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1.  Eurocan plus report: feasibility study for coordination of national cancer research activities 
Summary
The EUROCAN+PLUS Project, called for by the European Parliament, was launched in October 2005 as a feasibility study for coordination of national cancer research activities in Europe. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people, the largest Europe–wide consultation ever conducted in the field of cancer research.
Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
It is essential to include the patients’ voice in the establishment of priority areas in cancer research at the present time. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community is evident. A top priority should be the development of translational research (in its widest form), leading to the development of effective and innovative cancer treatments and preventive strategies. Translational research ranges from bench–to–bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
The EUROCAN+PLUS Project recommends the creation of a small, permanent and independent European Cancer Initiative (ECI). This should be a model structure and was widely supported at both General Assemblies of the project. The ECI should assume responsibility for stimulating innovative cancer research and facilitating processes, becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ organizations, European institutions, Member States, industry and small and medium enterprises (SMEs), putting into practice solutions aimed at alleviating barriers to collaboration and coordination of cancer research activities in the European Union, and dealing with legal and regulatory issues. The development of an effective ECI will require time, but this entity should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co–operation between comprehensive cancer centres and basic research laboratories throughout Europe and (3) networking between funding bodies at the European level.
The European Parliament and its instruments have had a major influence in cancer control in Europe, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
Executive Summary
Cancer is one of the biggest public health crises facing Europe in the 21st century—one for which Europe is currently not prepared nor preparing itself. Cancer is a major cause of death in Europe with two million casualties and three million new cases diagnosed annually, and the situation is set to worsen as the population ages.
These facts led the European Parliament, through the Research Directorate-General of the European Commission, to call for initiatives for better coordination of cancer research efforts in the European Union. The EUROCAN+PLUS Project was launched in October 2005 as a feasibility study for coordination of national cancer research activities. Over the course of the next two years, the Project process organized over 60 large meetings and countless smaller meetings that gathered in total over a thousand people. In this respect, the Project became the largest Europe-wide consultation ever conducted in the field of cancer research, implicating researchers, cancer centres and hospitals, administrators, healthcare professionals, funding agencies, industry, patients’ organizations and patients.
The Project first identified barriers impeding research and collaboration in research in Europe. Despite a strong tradition in biomedical science in Europe, fragmentation and lack of sustainability remain the formidable challenges for implementing innovative cancer research and cancer care improvement. There is an enormous duplication of research effort in the Member States, which wastes time, wastes money and severely limits the total intellectual concentration on the wide cancer problem. There is a striking lack of communication between some of the biggest actors on the European scene, and there are palpable tensions between funders and those researchers seeking funds.
In addition, there is a shortage of leadership, a multiplicity of institutions each focusing on its own agenda, sub–optimal contact with industry, inadequate training, non–existent career paths, low personnel mobility in research especially among clinicians and inefficient funding—all conspiring against efficient collaboration in cancer care and research. European cancer research today does not have a functional translational research continuum, that is the process that exploits biomedical research innovations and converts them into prevention methods, diagnostic tools and therapies. Moreover, epidemiological research is not integrated with other types of cancer research, and the implementation of the European Directives on Clinical Trials 1 and on Personal Data Protection 2 has further slowed the innovation process in Europe. Furthermore, large inequalities in health and research exist between the EU–15 and the New Member States.
The picture is not entirely bleak, however, as the European cancer research scene presents several strengths, such as excellent basic research and clinical research and innovative etiological research that should be better exploited.
When considering recommendations, several priority dimensions had to be retained. It is essential that proposals include actions and recommendations that can benefit all Member States of the European Union and not just States with the elite centres. It is also essential to have a broader patient orientation to help provide the knowledge to establish cancer control possibilities when we exhaust what can be achieved by the implementation of current knowledge. It is vital that the actions proposed can contribute to the Lisbon Strategy to make Europe more innovative and competitive in (cancer) research.
The Project participants identified six areas for which consensus solutions should be implemented in order to obtain better coordination of cancer research activities. The required solutions are as follows. The proactive management of innovation, detection, facilitation of collaborations and maintenance of healthy competition within the European cancer research community.The establishment of an exchange portal of information for health professionals, patients and policy makers.The provision of guidance for translational and clinical research including the establishment of a translational research platform involving comprehensive cancer centres and cancer research centres.The coordination of calls and financial management of cancer research projects.The construction of a ‘one–stop shop’ as a contact interface between the industry, small and medium enterprises, scientists and other stakeholders.The support of greater involvement of healthcare professionals in translational research and multidisciplinary training.
In the course of the EUROCAN+PLUS consultative process, several key collaborative projects emerged between the various groups and institutes engaged in the consultation. There was a collaboration network established with Europe’s leading Comprehensive Cancer Centres; funding was awarded for a closer collaboration of Owners of Cancer Registries in Europe (EUROCOURSE); there was funding received from FP7 for an extensive network of leading Biological Resource Centres in Europe (BBMRI); a Working Group identified the special needs of Central, Eastern and South–eastern Europe and proposed a remedy (‘Warsaw Declaration’), and the concept of developing a one–stop shop for dealing with academia and industry including the Innovative Medicines Initiative (IMI) was discussed in detail.
Several other dimensions currently lacking were identified. There is an absolute necessity to include the patients’ voice in the establishment of priority areas in cancer research at the present time. It was a salutary lesson when it was recognized that all that is known about the quality of life of the cancer patient comes from the experience of a tiny proportion of cancer patients included in a few clinical trials. The necessity to have dialogue between funders and scientists to establish the best mechanisms to meet the needs of the entire community was evident. A top priority should be the development of translational research (in its widest form) and the development of effective and innovative cancer treatments and preventative strategies in the European Union. Translational research ranges from bench-to-bedside innovative cancer therapies and extends to include bringing about changes in population behaviours when a risk factor is established.
Having taken note of the barriers and the solutions and having examined relevant examples of existing European organizations in the field, it was agreed during the General Assembly of 19 November 2007 that the EUROCAN+PLUS Project had to recommend the creation of a small, permanent and neutral ECI. This should be a model structure and was widely supported at both General Assemblies of the project. The proposal is based on the successful model of the European Molecular Biology Organisation (EMBO), and its principal aims include providing a forum where researchers from all backgrounds and from all countries can meet with members of other specialities including patients, nurses, clinicians, funders and scientific administrators to develop priority programmes to make Europe more competitive in research and more focused on the cancer patient.
The ECI should assume responsibility for: stimulating innovative cancer research and facilitating processes;becoming the common voice of the cancer research community and serving as an interface between the cancer research community and European citizens, patients’ and organizations;European institutions, Member States, industry and small and medium enterprises;putting into practice the aforementioned solutions aimed at alleviating barriers and coordinating cancer research activities in the EU;dealing with legal and regulatory issues.
Solutions implemented through the ECI will lead to better coordination and collaboration throughout Europe, more efficient use of resources, an increase in Europe’s attractiveness to the biomedical industry and better quality of cancer research and education of health professionals.
The Project considered that European legal instruments currently available were inadequate for addressing many aspects of the barriers identified and for the implementation of effective, lasting solutions. Therefore, the legal environment that could shelter an idea like the ECI remains to be defined but should be done so as a priority. In this context, the initiative of the European Commission for a new legal entity for research infrastructure might be a step in this direction. The development of an effective ECI will require time, but this should be established immediately. As an initial step, coordination efforts should be directed towards the creation of a platform on translational research that could encompass: (1) coordination between basic, clinical and epidemiological research; (2) formal agreements of co-operation between comprehensive cancer centres and basic research laboratories throughout Europe; (3) networking between funding bodies at the European level. Another topic deserving immediate attention is the creation of a European database on cancer research projects and cancer research facilities.
