The role of public health services in implementing heat health action plans in Germany

Background

The rise in extreme heat periods is a major public health challenge of climate change and the World Health Organization therefore recommends the implementation of heat health action plans (HHAPs). In Germany, HHAPs are not implemented in a comprehensive manner nor nationwide. Public health authorities have been identified as key actors with regards to heat and health. This study aims at assessing the role of public health services in the implementation of HHAPs in Germany.

Methods

First, a review of the scientific and grey literature on the role of public health services in heat adaptation in Europe was conducted. Second, a policy document analysis of the legislation of Germany's federal states for public health services and their potential role in the implementation of HHAPs was carried out. Finally, semi-structured interviews with selected experts from multiple sectors at the local, federal and national level on their perception of the role of public health services in the implementation of HHAPs in Germany were undertaken.

Results

Preliminary findings show that the legal framework for public health services in the different federal states addresses environmental health and civil protection to varying extents, but that climate change-specific health risks are barely mentioned. The expert interviews revealed perceived barriers for the public health services to implement HHAPs, notably with regards to personnel (e.g. competencies, time), organizational structures (e.g. financial resources, administrative structures, legal mandates) and competing other tasks (e.g. COVID-19 response). Facilitators included motivated individuals, funding opportunities for cross-sectoral collaboration and political support.

Conclusions

The role of public health services in HHAP implementation in Germany varies widely between the different geographic settings and is influenced by several factors at the individual, organizational and political level.

Key messages

Cross-sectional associations of schoolchildren's fruit and vegetable consumption, and meal choices, with their mental well-being: a cross-sectional study

BACKGROUND

Poor mental well-being is a major issue for young people and is likely to have long-term negative consequences. The contribution of nutrition is underexplored. We, therefore, investigated the association between dietary choices and mental well-being among schoolchildren.

METHODS

Data from 7570 secondary school and 1253 primary school children in the Norfolk Children and Young People Health and Well-being Survey, open to all Norfolk schools during October 2017, were analysed. Multivariable linear regression was used to measure the association between nutritional factors and mental well-being assessed by the Warwick-Edinburgh Mental Well-being Scale for secondary school pupils, or the Stirling Children's Well-being Scale for primary school pupils. We adjusted all analyses for important covariates including demographic, health variables, living/home situation and adverse experience variables.

RESULTS

In secondary school analyses, a strong association between nutritional variables and well-being scores was apparent. Higher combined fruit and vegetable consumption was significantly associated with higher well-being: well-being scores were 3.73 (95% CI 2.94 to 4.53) units higher in those consuming five or more fruits and vegetables (p<0.001; n=1905) compared with none (n=739). The type of breakfast or lunch consumed was also associated with significant differences in well-being score. Compared with children consuming a conventional type of breakfast (n=5288), those not eating any breakfast had mean well-being scores 2.73 (95% CI 2.11 to 3.35) units lower (p<0.001; n=1129) and those consuming only an energy drink had well-being scores 3.14 (95% CI 1.20 to 5.09) units lower (p=0.002; n=91). Likewise, children not eating any lunch had well-being scores 2.95 (95% CI 2.22 to 3.68) units lower (p<0.001; 860) than those consuming a packed lunch (n=3744). In primary school analyses, the type of breakfast or lunch was associated with significant differences in well-being scores in a similar way to those seen in secondary school data, although no significant association with fruit and vegetable intake was evident.

CONCLUSION

These findings suggest that public health strategies to optimise the mental well-being of children should include promotion of good nutrition.

Health system description and assessment: a review of systematic tools for analyses

Introduction

Comparing health systems allows policymakers to benchmark against other countries, and improve processes and performance. A template to guide authors on how to present systems' features and performance in a meaningful manner is the basis for understanding and assessing a country's health system. This study presents an overview of approaches for standardized descriptions and analyses of health systems.

Methods

We conceptualized four criteria to define a “template” for our analysis. It must have (1) a framework, (2) a list of indicators, (3) instructions for authors on how to write an informative document, and (4) should cover health systems design and performance.

Based on these criteria we searched the academic and grey literature, and the web for templates.

