Inclusive and intersectoral: community health improvement planning opportunities to advance the social determinants of health and health equity

BACKGROUND

Community health improvement plans (CHIPs) are strategic planning tools that help local communities identify and address their public health needs. Many local health departments have developed a CHIP, yet there is a lack of research on the extent to which these plans address root causes of health disparities such as the social determinants of health. This study aims to inventory the social determinants of health included in 13 CHIPs and examine facilitators and challenges faced by local health departments and partners when trying to include the social determinants of health.

METHODS

We conducted a comparative plan evaluation by scoring 13 CHIPs on their inclusion of equity orientation, inclusive planning processes, and five social determinants of health: health care access and quality, the neighborhood and built environment, economic stability, social and community context, and education access and quality. To supplement the plan evaluation, we conducted 32 in-depth interviews with CHIP leaders and stakeholders to understand the factors contributing to the inclusion and exclusion of the social determinants of health in the planning process.

RESULTS

CHIPs received an average score of 49/100 for the inclusion of the social determinants of health. Most plans addressed health care access and quality and the neighborhood and built environment, but they often did not address economic stability, the social and community context, and education access and quality. Regarding their overall equity orientation, CHIPs received an average score of 35/100, reflecting a relative lack of attention to equity and inclusive planning processes in the plans. Interviews revealed that challenges engaging partners, making clear connections between CHIPs and social determinants, and a lack of capacity or public and partner support often led to the exclusion of the social determinants of health. Recommendations to improve planning processes include improving data infrastructure, providing resources for dedicated planning staff and community engagement incentives, and centering equity throughout the planning process.

CONCLUSIONS

Although local health departments can leverage CHIPs to improve population health and address health disparities, they face a range of challenges to including the social determinants of health in CHIPs. Additional resourcing and improved data are needed to facilitate broader inclusion of these determinants, and more work is needed to elevate equity throughout these planning processes.

Simultaneous Transport of Synthetic Colloids and a Nonsorbing Solute Through Single Saturated Natural Fractures

Tracer transport experiments involving colloids that showed little tendency to attach to rock surfaces and a nonsorbing solute (iodide) were conducted in three different well-characterized natural fractures in tuff. The objective was to investigate the potential for using nonattaching colloids in tracer experiments to (1) obtain a measure of the dispersion in a fractured system in the absence of diffusion into the matrix or into stagnant zones along the fracture walls, and (2) provide insights into predicting colloid transport in fractures under conditions of minimal deposition.

In the experiments, the colloids always arrived earlier in the effluent than the iodide, which we believe is evidence of (1) hydrodynamic chromatography and/or (2) the fact that the colloids experience a smaller effective volume in the fracture because they diffuse too slowly to enter low-velocity regions (dead zones) along the rough fracture walls. The iodide also approached the inlet concentration in the effluent more slowly than the colloids, with the concentration at a given elution volume being greater at higher flow rates. By contrast, the rate of approach of the colloid concentration to the inlet concentration did not vary with flow rate. We attribute this behavior to matrix diffusion of the iodide, with the colloids being too large/nondiffusive to experience this phenomenon. Dispersion of all tracers was greatest in the fracture of widest average aperture and least in the fracture of narrowest aperture, which is consistent with Taylor dispersion theory.

The tracer experiments were modeled/interpreted using a three-step approach that involved (1) estimating the aperture distribution in each fracture using surface profiling techniques, (2) predicting the flow field in the fractures using a localized parallel-plate approximation, and (3) predicting tracer transport in the fractures using particle-tracking techniques. Although considered preliminary at this time, the model results were in qualitative agreement with the experiments.

Management of Vascular Injuries in a Forward Hospital

BACKGROUND

Management of vascular injuries poses a challenging problem under warlike conditions. Several authorities recommend limb revascularisation only within first 6-8 hours, as the outcome after delayed revascularisation is poor.

METHODS

A retrospective analysis of 61 consecutive patients with vascular injury in a forward hospital over a 25- month period was carried out.

RESULTS

Vascular injuries constituted 3.1% of all injuries. The mean injury to treatment delay (lag time) was 11 hours, and 10 patients received treatment after 12 hours. The overall amputation rate was 15%, but only 6.5% for those revascularised within 12 hours and 44% for those undergoing surgery after 12 hours (Chi-square 4.59, p < 0.05). Presence of associated fractures was associated with an adverse outcome (Chi-square 4.24, p < 0.05), as was ligation in comparison to revascularisation (Chi-square 7.86, p < 0.005). Popliteal injuries were associated with a high amputation rate.

CONCLUSIONS

Failure to revascularise (ligation of artery), presence of associated fracture, and restoration of circulation beyond 12 hours are associated with a high amputation rate.

Laparoscopic orchiopexy: is closure of the internal ring necessary?

BACKGROUND

Narrowing of the internal ring around the pulled through spermatic cord in cases of laparoscopic orchiopexy is the norm.

AIM

To carry out a prospective study to see if closure of the internal ring is really necessary, hypothesis being that mobilization of the impalpable testis leaves a raw surface, which, coupled with the presence of the spermatic cord results in effective closure of the internal ring.

METHODS AND MATERIALS

51 patients with 65 impalpable testes underwent laparoscopic orchiopexy between July 1998 and June 2003. An impalpable testis was present in 21 cases on the left, 16 cases on the right and bilateral in 14 cases. Following complete mobilization required for orchiopexy, all testes with adequate length of spermatic cord were pulled down into the scrotum through the inguinal canal. No suture was applied to narrow the internal ring around the pulled through spermatic cord. Five testes were pulled down by an opening in the medial end of the inguinal canal due to inadequate length of the spermatic cord. In these cases the internal ring was closed by a suture.