Despite enormous progress in cancer control in Europe during the past two decades, there was an increase of 300,000 in the number of new cases of cancer diagnosed between 2004 and 2006. The European Parliament and its instruments have had a major influence in cancer control, notably in tobacco control and in the implementation of effective population–based screening. To make further progress there is a need for novelty and innovation in cancer research and prevention in Europe, and having a platform such as the ECI, where those involved in all aspects of cancer research can meet, discuss and interact, is a decisive development for Europe.
doi:10.3332/ecancer.2011.84
PMCID: PMC3234055  PMID: 22274749
2.  The Effectiveness of Mobile-Health Technologies to Improve Health Care Service Delivery Processes: A Systematic Review and Meta-Analysis 
PLoS Medicine  2013;10(1):e1001363.
Caroline Free and colleagues systematically review controlled trials of mobile technology interventions to improve health care delivery processes and show that current interventions give only modest benefits and that high-quality trials measuring clinical outcomes are needed.
Background
Mobile health interventions could have beneficial effects on health care delivery processes. We aimed to conduct a systematic review of controlled trials of mobile technology interventions to improve health care delivery processes.
Methods and Findings
We searched for all controlled trials of mobile technology based health interventions using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors independently extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and we used random effects meta-analysis to give pooled estimates.
We identified 42 trials. None of the trials had low risk of bias. Seven trials of health care provider support reported 25 outcomes regarding appropriate disease management, of which 11 showed statistically significant benefits. One trial reported a statistically significant improvement in nurse/surgeon communication using mobile phones. Two trials reported statistically significant reductions in correct diagnoses using mobile technology photos compared to gold standard. The pooled effect on appointment attendance using text message (short message service or SMS) reminders versus no reminder was increased, with a relative risk (RR) of 1.06 (95% CI 1.05–1.07, I2 = 6%). The pooled effects on the number of cancelled appointments was not significantly increased RR 1.08 (95% CI 0.89–1.30). There was no difference in attendance using SMS reminders versus other reminders (RR 0.98, 95% CI 0.94–1.02, respectively). To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
The results for health care provider support interventions on diagnosis and management outcomes are generally consistent with modest benefits. Trials using mobile technology-based photos reported reductions in correct diagnoses when compared to the gold standard. SMS appointment reminders have modest benefits and may be appropriate for implementation. High quality trials measuring clinical outcomes are needed.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Over the past few decades, computing and communication technologies have changed dramatically. Bulky, slow computers have been replaced by portable devices that can complete increasingly complex tasks in less and less time. Similarly, landlines have been replaced by mobile phones and other mobile communication technologies that can connect people anytime and anywhere, and that can transmit text messages (short message service; SMS), photographs, and data at the touch of a button. These advances have led to the development of mobile-health (mHealth)—the use of mobile computing and communication technologies in health care and public health. mHealth has many applications. It can be used to facilitate data collection and to encourage health-care consumers to adopt healthy lifestyles or to self-manage chronic conditions. It can also be used to improve health-care service delivery processes by targeting health-care providers or communication between these providers and their patients. So, for example, mobile technologies can be used to provide clinical management support in settings where there are no specialist clinicians, and they can be used to send patients test results and timely reminders of appointments.
Why Was This Study Done?
Many experts believe that mHealth interventions could greatly improve health-care delivery processes, particularly in resource-poor settings. The results of several controlled trials (studies that compare the outcomes of people who do or do not receive an intervention) of mHealth interventions designed to improve health-care delivery processes have been published. However, these data have not been comprehensively reviewed, and the effectiveness of this type of mHealth intervention has not been quantified. Here, the researchers rectify this situation by undertaking a systematic review and meta-analysis of controlled trials of mobile technology-based interventions designed to improve health-care service delivery processes. A systematic review is a study that uses predefined criteria to identify all the research on a given topic; a meta-analysis is a statistical approach that is used to pool the results of several independent studies.
What Did the Researchers Do and Find?
The researchers identified 42 controlled trials that investigated mobile technology-based interventions designed to improve health-care service delivery processes. None of the trials were of high quality—many had methodological problems likely to affect the accuracy of their findings—and nearly all were undertaken in high-income countries. Thirty-two of the trials tested interventions directed at health-care providers. Of these trials, seven investigated interventions providing health-care provider education, 18 investigated interventions supporting clinical diagnosis and treatment, and seven investigated interventions to facilitate communication between health-care providers. Several of the trials reported that the tested intervention led to statistically significant improvements (improvements unlikely to have happened by chance) in outcomes related to disease management. However, two trials that used mobile phones to transmit photos to off-site clinicians for diagnosis reported significant reductions in correct diagnoses compared to diagnosis by an on-site specialist. Ten of the 42 trials investigated interventions targeting communication between health-care providers and patients. Eight of these trials investigated SMS-based appointment reminders. Meta-analyses of the results of these trials indicated that using SMS appointment reminders significantly but modestly increased patient attendance compared to no reminders. However, SMS reminders were no more effective than postal or phone call reminders, and texting reminders to patients who persistently missed appointments did not significantly change the number of cancelled appointments.
What Do These Findings Mean?
These findings indicate that some mHealth interventions designed to improve health-care service delivery processes are modestly effective, but they also highlight the need for more trials of these interventions. Specifically, these findings show that although some interventions designed to provide support for health-care providers modestly improved some aspects of clinical diagnosis and management, other interventions had deleterious effects—most notably, the use of mobile technology–based photos for diagnosis. In terms of mHealth interventions targeting communication between health-care providers and patients, the finding that SMS appointment reminders have modest benefits suggests that implementation of this intervention should be considered, at least in high-income settings. However, the researchers stress that more trials are needed to robustly establish the ability of mobile technology-based interventions to improve health-care delivery processes. These trials need to be of high quality, they should be undertaken in resource-limited settings as well as in high-income countries, and, ideally, they should consider interventions that combine mHealth and conventional approaches.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001363.
A related PLOS Medicine Research Article by Free et al. investigates the effectiveness of mHealth technology-based health behavior change and disease management interventions for health-care consumers
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
The US National Institutes of Health Fogarty International Center provides links to resources and information about mHealth
doi:10.1371/journal.pmed.1001363
PMCID: PMC3566926  PMID: 23458994
3.  Appraisal of the national response to the caries epidemic in children in Nigeria 
BMC Oral Health  2014;14:76.
Background
This article reviews the caries profile for children in Nigeria and proposes an appropriate framework for addressing the silent caries epidemic.
Discussion
We reviewed the caries prevalence among children in Nigeria, assessed the existing responses to the caries epidemic including the national oral healthcare delivery situation in the country and discussed the current caries management in children. We then proposed a response framework for Nigeria. We argue that successful interventions will require the adoption of a socio-ecological model. This would ensure that the micro-, meso-, exo- and macrosystems required to support the behavioural, structural and biological interventions for promoting caries prevention are addressed. National oral health surveys are required to help understand the epidemiology, social determinants of and factors that undermine the ability of children to access oral health care. A global caries prevention agenda for children would help get the government’s support for a national response agenda. Currently, there is no global call for action on the caries epidemic in children. This lack of an agenda needs to be urgently addressed.
