Gynaecology and Obstetrics, ASST Fatebenefratelli-Sacco, Milan, Italy
3 M.D., Department of Cardiology, ASST Fatebenefratelli-Sacco, Milan, Italy
During pregnancy some aspecific physiological electrocardiographic changes are described in literature. We report a case of a young pregnant aged 32 who showed, during labour at 39 weeks, electrocardiogram signs of biatrial enlargement resolved post-partum. The cardiovascular system is subject to a reversible series of structural and functional adaptations during pregnancy. Emergency physicians, gynecologists and obstetricians should be aware of these physiological electrocardiographic changes during pregnancy in order to obtain a correct and an appropriate diagnosis in emergency room.
Keywords: Atrial enlargement; electrocardiogram; pregnancy.
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