Results

We found 29 tools that can be used as templates to describe and assess health systems. While ten tools are comprehensive, 19 tools focus on specific topics such as primary care, universal coverage, and quality of care. Another 21 tools focused on health system performance assessment but cannot serve as templates, as we define it. Most tools were developed by big organizations such as WHO, OECD and USAID.

Discussion

New models of governance and accountability are leading to increased interest in health system performance. A good template is key to write documents with an organized, coherent and meaningful description and assessment of a health system while allowing for cross-country comparison. We found ten tools that may serve as models of comprehensive templates, while most tools focus on specific topics or on performance assessment only.

Conclusions

This study provides a first-ever overview of templates that analyze health systems features and performance. Future studies could explore successful examples to consolidate a template that may potentially improve analysis and comparison of health systems in order to support policymaking.

Key messages

We found ten comprehensive tools for describing and assessing health systems. Our overview may help to improve existing templates by learning from experiences of different organizations.

Assessing the health impact of staying at home, social distancing and lockdown measures during the Covid-19 epidemic

Objectives

To systematically review the evidence published in systematic reviews on the health impact of staying at home, social distancing and lockdown measures.

Study design

We followed a systematic review approach, in line with PRISMA guidelines.

Methods

In October 2020, we searched the databases Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase, and Web of Science, using a pre-defined search strategy.

Results

The literature search yielded an initial list of 2172 records. After screening of titles and abstracts, followed by full-text screening, 51 articles were retained and included in the analysis. All of them referred to the first wave of the COVID-19 pandemic. The direct health impact that was covered in the greatest number (25) of systematic reviews related to mental health, followed by 13 systematic reviews on healthcare delivery(1-13)(1-13)(1-13), and 12 on infection control. The predominant areas of indirect health impacts covered by the included studies relate to the economic and social impacts (15 and 7 articles respectively. Only 3 articles mentioned the negative impact on education.

Conclusions

The focus of systematic reviews so far has been uneven, with mental health receiving the most attention. The impact of measures to contain the spread of the virus can be direct and indirect, having both intended and unintended consequences.

Barriers and facilitators to a health information exchange system for general practitioners

Background

Health information exchange (HIE) systems, that are computer-based tools used by healthcare providers for secure access to share patient's medical information electronically, seem to help reduce the use of specific resources and improve the quality of care. This highlights the importance of this issue in the Public Health sector. This research goal is to identify barriers and facilitators perceived by general practitioners (GPs) when using an HIE system in a Southern Switzerland area.

Methods

we performed a qualitative study using semi-structured interviews, interviewed 10 GPs, randomly selected among some 500 HIE system local users and analysed interview transcripts using thematic content analysis with an abductive approach (a mix of deductive and inductive approaches).

Results

findings showed the following key facilitators: a) perception of dealing with a secure system; b) possibility of delegating management to secretaries and healthcare assistants; c) technical support and training; d) high quality of the information exchange; e) positive impact on clinical practice; and f) regional context. However, major challenges persist, and GPs reported the following main barriers to using an HIE system: a) frequent lack of all patient information needed; b) no effective workflow improvements; c) lack of some technical features.

Conclusions

We propose four recommendations based on findings: 1. Future initiatives should focus on developing HIE systems giving GPs access to all possible patient medical information; 2. Crucial data privacy and security issues should never be overlooked; 3. Technical and workflow improvements should particularly consider the socio-technical nature of HIE systems; 4. Much attention needs to be paid to the importance of relationships between health care providers and between these and local health institutions when implementing HIE systems.

Key messages

This study filled a research gap as it is the first that tackles HIE system barriers and facilitators in Ticino. When information sharing for clinical practice focuses on improving the quality and costs of healthcare, GP's trust in HIE system security is crucial.

The organization and delivery of vaccination services in the European Union

Background

The design and operation of health systems can influence vaccine uptake, including through the way that vaccination programmes are governed, financed and delivered. This study examined the organization and delivery of vaccination programmes in the 28 EU member states and key barriers and facilitators to improved vaccination coverage.

Methods

We undertook an umbrella review of systematic reviews on health system related factors influencing vaccine uptake and commissioned country fiches that describe the organization and delivery of vaccination programmes in each of the EU member states, followed by a comparative analysis. The focus was on measles vaccination for children and seasonal influenza vaccination for adults.