Summary
A combination of approaches for the prevention of caries in children in Nigeria is needed. A national survey is needed to generate the needed evidence for the planning of community relevant responses to the national caries epidemic in children. The design of a global health agenda for children is an important first step that can facilitate the development of a national oral health programme for children in Nigeria.
doi:10.1186/1472-6831-14-76
PMCID: PMC4091672  PMID: 24957148
Caries; Epidemic; Global response; Nigeria; Children
4.  The Effectiveness of Mobile-Health Technology-Based Health Behaviour Change or Disease Management Interventions for Health Care Consumers: A Systematic Review 
PLoS Medicine  2013;10(1):e1001362.
Caroline Free and colleagues systematically review a fast-moving field, that of the effectiveness of mobile technology interventions delivered to healthcare consumers, and conclude that high-quality, adequately powered trials of optimized interventions are required to evaluate effects on objective outcomes.
Background
Mobile technologies could be a powerful media for providing individual level support to health care consumers. We conducted a systematic review to assess the effectiveness of mobile technology interventions delivered to health care consumers.
Methods and Findings
We searched for all controlled trials of mobile technology-based health interventions delivered to health care consumers using MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, Cochrane Library, UK NHS HTA (Jan 1990–Sept 2010). Two authors extracted data on allocation concealment, allocation sequence, blinding, completeness of follow-up, and measures of effect. We calculated effect estimates and used random effects meta-analysis. We identified 75 trials. Fifty-nine trials investigated the use of mobile technologies to improve disease management and 26 trials investigated their use to change health behaviours. Nearly all trials were conducted in high-income countries. Four trials had a low risk of bias. Two trials of disease management had low risk of bias; in one, antiretroviral (ART) adherence, use of text messages reduced high viral load (>400 copies), with a relative risk (RR) of 0.85 (95% CI 0.72–0.99), but no statistically significant benefit on mortality (RR 0.79 [95% CI 0.47–1.32]). In a second, a PDA based intervention increased scores for perceived self care agency in lung transplant patients. Two trials of health behaviour management had low risk of bias. The pooled effect of text messaging smoking cessation support on biochemically verified smoking cessation was (RR 2.16 [95% CI 1.77–2.62]). Interventions for other conditions showed suggestive benefits in some cases, but the results were not consistent. No evidence of publication bias was demonstrated on visual or statistical examination of the funnel plots for either disease management or health behaviours. To address the limitation of the older search, we also reviewed more recent literature.
Conclusions
Text messaging interventions increased adherence to ART and smoking cessation and should be considered for inclusion in services. Although there is suggestive evidence of benefit in some other areas, high quality adequately powered trials of optimised interventions are required to evaluate effects on objective outcomes.
Please see later in the article for the Editors' Summary
Editors’ Summary
Background
Every year, millions of people die from cardiovascular diseases (diseases of the heart and circulation), chronic obstructive pulmonary disease (a long-term lung disease), lung cancer, HIV infection, and diabetes. These diseases are increasingly important causes of mortality (death) in low- and middle-income countries and are responsible for nearly 40% of deaths in high-income countries. For all these diseases, individuals can adopt healthy behaviors that help prevent disease onset. For example, people can lower their risk of diabetes and cardiovascular disease by maintaining a healthy body weight, and, if they are smokers, they can reduce their risk of lung cancer and cardiovascular disease by giving up cigarettes. In addition, optimal treatment of existing diseases can reduce mortality and morbidity (illness). Thus, in people who are infected with HIV, antiretroviral therapy delays the progression of HIV infection and the onset of AIDS, and in people who have diabetes, good blood sugar control can prevent retinopathy (a type of blindness) and other serious complications of diabetes.
Why Was This Study Done?
Health-care providers need effective ways to encourage "health-care consumers" to make healthy lifestyle choices and to self-manage chronic diseases. The amount of information, encouragement and support that can be conveyed to individuals during face-to-face consultations or through traditional media such as leaflets is limited, but mobile technologies such as mobile phones and portable computers have the potential to transform the delivery of health messages. These increasingly popular technologies—more than two-thirds of the world's population now owns a mobile phone—can be used to deliver health messages to people anywhere and at the most relevant times. For example, smokers trying to quit smoking can be sent regular text messages to sustain their motivation, but can also use text messaging to request extra support when it is needed. But is "mHealth," the provision of health-related services using mobile communication technology, an effective way to deliver health messages to health-care consumers? In this systematic review (a study that uses predefined criteria to identify all the research on a given topic), the researchers assess the effectiveness of mobile technology-based health behavior change interventions and disease management interventions delivered to health-care consumers.
What Did the Researchers Do and Find?
The researchers identified 75 controlled trials (studies that compare the outcomes of people who do and do not receive an intervention) of mobile technology-based health interventions delivered to health-care consumers that met their predefined criteria. Twenty-six trials investigated the use of mobile technologies to change health behaviors, 59 investigated their use in disease management, most were of low quality, and nearly all were undertaken in high-income countries. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lower-quality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases.
What Do These Findings Mean?
These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using mobile technologies. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a high-income setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other mobile technology–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further trials are undertaken to establish their clinical benefits.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001362.
A related PLOS Medicine Research Article by Free et al. investigates the ability of mHealth technologies to improve health-care service delivery processes
Wikipedia has a page on mHealth (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
mHealth: New horizons for health through mobile technologies is a global survey of mHealth prepared by the World Health Organization’s Global Observatory for eHealth (eHealth is health-care practice supported by electronic processes and communication)
The mHealth in Low-Resource Settings website, which is maintained by the Netherlands Royal Tropical Institute, provides information on the current use, potential, and limitations of mHealth in low-resource settings
More information about Txt2stop is available, the UK National Health Service Choices website provides an analysis of the Txt2stop trial and what its results mean, and the UK National Health Service Smokefree website provides a link to a Quit App for the iPhone
The US Centers for Disease Control and Prevention has launched a text messaging service that delivers regular health tips and alerts to mobile phones
doi:10.1371/journal.pmed.1001362
PMCID: PMC3548655  PMID: 23349621
5.  Inequalities of caries experience in Nevada youth expressed by DMFT index vs. Significant Caries Index (SiC) over time 
BMC Oral Health  2011;11:12.
Background
With the increasingly polarized distribution of dental caries among children and adolescents, the usual DMFT measure has become a less meaningful population descriptor. To re-focus on identifying the high caries prevalence group the Significant Caries Index (SiC) was created. The aims of this study were to analyze the prevalence and severity of dental caries in Nevada youth over a period of eight years and to compare its expression by means of DMFT and SiC; analyze the caries trends in the population and their underlying factors, and determine whether Nevada youth were at risk for significantly high levels of dental caries.
Methods
Retrospective data was analyzed from a series of sequential, standardized oral health surveys across eight years (2001/2002-2008/2009) that included over 62,000 examinations of adolescents 13-19 years of age, attending public/private Nevada schools. Mean Decayed-Missing-Filled Teeth index (DMFT) and Significant Caries Index (SiC) were subsequently computed for each academic year. Descriptive statistics were reported for analysis of comparative DMFT and SiC scores in relation to age, gender, racial background, and residence in a fluoridated/non-fluoridated community. Logistic regression analysis was used to analyze the differential impact of the variables on the probability of being in the high caries prevalence group.