RESULTS

Follow up of all cases ranged between 1.5 years to 6.5 years. Not a single case has reported with recurrence of a hernia.

CONCLUSION

The results suggest that narrowing of the internal ring around the pulled through spermatic cord may not be necessary.

Treatment of Casualties in a Forward Hospital of Indian Army : Nine year Experience

BACKGROUND

To analyze the outcome of the management of casualties in a level II trauma centre of a forward hospital of Armed Forces over a nine year period. Retrospective analysis of all casualties received in a single forward hospital of Indian Army was carried out.

METHOD

During 9 years (1990-1998), a total of 5737 casualties were received in a single level II zonal hospital of the Army in a forward area. Majority of the injuries were caused by bullets, or by fragments of improvised explosive devices. A policy of aggressive resuscitation and early primary repair of injuries was followed. General surgeons routinely performed craniotomies, thoracotomies, laparotomies, stabilization of fractures by fixators and repair of vascular injuries.

RESULT

38% of patients had injuries to several body parts (polytrauma), resulting in a total of 8578 injuries. Region-wise distribution of injuries was as follows : 14.2% head and neck injuries, 13.3% chest wounds, 13.5% abdominal injury and 59% extremity wounds. The overall mortality rate was 3.6%. The complication rate was about 7% with infection as the major complication. The results of primary repair of colonic injuries were similar to those of staged repairs. The results after primary closure of war wounds were better than those treated with delayed primary closure in selected cases.

CONCLUSION

Prompt evacuation, speedy resuscitation and early definitive repair of war injuries results in low mortality and morbidity. A motivated and dedicated team and adequate availability of blood and ancillary services adds to the excellent outcome. The policy of primary repair of colonic and selected soft tissue injuries appears justified in selected cases.

Maternal mortality in India. Maternal mortality is falling in India but at slower rate than in Britain

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South Africa's health. Restructuring South Africa's health care: dilemmas for planners

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New South Africa's doctors: a state of flux

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New South Africa's mental health

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Traditional healers in South Africa: a parallel health care system

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Impressions of health in the new South Africa: a period of convalescence

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Induction of delayed mutations by benzene and ethylene dibromide in Drosophila

Two carcinogens, ethylene dibromide and benzene, were used to induce delayed (germinal mosaic) sex-linked recessive lethal mutations in spermatozoa and spermatids of adult Drosophila males. Significant numbers of delayed mutations (in F3) were scored in absence of conventional (in F2) mutations. A large proportion of nonlethal F2 cultures carried delayed mutations, so much so that, in some cultures, all F2 females were carriers of mutations. The mechanism through which single strand damage to treated X chromosomes can result in such delayed lethals is discussed. These observations indicate that the delayed mutation test should be used for testing the mutagenicity of environmental compounds, especially carcinogens, which tested negative in the conventional sex-linked recessive lethal mutation test. The data will support the relationship between mutagenesis and carcinogenesis and, also will further enhance the sensitivity of the Drosophila mutation assay.

Mutagenicity testing of nine herbicides and pesticides currently used in agriculture

Nine herbicides and pesticides were tested for their mutagenicity using the Drosophila sex-linked recessive lethal mutation assay. These are Ambush, Treflan, Blazer, Roundup, 2,4-D Amine, Crossbow, Galecron, Pramitol, and Pondmaster. All of these are in wide use at present. Unlike adult feeding and injection assays, the larvae were allowed to grow in medium with the test chemical, thereby providing long and chronic exposure to the sensitive and dividing diploid cells, i.e., mitotically active spermatogonia and sensitive spermatocytes. All chemicals induced significant numbers of mutations in at least one of the cell types tested. Some of these compounds were found to be negative in earlier studies. An explanation for the difference in results is provided. It is probable that different germ cell stages and treatment regimens are suitable for different types of chemicals. larval treatment may still be valuable and can complement adult treatment in environmental mutagen testing.

Health information for the developing world

Doctors and other health professionals in developing countries are missing out on relevant information about health. A lot of the information they need is available in the developed countries, and those who have it are happy to share it with them. But transporting information, like food or medicines, from one part of the world to another is not an easy task nor is it the complete answer to the information drought. It is one thing to ferry books and journals from Europe to Africa and another to make relevant information available to the right person at the right time at an affordable cost.

Application of ESEM to environmental colloids

Environmental colloids are toxic or radioactive particles suspended in ground or surface water. These hazardous particles can facilitate and accelerate the transport of toxicants and enhance the threat to humans by exposure to pathogenic substances. The chemical and physical properties of hazardous colloids have not been well characterized nor are there standard colloid remediation technologies to prevent their deleterious effects. Colloid characterization requires measurement of their size distribution, zeta potential, chemical composition, adsorption capacity, and morphology. The environmental scanning electron microscope (ESEM) by ElectroScan, Inc., analyzes particle sizes, composition, and morphology. It is also used in this study to identify the attachment of colloids onto packing or rock surfaces in our development of a colloid remediation process. The ESEM has confirmed the composition of groundwater colloids in our studies to be generally the same material as the surrounding rock. The morphology studies have generally shown that colloids are simply small pieces of the rock surface that has exfoliated into the surrounding water. However, in general, the source and chemical composition of groundwater colloids is site dependent. We have found that an ESEM works best as a valuable analysis tool within a suite of colloid characterization instruments.