Results

In all countries covered, there is a dedicated agency in charge of developing and overseeing implementation of national vaccination plans and programmes. In 9 EU member states (Bulgaria, Croatia, Czech Republic, France, Hungary, Italy, Poland, Slovakia and Slovenia), vaccinations against measles are mandatory for children, while in the remaining 19 countries they are voluntary, but recommended by the relevant authorities. However, the distinction between voluntary and mandatory immunization is not always clear-cut. In contrast, vaccinations for adults against influenza are voluntary in almost all EU member states, with the exception of Slovakia. Vaccinations are provided in most countries through primary care physicians or nurses.

Conclusions

There are many actions that health systems can take to improve vaccination coverage. These include a mix of incentives and sanctions, targeted measures and outreach services for vulnerable population groups, and an expansion of public financing for vaccinations against influenza, as well as the removal of administrative barriers.

How to enhance collaboration between primary care and public health?

Background

There are almost universal calls for improved collaboration between public health and primary care, but it is less clear how this can be achieved in practice. This presentation summarises key findings from an Observatory policy brief on how to enhance collaboration.

Methods

The policy brief iss based on a systematic review of the academic literature on collaboration between public health and primary care, searching the databases Medline and Embase for articles published since 2010. After title, abstract and full-text screening, 46 articles were retained and included in the review.

Results

Most academic articles on collaboration between primary care and public health are concerned with the United States and Canada. From the European countries, the Netherlands and the United Kingdom are most strongly represented. There is also a very uneven timeline in publication, with a spike in articles published in 2012, following an influential Institute of Medicine report. Research has identified organizational models of primary care that are conducive to collaboration with public health, as well as systemic, organizational and interpersonal factors that can facilitate or hinder collaboration. However, the relative importance of these factors remains poorly understood. Improved collaboration between public health and primary care promises to bring major benefits, but these are rarely documented in the literature so far. Furthermore, collaboration may also bring certain risks, such as competition over scarce resources.

Conclusions

The literature on collaboration between public health and primary care points to many illustrative examples, but also identifies relevant principles and factors that can hinder or facilitate collaboration. Policy interventions to improve collaboration will need to be mindful of potential risks and should aim to demonstrate benefits, which will help to increase buy-in from primary care and public health professionals and the public.

Panelists: Ilana Ventura

Federal Ministry of Labour, Social Affairs, Health and Consumer Protection, Austrian Government, Vienna, Austria

Contact: ilana.ventura@sozialministerium.at

Birger Forsberg

International Health, Karolinska Institutet, Stockholm, Sweden

Contact: Birger.Forsberg@sll.se

Rémi Pécault-Charby

Caisse Nationale de l’Assurance Maladie, Paris, France

Contact: remi.pecault-charby@assurance-maladie.fr

Utilization of health care services by migrants in Europe-a systematic literature review

INTRODUCTION

Our study reviewed the empirical evidence on the utilization of health care services by migrants in Europe, and on differences in health service utilization between migrants and non-migrants across European countries.

SOURCES OF DATA

A systematic literature review was performed, searching the databases Medline, Cinahl and Embase and covering the period from January 2009 to April 2016. The final number of articles included was 39.

AREAS OF AGREEMENT

Utilization of accident and emergency services and hospitalizations were higher among migrants compared with non-migrants in most countries for which evidence was available. In contrast, screening and outpatient visits for specialized care were generally used less often by migrants.

AREAS OF CONTROVERSY

Utilization of general practitioner services among migrants compared with non-migrants presents a diverging picture.

GROWING POINTS

Compared with previous systematic reviews, the results indicate a clearer picture of the differences in health service utilization between migrants and non-migrants in Europe.

AREAS TIMELY FOR DEVELOPING RESEARCH

A comprehensive comparison across European countries is impossible because the number of studies is still limited. Further research should also help to identify barriers regarding the utilization of health care services by migrants.

Ethnic differences in all-cause mortality rates in Kazakhstan

OBJECTIVES

This article explores mortality rates in Kazakhstan by ethnic group and some of the potential lifestyle factors that might help to explain the observed differences on a population level.