Results
Comparison of students' mean DMFT to National (NHANES) data confirmed that dental caries remains a common chronic disease among Nevada youth, presenting higher prevalence rates and greater mean scores than the national averages. Downward trends were found across all demographics compared between survey years 1 and 6 with the exception of survey year 3. An upward trend began in survey year six. Over time, the younger group displayed an increasing proportion of cariesfree individuals while a decreasing proportion was found among older examinees. As expected, the mean SiC score was significantly higher than DMFT scores within each survey year across comparison groups (p < 0.001).
Conclusions
Using both caries indices together may help to highlight oral health inequalities more accurately among different population groups within the community in order to identify the need for special preventive oral health interventions in adolescent Nevadans. At the community level, action should focus on retaining and expanding the community fluoridation program as an effective preventive measure. At the individual level the study identifies the need for more targeted efforts to reach children early with a focus on females, Hispanics and Blacks, and uninsured children.
doi:10.1186/1472-6831-11-12
PMCID: PMC3082236  PMID: 21466692
6.  The VicGeneration study - a birth cohort to examine the environmental, behavioural and biological predictors of early childhood caries: background, aims and methods 
BMC Public Health  2010;10:97.
Background
Dental caries (decay) during childhood is largely preventable however it remains a significant and costly public health concern, identified as the most prevalent chronic disease of childhood. Caries in children aged less than five years (early childhood caries) is a rapid and progressive disease that can be painful and debilitating, and significantly increases the likelihood of poor child growth, development and social outcomes. Early childhood caries may also result in a substantial social burden on families and significant costs to the public health system. A disproportionate burden of disease is also experienced by disadvantaged populations.
Methods/Design
This study involves the establishment of a birth cohort in disadvantaged communities in Victoria, Australia. Children will be followed for at least 18 months and the data gathered will explore longitudinal relationships and generate new evidence on the natural history of early childhood caries, the prevalence of the disease and relative contributions of risk and protective biological, environmental and behavioural factors. Specifically, the study aims to:
1. Describe the natural history of early childhood caries (at ages 1, 6, 12 and 18 months), tracking pathways from early bacterial colonisation, through non-cavitated enamel white spot lesions to cavitated lesions extending into dentine.
2. Enumerate oral bacterial species in the saliva of infants and their primary care giver.
3. Identify the strength of concurrent associations between early childhood caries and putative risk and protective factors, including biological (eg microbiota, saliva), environmental (fluoride exposure) and socio-behavioural factors (proximal factors such as: feeding practices and oral hygiene; and distal factors such as parental health behaviours, physical health, coping and broader socio-economic conditions).
4. Quantify the longitudinal relationships between these factors and the development and progression of early childhood caries from age 1-18 months.
Discussion
There is currently a lack of research describing the natural history of early childhood caries in very young children, or exploring the interactions between risk and protective factors that extend to include contemporary measures of socio-behavioural factors. This study will generate knowledge about pathways, prevalence and preventive opportunities for early childhood caries, the most prevalent child health inequality.
doi:10.1186/1471-2458-10-97
PMCID: PMC2847982  PMID: 20181292
7.  An Epidemiological Network Model for Disease Outbreak Detection 
PLoS Medicine  2007;4(6):e210.
Background
Advanced disease-surveillance systems have been deployed worldwide to provide early detection of infectious disease outbreaks and bioterrorist attacks. New methods that improve the overall detection capabilities of these systems can have a broad practical impact. Furthermore, most current generation surveillance systems are vulnerable to dramatic and unpredictable shifts in the health-care data that they monitor. These shifts can occur during major public events, such as the Olympics, as a result of population surges and public closures. Shifts can also occur during epidemics and pandemics as a result of quarantines, the worried-well flooding emergency departments or, conversely, the public staying away from hospitals for fear of nosocomial infection. Most surveillance systems are not robust to such shifts in health-care utilization, either because they do not adjust baselines and alert-thresholds to new utilization levels, or because the utilization shifts themselves may trigger an alarm. As a result, public-health crises and major public events threaten to undermine health-surveillance systems at the very times they are needed most.
Methods and Findings
To address this challenge, we introduce a class of epidemiological network models that monitor the relationships among different health-care data streams instead of monitoring the data streams themselves. By extracting the extra information present in the relationships between the data streams, these models have the potential to improve the detection capabilities of a system. Furthermore, the models' relational nature has the potential to increase a system's robustness to unpredictable baseline shifts. We implemented these models and evaluated their effectiveness using historical emergency department data from five hospitals in a single metropolitan area, recorded over a period of 4.5 y by the Automated Epidemiological Geotemporal Integrated Surveillance real-time public health–surveillance system, developed by the Children's Hospital Informatics Program at the Harvard-MIT Division of Health Sciences and Technology on behalf of the Massachusetts Department of Public Health. We performed experiments with semi-synthetic outbreaks of different magnitudes and simulated baseline shifts of different types and magnitudes. The results show that the network models provide better detection of localized outbreaks, and greater robustness to unpredictable shifts than a reference time-series modeling approach.
Conclusions
The integrated network models of epidemiological data streams and their interrelationships have the potential to improve current surveillance efforts, providing better localized outbreak detection under normal circumstances, as well as more robust performance in the face of shifts in health-care utilization during epidemics and major public events.
Most surveillance systems are not robust to shifts in health care utilization. Ben Reis and colleagues developed network models that detected localized outbreaks better and were more robust to unpredictable shifts.
Editors' Summary
Background.
The main task of public-health officials is to promote health in communities around the world. To do this, they need to monitor human health continually, so that any outbreaks (epidemics) of infectious diseases (particularly global epidemics or pandemics) or any bioterrorist attacks can be detected and dealt with quickly. In recent years, advanced disease-surveillance systems have been introduced that analyze data on hospital visits, purchases of drugs, and the use of laboratory tests to look for tell-tale signs of disease outbreaks. These surveillance systems work by comparing current data on the use of health-care resources with historical data or by identifying sudden increases in the use of these resources. So, for example, more doctors asking for tests for salmonella than in the past might presage an outbreak of food poisoning, and a sudden rise in people buying over-the-counter flu remedies might indicate the start of an influenza pandemic.
Why Was This Study Done?
Existing disease-surveillance systems don't always detect disease outbreaks, particularly in situations where there are shifts in the baseline patterns of health-care use. For example, during an epidemic, people might stay away from hospitals because of the fear of becoming infected, whereas after a suspected bioterrorist attack with an infectious agent, hospitals might be flooded with “worried well” (healthy people who think they have been exposed to the agent). Baseline shifts like these might prevent the detection of increased illness caused by the epidemic or the bioterrorist attack. Localized population surges associated with major public events (for example, the Olympics) are also likely to reduce the ability of existing surveillance systems to detect infectious disease outbreaks. In this study, the researchers developed a new class of surveillance systems called “epidemiological network models.” These systems aim to improve the detection of disease outbreaks by monitoring fluctuations in the relationships between information detailing the use of various health-care resources over time (data streams).
What Did the Researchers Do and Find?
The researchers used data collected over a 3-y period from five Boston hospitals on visits for respiratory (breathing) problems and for gastrointestinal (stomach and gut) problems, and on total visits (15 data streams in total), to construct a network model that included all the possible pair-wise comparisons between the data streams. They tested this model by comparing its ability to detect simulated disease outbreaks implanted into data collected over an additional year with that of a reference model based on individual data streams. The network approach, they report, was better at detecting localized outbreaks of respiratory and gastrointestinal disease than the reference approach. To investigate how well the network model dealt with baseline shifts in the use of health-care resources, the researchers then added in a large population surge. The detection performance of the reference model decreased in this test, but the performance of the complete network model and of models that included relationships between only some of the data streams remained stable. Finally, the researchers tested what would happen in a situation where there were large numbers of “worried well.” Again, the network models detected disease outbreaks consistently better than the reference model.
What Do These Findings Mean?
These findings suggest that epidemiological network systems that monitor the relationships between health-care resource-utilization data streams might detect disease outbreaks better than current systems under normal conditions and might be less affected by unpredictable shifts in the baseline data. However, because the tests of the new class of surveillance system reported here used simulated infectious disease outbreaks and baseline shifts, the network models may behave differently in real-life situations or if built using data from other hospitals. Nevertheless, these findings strongly suggest that public-health officials, provided they have sufficient computer power at their disposal, might improve their ability to detect disease outbreaks by using epidemiological network systems alongside their current disease-surveillance systems.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040210.
Wikipedia pages on public health (note that Wikipedia is a free online encyclopedia that anyone can edit, and is available in several languages)
A brief description from the World Health Organization of public-health surveillance (in English, French, Spanish, Russian, Arabic, and Chinese)
A detailed report from the US Centers for Disease Control and Prevention called “Framework for Evaluating Public Health Surveillance Systems for the Early Detection of Outbreaks”
The International Society for Disease Surveillance Web site
doi:10.1371/journal.pmed.0040210
PMCID: PMC1896205  PMID: 17593895
8.  Twenty-five-year atraumatic restorative treatment (ART) approach: a comprehensive overview 
Clinical Oral Investigations  2012;16(5):1337-1346.
Background
The atraumatic restorative treatment (ART) approach was born 25 years ago in Tanzania. It has evolved into an essential caries management concept for improving quality and access to oral care globally.
Results
Meta-analyses and systematic reviews have indicated that the high effectiveness of ART sealants using high-viscosity glass ionomers in carious lesion development prevention is not different from that of resin fissure sealants. ART using high-viscosity glass ionomer can safely be used to restore single-surface cavities both in primary and in permanent posterior teeth, but its quality in restoring multiple surfaces in primary posterior teeth cavities needs to be improved. Insufficient information is available regarding the quality of ART restorations in multiple surfaces in permanent anterior and posterior teeth. There appears to be no difference in the survival of single-surface high-viscosity glass-ionomer ART restorations and amalgam restorations.
Discussion
The use of ART results in smaller cavities and in high acceptance of preventive and restorative care by children. Because local anaesthesia is seldom needed and only hand instruments are used, ART is considered to be a promising approach for treating children suffering from early childhood caries. ART has been implemented in the public oral health services of a number of countries, and clearly, proper implementation requires the availability of sufficient stocks of good high-viscosity glass ionomers and sets of ART instruments right from the start. Textbooks including chapters on ART are available, and the concept is being included in graduate courses at dental schools in a number of countries. Recent development and testing of e-learning modules for distance learning has increasingly facilitated the distribution of ART information amongst professionals, thus enabling more people to benefit from ART. However, this development and further research require adequate funding, which is not always easily obtainable. The next major challenge is the continuation of care to the frail elderly, in which ART may play a part.
Conclusion
ART, as part of the Basic Package of Oral Care, is an important cornerstone for the development of global oral health and alleviating inequality in oral care.
doi:10.1007/s00784-012-0783-4
PMCID: PMC3443346  PMID: 22824915
Atraumatic restorative treatment; Glass ionomer; Restoration; Fissure sealants; Review article; Dental public health
9.  "We can move forward": challenging historical inequity in public health research in Solomon Islands 
Background
In resource-poor countries, such as Solomon Islands, the research agenda on health is often dominated by researchers from resource-rich countries. New strategies are needed to empower local researchers to set directions for health research. This paper presents a process which seeks to enable a local and potentially more equitable research agenda at a remote hospital in Solomon Islands.
Methods
In preparation for a health research capacity-building workshop at Atoifi Adventist Hospital, Malaita, Solomon Islands, a computer-based search was conducted of Solomon Islands public health literature. Using a levels-of-agreement approach publications were categorised as: a) original research, b) reviews, c) program descriptions and d) commentaries or discussion. Original research publications were further sub-categorised as: i) measurement, ii) descriptive research and iii) intervention studies. Results were reviewed with Solomon Islander health professionals in a focus group discussion during the health research workshop. Focus group participants were invited to discuss reactions to literature search results and how results might assist current or future local researchers to identify gaps in the published research literature and possible research opportunities at the hospital and surrounding communities. Focus group data were analysed using a grounded theory approach.
Results
Of the 218 publications meeting inclusion criteria, 144 (66%) were categorised as 'original research', 42 (19%) as 'commentaries/discussion', 28 (13%) as 'descriptions of programs' and 4 (2%) as 'reviews'. Agreement between three authors' (MRM, DM, AC) independent categorisation was 'excellent' (0.8 <κ). The 144 'original research' publications included 115 (80%) 'descriptive studies' (κ = 0.82); 19 (13%) 'intervention studies' (κ = 0.77); and 10 (7%) 'measurement studies'(κ = 0.80). Key themes identified in the focus group discussion challenged historical inequities evident from the literature review. These included: i) who has done/is doing research in Solomon Islands (largely non-Solomon Islanders); ii) when the research was done (research needs to keep up to date); iii) amount of published research (there should be more); iv) types of research (lack of intervention and operational research); v) value of published research (important); vi) gaps in published literature (need more research about nursing); vii) opportunities for research action (start small); viii) support required to undertake research at the hospital and in surrounding communities (mentoring and partnering with experienced researchers).
Conclusions
A search and collaborative review of public health literature for Solomon Islands at a health research capacity building workshop has uncovered and challenged historical inequity in the conduct and access to public health research. Emerging Solomon Islander researchers at a remote hospital are now working to set priorities and strengthen local research efforts. These efforts have highlighted the importance of collaboration and mentoring for Solomon Islanders to instigate and implement public health research to improve the health of individuals and communities served by this remote hospital.
doi:10.1186/1475-9276-9-25
PMCID: PMC2992041  PMID: 21050492
10.  AN EXAMINATION OF THE ADVANCES IN SCIENCE AND TECHNOLOGY OF PREVENTION OF TOOTH DECAY IN YOUNG CHILDREN SINCE THE SURGEON GENERAL’S REPORT ON ORAL HEALTH 
Academic pediatrics  2009;9(6):404-409.
This paper addresses a number of areas related to how effectively science and technology have met Healthy People 2010 goals for tooth decay prevention. In every area mentioned, it appears that science and technology are falling short of these goals. Earlier assessments identified water fluoridation as one of the greatest public health accomplishments of the last century. Yet, failure to complete needed clinical and translational research has shortchanged the caries prevention agenda that incomplete at a critical juncture.