STUDY DESIGN

Repeated cross-sectional data analysis.

METHODS

We calculated age-standardized mortality rates from all causes by ethnic group, gender and age for 2009-2012. We analysed data on self-reported alcohol and tobacco consumption and other lifestyle factors from the nationally representative 5th National Behavior Study, conducted in 2012.

RESULTS

Age-standardized all-cause mortality rates are generally much higher among ethnic Russians than among ethnic Kazakhs, both among women and men and in rural as well as urban areas. These differences are most pronounced in the age group 20-59 years. Information on self-reported alcohol consumption and smoking by ethnic group, gender and age shows major differences between ethnic groups, with consistently higher rates of alcohol consumption and smoking among ethnic Russians, both in women and men and across all adult age groups.

CONCLUSIONS

Policies to improve the health of the population of Kazakhstan must take account of ethnic differences.

Regulatory barriers to equity in a health system in transition: a qualitative study in Bulgaria

BACKGROUND

Health reforms in Bulgaria have introduced major changes to the financing, delivery and regulation of health care. As in many other countries of Central and Eastern Europe, these included introducing general practice, establishing a health insurance system, reorganizing hospital services, and setting up new payment mechanisms for providers, including patient co-payments. Our study explored perceptions of regulatory barriers to equity in Bulgarian child health services.

METHODS

50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia.

RESULTS

The participants in our study reported a variety of regulatory barriers which undermined the principles of equity and, as far as the health insurance system is concerned, solidarity. These included non-participation in the compulsory health insurance system, informal payments, and charging user fees to exempted patients. The participants also reported seemingly unnecessary treatments in the growing private sector. These regulatory failures were associated with the fast pace of reforms, lack of consultation, inadequate public financing of the health system, a perceived "commercialization" of medicine, and weak enforcement of legislation. A recurrent theme from the interviews was the need for better information about patient rights and services covered by the health insurance system.

CONCLUSIONS

Regulatory barriers to equity and compliance in daily practice deserve more attention from policy-makers when embarking on health reforms. New financing sources and an increasing role of the private sector need to be accompanied by an appropriate and enforceable regulatory framework to control the behavior of health care providers and ensure equity in access to health services.

Investigation of a spatiotemporal cluster of verotoxin-producing Escherichia coli O157 infections in eastern England in 2007

An outbreak of verotoxin-producing Escherichia coli O157 (VTEC O157) infections linked to an open farm occurred in eastern England in April and May 2007. This paper describes the investigation and highlights the importance of multidisciplinary collaboration for successful control of such outbreaks. There was a temporal cluster of 12 confirmed symptomatic cases of VTEC O157 and one asymptomatic carrier, from five families. The investigation revealed that four of these cases formed part of an outbreak involving two families who visited an open farm. The phenotypic and genotypic characteristics of the isolates from the two families and the putative farm animal contacts were indistinguishable, indicating that the animals were the source of the primary infections. No epidemiological link could be established between the remaining three families affected and the open farm or people having visited the farm. Control measures included improved hand washing facilities on the farm, information for visitors and staff, restricted access and suspended petting and feeding of animals, and thorough cleaning and disinfection of affected areas.

Investigation of a spatiotemporal cluster of verotoxin-producing Escherichia coli O157 infections in eastern England in 2007

An outbreak of verotoxin-producing Escherichia coli O157 (VTEC O157) infections linked to an open farm occurred in eastern England in April and May 2007. This paper describes the investigation and highlights the importance of multidisciplinary collaboration for successful control of such outbreaks. There was a temporal cluster of 12 confirmed symptomatic cases of VTEC O157 and one asymptomatic carrier, from five families. The investigation revealed that four of these cases formed part of an outbreak involving two families who visited an open farm. The phenotypic and genotypic characteristics of the isolates from the two families and the putative farm animal contacts were indistinguishable, indicating that the animals were the source of the primary infections. No epidemiological link could be established between the remaining three families affected and the open farm or people having visited the farm. Control measures included improved hand washing facilities on the farm, information for visitors and staff, restricted access and suspended petting and feeding of animals, and thorough cleaning and disinfection of affected areas.