Science has firmly established the transmissible nature of tooth decay. However, there is evidence that tooth decay in young children is increasing although progress has been made in other age groups. Studies of risk assessment have not been translated into improved practice. Antiseptics, chlorhexidine varnish, and PVP-iodine may have value, but definitive trials are needed. Fluorides remain the most effective agents, but are not widely disseminated to the most needy. Fluoride varnish provides a relatively effective topical preventive for very young children, yet definitive trials have not been conducted. Silver diammine fluoride also has potential but requires study in the US. Data support effectiveness and safety of xylitol, but adoption is not widespread. Dental sealants remain a mainstay of public policy, yet after decades of research, widespread use has not occurred.
We conclude that research has established the public health burden of tooth decay, but insufficient research addresses the problems identified in the Surgeon General's Report. Transfer of technology from studies to implementation is needed to prevent tooth decay among children. This should involve translational research and implementation of scientific and technological advances into practice.
doi:10.1016/j.acap.2009.09.001
PMCID: PMC2787840  PMID: 19837019
11.  Impact of Community-Based Maternal Health Workers on Coverage of Essential Maternal Health Interventions among Internally Displaced Communities in Eastern Burma: The MOM Project 
PLoS Medicine  2010;7(8):e1000317.
Mullany and colleagues report outcomes from a project involving delivery of community-based maternal health services in eastern Burma, and report substantial increases in coverage of care.
Background
Access to essential maternal and reproductive health care is poor throughout Burma, but is particularly lacking among internally displaced communities in the eastern border regions. In such settings, innovative strategies for accessing vulnerable populations and delivering basic public health interventions are urgently needed.
Methods
Four ethnic health organizations from the Shan, Mon, Karen, and Karenni regions collaborated on a pilot project between 2005 and 2008 to examine the feasibility of an innovative three-tiered network of community-based providers for delivery of maternal health interventions in the complex emergency setting of eastern Burma. Two-stage cluster-sampling surveys among ever-married women of reproductive age (15–45 y) conducted before and after program implementation enabled evaluation of changes in coverage of essential antenatal care interventions, attendance at birth by those trained to manage complications, postnatal care, and family planning services.
Results
Among 2,889 and 2,442 women of reproductive age in 2006 and 2008, respectively, population characteristics (age, marital status, ethnic distribution, literacy) were similar. Compared to baseline, women whose most recent pregnancy occurred during the implementation period were substantially more likely to receive antenatal care (71.8% versus 39.3%, prevalence rate ratio [PRR] = 1.83 [95% confidence interval (CI) 1.64–2.04]) and specific interventions such as urine testing (42.4% versus 15.7%, PRR = 2.69 [95% CI 2.69–3.54]), malaria screening (55.9% versus 21.9%, PRR = 2.88 [95% CI 2.15–3.85]), and deworming (58.2% versus 4.1%, PRR = 14.18 [95% CI 10.76–18.71]. Postnatal care visits within 7 d doubled. Use of modern methods to avoid pregnancy increased from 23.9% to 45.0% (PRR = 1.88 [95% CI 1.63–2.17]), and unmet need for contraception was reduced from 61.7% to 40.5%, a relative reduction of 35% (95% CI 28%–40%). Attendance at birth by those trained to deliver elements of emergency obstetric care increased almost 10-fold, from 5.1% to 48.7% (PRR = 9.55 [95% CI 7.21–12.64]).
Conclusions
Coverage of maternal health interventions and higher-level care at birth was substantially higher during the project period. The MOM Project's focus on task-shifting, capacity building, and empowerment at the community level might serve as a model approach for similarly constrained settings.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every minute, somewhere in the world, a woman dies of complications related to pregnancy and childbirth. Access to essential maternal and reproductive health care (including family planning) is particularly bad in war-torn countries. In Burma, for example, where there have been decades of conflict between the military junta and ethnic minority resistance groups, the maternal mortality rate (the number of deaths among women from pregnancy-related causes per 100,000 live births) is around 380, whereas in neighboring Thailand it is only 44. Maternal health is even worse in the Shan, Mon, Karen, and Karenni regions of eastern Burma where ethnic conflicts and enforced village relocations have internally displaced more than half a million people. Here, the maternal mortality rate is around 1,200. In an effort to improve access to maternal health services in these regions, community-based organizations in Burma, the Johns Hopkins Center for Public Health and Human Rights, and the Global Health Access Program undertook an innovative pilot project—the Mobile Obstetric Medics (MOM) project—between 2005 and 2008. Local health workers from 12 communities in eastern Burma received training in antenatal care, obstetrics (the care of women during childbirth), postnatal care, and family planning at the Mae Tao Clinic in Mae Sot, Thailand. These “maternal health workers” then returned to Burma where they trained local health workers and traditional birth attendants to provide maternal health care to their communities.
Why Was This Study Done?
Before the MOM project started, nearly 3,000 women living in the study communities were surveyed to evaluate the coverage of essential antenatal care interventions such as urine testing for infections during pregnancy, screening for malaria, and deworming; Urinary tract infections, malaria, and hookworm infections all increase the risk of poor maternal and neonatal outcomes. The preproject survey also evaluated how many births were attended by people able to deal with complications, and the provision of postnatal care and family planning services. In this study, the researchers undertake a similar postproject survey to evaluate the impact of MOM on the coverage of essential maternal health interventions among internally displaced communities in eastern Burma.
What Did the Researchers Do and Find?
Between October 2008 and December 2008, trained survey workers asked nearly 2,500 ever-married women of reproductive age from the project's study communities about their access to antenatal and postnatal care, skilled birth attendants, and family planning. The results of the postproject survey were then compared with those of the “baseline,” preproject survey. The general characteristics (age, marital status, ethnicity, and literacy) of the women included in the two surveys were very similar. However, 71.8% of the women whose most recent pregnancy occurred during the implementation period of the MOM project had received antenatal care compared to only 39.3% of women surveyed at baseline. Similarly, among the women questioned during the postproject survey, 42.4% had had their urine tested and 55.9% had been screened for malaria during pregnancy compared to only 15.7% and 21.9%, respectively, of the women questioned in the preproject survey. Deworming had increased from 4.1% to 58.2% during the project, postnatal care visits within 7 days had doubled, and attendance at birth by people trained to deal with obstetric emergencies had increased 10-fold from 5.1% to 48.7%. Finally, the use of modern contraception methods (slow-release contraceptives, oral contraceptives, and condoms) had increased from 23.9% to 45.0%.
What Do These Findings Mean?
These findings reveal a substantial improvement in access to maternal and reproductive health care in the study communities during the MOM project. However, because the study compared two independent groups of women before and after implementation of the MOM project rather than concurrently comparing groups of women who did and did not receive the services provided by the MOM project, this study does not prove that the MOM approach was the cause of the changes in the coverage of essential maternal health care. Nevertheless, these findings suggest that the type of approach used in the MOM project—the expansion of interventions (including components of emergency obstetric care) delivered outside healthcare facilities by community-based providers—might be an effective way to deliver maternal and reproductive health services in other parts of Burma and in other places where there are ongoing conflicts.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000317.
More information about the MOM project is available in previous publications by the researchers in PLoS Medicine, in Reproductive Health Matters, and in Social Science and Medicine
Additional resources are also available on the MOM Project
The Reproductive Health Response in Conflict Consortium provides information on how conflicts affect reproductive health
The World Health Organization provides information on all aspects of health in Burma (in several languages)
The Mae Tao clinic also provides general information about Burma and its health services
The Burma Campaign UK and Human Rights Watch both provide detailed information about human rights violations, including those that affect maternal health in Burma
The United Nations Population Fund provides information about safe motherhood and maternal and reproductive health during conflicts and among refugees (in several languages)
doi:10.1371/journal.pmed.1000317
PMCID: PMC2914639  PMID: 20689805
12.  Biotech and Biomaterials Research to Reduce the Caries Epidemic 
BMC Oral Health  2006;6(Suppl 1):S1.
The goal of this workshop is to develop a consensus within the biomaterials/bioengineering community for a research agenda focused on creating technologies that will address the current dental caries pandemic. The workshop will bring together expertise from academia, industry, and the NIH institutes in the areas of oral biofilm microbiology and innovative biomaterials. The rationale for the workshop is that science and technology have not produced sufficient practical tools for public health practitioners and the private delivery system to address the pandemic in dental caries that exists for children and adults from families with low incomes and for numerous ethnic minority and racial groups. Moreover, it is unclear whether the barriers are remediable bioengineering and technical problems or fundamental science questions. Nevertheless, the obligation to address the gap between scientific research and practical application is especially relevant today. The U.S. and state governments bear the majority of the cost of trying to control this pandemic through Medicaid, the Public Health Service, Indian Health Service and other similar programs. These costs continue to escalate as continued applications of existing technology are unlikely to markedly reduce disparities. The mainstays of caries prevention, topical and systemic fluorides and pit and fissure sealants, are technologies developed in the 1950s and 1960s.
doi:10.1186/1472-6831-6-S1-S1
PMCID: PMC2147601  PMID: 16934110
13.  Stroke: Working toward a Prioritized World Agenda 
Background and Purpose
The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.
Methods
Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.
Results
Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent ‘silo’ mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (e.g., social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a ‘Brain Health’ concept that enables promotion of preventive measures.
Conclusions
To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.
doi:10.1159/000315099
PMCID: PMC3221270  PMID: 20516682
Prevention; Rehabilitation; Stroke; Translational; Treatment
14.  Stroke: Working toward a Prioritized World Agenda 
Background and Purpose
The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.
Methods
Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.
Results
Recommendations of the Synergium are: Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent ‘silo’ mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science. Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (e.g., social media/marketing) techniques. Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks. Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery. Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries. Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care. Educate and energize professionals, patients, the public and policy makers by using a ‘Brain Health’ concept that enables promotion of preventive measures.
Conclusions
To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress
doi:10.1111/j.1747-4949.2010.00442.x
PMCID: PMC3712839  PMID: 20636706
Prevention; Rehabilitation; Stroke; Translational; Treatment
15.  Stroke: Working Toward a Prioritized World Agenda 
Background and Purpose
The aim of the Synergium was to devise and prioritize new ways of accelerating progress in reducing the risks, effects, and consequences of stroke.
Methods
Preliminary work was performed by 7 working groups of stroke leaders followed by a synergium (a forum for working synergistically together) with approximately 100 additional participants. The resulting draft document had further input from contributors outside the synergium.
Results
Recommendations of the Synergium are:
Basic Science, Drug Development and Technology: There is a need to develop: (1) New systems of working together to break down the prevalent “silo” mentality; (2) New models of vertically integrated basic, clinical, and epidemiological disciplines; and (3) Efficient methods of identifying other relevant areas of science.
Stroke Prevention: (1) Establish a global chronic disease prevention initiative with stroke as a major focus. (2) Recognize not only abrupt clinical stroke, but subtle subclinical stroke, the commonest type of cerebrovascular disease, leading to impairments of executive function. (3) Develop, implement and evaluate a population approach for stroke prevention. (4) Develop public health communication strategies using traditional and novel (eg, social media/marketing) techniques.
Acute Stroke Management: Continue the establishment of stroke centers, stroke units, regional systems of emergency stroke care and telestroke networks.
Brain Recovery and Rehabilitation: (1) Translate best neuroscience, including animal and human studies, into poststroke recovery research and clinical care. (2) Standardize poststroke rehabilitation based on best evidence. (3) Develop consensus on, then implementation of, standardized clinical and surrogate assessments. (4) Carry out rigorous clinical research to advance stroke recovery.
Into the 21st Century: Web, Technology and Communications: (1) Work toward global unrestricted access to stroke-related information. (2) Build centralized electronic archives and registries.
Foster Cooperation Among Stakeholders (large stroke organizations, nongovernmental organizations, governments, patient organizations and industry) to enhance stroke care.
Educate and energize professionals, patients, the public and policy makers by using a “Brain Health” concept that enables promotion of preventive measures.
Conclusions
To accelerate progress in stroke, we must reach beyond the current status scientifically, conceptually, and pragmatically. Advances can be made not only by doing, but ceasing to do. Significant savings in time, money, and effort could result from discontinuing practices driven by unsubstantiated opinion, unproven approaches, and financial gain. Systematic integration of knowledge into programs coupled with careful evaluation can speed the pace of progress.
doi:10.1161/STROKEAHA.110.586156
PMCID: PMC3712843  PMID: 20498453
prevention; rehabilitation; stroke; translational; treatment
16.  Promoting the social value of research in Kenya: Examining the practical aspects of collaborative partnerships using an ethical framework 
Social Science & Medicine (1982)  2008;67(5):734-747.
The ethics of research continue to attract considerable debate, particularly when that research is sponsored by partners from the North and carried out in the South. Ethical research should contribute to social value in the country where research is being carried out, but there is significant debate around how this might be achieved and who is responsible. The literature suggests that researchers might employ two inter-related strategies to maximise social value: collaborative partnerships with policy makers and communities from the outset of research, and dissemination of research results to participants, policy makers and implementers once the research is over. These areas have received relatively little empirical attention. In this study, we carried out 40 in-depth interviews to explore the role of collaborative partnerships in health research priority setting, and the way in which research findings are disseminated to aid policy making and implementation in Kenya. Interviewees included policy makers, researchers, policy implementers and representatives of organisations funding health reforms in Kenya. Two policy issues were drawn upon as tracers wherever possible: (1) the introduction of Artemesinin- based Combination Therapies (ACTs), an anti-malarial treatment policy; and (2) Haemophilus influenzae (Hib) vaccine for the prevention of pneumococcal diseases among children.
The findings point to significant gaps in the ‘research to policy to practice’ pathway, particularly for national research institutions with a focus on clinical/biomedical research. These gaps reflect poorly effective partnerships among stakeholders and limit the potential social value of much research. While more investment is needed to establish strong structures for promoting and directing collaboration and partnership, how to target this investment is not entirely clear, especially in the context of the considerable power of the global health agenda and the research financing tied to it.
doi:10.1016/j.socscimed.2008.02.016
PMCID: PMC2656129  PMID: 18403077
Kenya; Ethics; Social value; Research benefits; Collaborative research
17.  Research on Implementation of Interventions in Tuberculosis Control in Low- and Middle-Income Countries: A Systematic Review 
PLoS Medicine  2012;9(12):e1001358.
Cobelens and colleagues systematically reviewed research on implementation and cost-effectiveness of the WHO-recommended interventions for tuberculosis.