The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence

There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment. The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the "SIR" (susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses by governments. Like other emergencies and natural disasters, preparedness for financial crises should include consideration of consequences for communicable disease control.

Lessons from two decades of health reform in Central Asia

Since becoming independent at the break-up of the Soviet Union in 1991, the countries of Central Asia have made profound changes to their health systems, affecting organization and governance, financing and delivery of care. The changes took place in a context of adversity, with major political transition, economic recession, and, in the case of Tajikistan, civil war, and with varying degrees of success. In this paper we review these experiences in this rarely studied part of the world to identify what has worked. This includes effective governance, the co-ordination of donor activities, linkage of health care restructuring to new economic instruments, and the importance of pilot projects as precursors to national implementation, as well as gathering support among both health workers and the public.

The impact of economic crises on communicable disease transmission and control: a systematic review of the evidence

There is concern among public health professionals that the current economic downturn, initiated by the financial crisis that started in 2007, could precipitate the transmission of infectious diseases while also limiting capacity for control. Although studies have reviewed the potential effects of economic downturns on overall health, to our knowledge such an analysis has yet to be done focusing on infectious diseases. We performed a systematic literature review of studies examining changes in infectious disease burden subsequent to periods of crisis. The review identified 230 studies of which 37 met our inclusion criteria. Of these, 30 found evidence of worse infectious disease outcomes during recession, often resulting from higher rates of infectious contact under poorer living circumstances, worsened access to therapy, or poorer retention in treatment. The remaining studies found either reductions in infectious disease or no significant effect. Using the paradigm of the "SIR" (susceptible-infected-recovered) model of infectious disease transmission, we examined the implications of these findings for infectious disease transmission and control. Key susceptible groups include infants and the elderly. We identified certain high-risk groups, including migrants, homeless persons, and prison populations, as particularly vulnerable conduits of epidemics during situations of economic duress. We also observed that the long-term impacts of crises on infectious disease are not inevitable: considerable evidence suggests that the magnitude of effect depends critically on budgetary responses by governments. Like other emergencies and natural disasters, preparedness for financial crises should include consideration of consequences for communicable disease control.

Perceived barriers to the development of modern public health in Bulgaria: a qualitative study

OBJECTIVES

This qualitative investigation documents Bulgarian perspectives on public health following its accession to the European Union (EU) and explores perceived obstacles to the modernization of public health sciences to more effectively address the country's high rates of premature avoidable mortality.

METHODS

28 semi-structured interviews were conducted throughout Bulgaria in April 2007 with Bulgarian academics, clinicians, policymakers and students in Sofia, Varna and Pleven. Full transcripts were subjected to formal thematic analysis.

RESULTS

Respondents identified various barriers to the development and modernization to public health infrastructures in Bulgaria that were classified by four key interlinked themes: (1) institutional and political, (2) financial, (3) dearth of local epidemiological studies, and (4) insufficient public health capacity.

CONCLUSIONS

This study is the first to explore specific perspectives and beliefs regarding barriers to the development, modernization, and utilization of public health sciences in Bulgaria. Although the reorientation and strengthening of public health institutions are unlikely to proceed without resistance, optimism for improvement in this field exists now that Bulgaria has joined the EU.

Access to health care for Roma children in Central and Eastern Europe: findings from a qualitative study in Bulgaria

Background

Despite the attention the situation of the Roma in Central and Eastern Europe has received in the context of European Union enlargement, research on their access to health services is very limited, in particular with regard to child health services.

Methods

50 qualitative in-depth interviews with users, providers and policy-makers concerned with child health services in Bulgaria, conducted in two villages, one town of 70,000 inhabitants, and the capital Sofia.

Results

Our findings provide important empirical evidence on the range of barriers Roma children face when accessing health services. Among the most important barriers are poverty, administrative and geographical obstacles, low levels of parental education, and lack of ways to accommodate the cultural, linguistic and religious specifics of this population group.

Conclusion

Our research illustrates the complexity of the problems the Roma face. Access to health care cannot be discussed in isolation from other problems this population group experiences, such as poverty, restricted access to education, and social exclusion.