Background
Several interventions for tuberculosis (TB) control have been recommended by the World Health Organization (WHO) over the past decade. These include isoniazid preventive therapy (IPT) for HIV-infected individuals and household contacts of infectious TB patients, diagnostic algorithms for rule-in or rule-out of smear-negative pulmonary TB, and programmatic treatment for multidrug-resistant TB. There is no systematically collected data on the type of evidence that is publicly available to guide the scale-up of these interventions in low- and middle-income countries. We investigated the availability of published evidence on their effectiveness, delivery, and cost-effectiveness that policy makers need for scaling-up these interventions at country level.
Methods and Findings
PubMed, Web of Science, EMBASE, and several regional databases were searched for studies published from 1 January 1990 through 31 March 2012 that assessed health outcomes, delivery aspects, or cost-effectiveness for any of these interventions in low- or middle-income countries. Selected studies were evaluated for their objective(s), design, geographical and institutional setting, and generalizability. Studies reporting health outcomes were categorized as primarily addressing efficacy or effectiveness of the intervention. These criteria were used to draw landscapes of published research. We identified 59 studies on IPT in HIV infection, 14 on IPT in household contacts, 44 on rule-in diagnosis, 19 on rule-out diagnosis, and 72 on second-line treatment. Comparative effectiveness studies were relatively few (n = 9) and limited to South America and sub-Saharan Africa for IPT in HIV-infection, absent for IPT in household contacts, and rare for second-line treatment (n = 3). Evaluations of diagnostic and screening algorithms were more frequent (n = 19) but geographically clustered and mainly of non-comparative design. Fifty-four studies evaluated ways of delivering these interventions, and nine addressed their cost-effectiveness.
Conclusions
There are substantial gaps in published evidence for scale-up for five WHO-recommended TB interventions settings at country level, which for many countries possibly precludes program-wide implementation of these interventions. There is a strong need for rigorous operational research studies to be carried out in programmatic settings to inform on best use of existing and new interventions in TB control.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Tuberculosis (TB), caused by Mycobacterium tuberculosis, is curable and preventable, but according to the World Health Organization (WHO), in 2011, 8.7 million people had symptoms of TB (usually a productive cough and fever) and 1.4 million people—95% from low- and middle-income countries—died from TB. TB is also the leading cause of death in people with HIV worldwide, and in 2010 about 10 million children were orphaned as a result of their parents dying from TB. To help reduce the considerable global burden of TB, a global initiative called the Stop TB Partnership, led by WHO, has implemented a strategy to reduce deaths from TB by 50% by 2015—even greater than the target of Millennium Development Goal 6 (to reverse the increase in TB incidence by 2015).
Why Was This Study Done?
Over the past few years, WHO has recommended that countries implement several interventions to help control the spread of tuberculosis through measures to improve prevention, diagnosis, and treatment. Five such interventions currently recommended by WHO are: treatment with isoniazid to prevent TB among people who are HIV positive, and also among household contacts of people infected with TB; the use of clinical pathways (algorithms) for diagnosing TB in people accessing health care who have a negative smear test—the most commonly used diagnostic test, which relies on sputum samples—(“rule-in algorithms”); screening algorithms for excluding TB in people who have HIV (“rule-out algorithms”); and finally, provision of second-line treatment for multidrug-resistant tuberculosis (a form of TB that does not respond to the most commonly used drugs) under programmatic conditions. The effectiveness of these interventions, their costs, and the practicalities of implementation are all important information for countries seeking to control TB following the WHO guidelines, but little is known about the availability of this information. Therefore, in this study the researchers systematically reviewed published studies to find evidence of the effectiveness of each of these interventions when implemented in routine practice, and also for additional information on the setting and conditions of implemented interventions, which might be useful to other countries.
What Did the Researchers Do and Find?
Using a specific search strategy, the researchers comprehensively searched through several key databases of publications, including regional databases, to identify 208 (out of 11,489 found initially) suitable research papers published between January 1990 and March 2012. For included studies, the researchers also noted the geographical location and setting and the type and design of study.
Of the 208 included studies, 59 focused on isoniazid prevention therapy in HIV infection, and only 14 on isoniazid prevention therapy for household contacts. There were 44 studies on “rule-in” clinical diagnosis, 19 on “rule-out” clinical diagnosis, and 72 studies on second-line treatment for TB. Studies on each intervention had some weaknesses, and overall, researchers found that there were very few real-world studies reporting on the effectiveness of interventions in program settings (rather than under optimal conditions in research settings). Few studies evaluated the methods used to implement the intervention or addressed delivery and operational issues (such as adherence to treatment), and there were limited economic evaluations of the recommended interventions. Furthermore, the researchers found that in general, the South Asian region was poorly represented.
What Do These Findings Mean?
These findings suggest that there is limited evidence on effectiveness, delivery, and cost-effectiveness to guide the scale-up of five WHO recommended interventions to control tuberculosis in the countries and settings, despite the urgent need for such interventions to be implemented. The poor evidence base identified in this review highlights the tension between the decision to adopt the recommendation and its implementation adapted to local circumstances, and may be an important reason as to why these interventions are not implemented in many countries. This study also suggests creative thinking is necessary to address the gaps between WHO recommendations and global health policy on new interventions and their real-world implementation in country-wide TB control programs. Future research should focus more on operational studies, the results of which should be made publicly available, and researchers, donors, and medical journals could perhaps re-consider their priorities to help bridge the knowledge gap identified in this study.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001358.
WHO has a wide range of information about TB and research on TB, including more about the STOP TB strategy and the STOP TB Partnership
The UN website has more information about MDG 6
The Global Fund to Fight AIDS, Tuberculosis and Malaria has specific information about progress on TB control
doi:10.1371/journal.pmed.1001358
PMCID: PMC3525528  PMID: 23271959
18.  Promoting the social value of research in Kenya: examining the practical aspects of collaborative partnerships using an ethical framework 
Social science & medicine (1982)  2008;67(5):734-747.
The ethics of research continue to attract considerable debate, particularly when sponsored by partners from the North and carried out in the South. Ethical research should contribute to social value in the country where research is being carried out, but there is significant debate around how this might be achieved, and who is responsible. The literature suggests that researchers might employ two inter-related strategies to maximise social value: collaborative partnerships with policy makers and communities from the outset of research, and dissemination of research results to participants, policy makers and implementers once the research is over. These areas have received relatively little empirical attention. In this study we carried out 40 in-depth interviews to explore the role of collaborative partnerships in health research priority setting, and the way in which research findings are disseminated to aid policy making and implementation in Kenya. Interviewees included policy makers, researchers, policy implementers and representatives of organisations funding health reforms in Kenya. Two policy issues were drawn upon as tracers wherever possible: 1) the introduction of Artemesinin- based Combination Therapies (ACTs); an anti malarial treatment policy; and 2) Haemophilus Influenzae (Hib) vaccine for the prevention of Pneumococcal diseases among children.
The findings point to significant gaps in the research to policy to practice pathway, particularly for national research institutions with a focus on clinical/biomedical research. These gaps reflect poorly effective partnerships among stakeholders, and limit the potential social value of much research. While more investment is needed to establish strong structures for promoting and directing collaboration and partnership how to target this investment is not entirely clear, especially in the context of considerable power of the global health agenda and the financial flows for research tied to it.
doi:10.1016/j.socscimed.2008.02.016
PMCID: PMC2656129  PMID: 18403077
19.  “Efforts to Reprioritise the Agenda” in China: British American Tobacco's Efforts to Influence Public Policy on Secondhand Smoke in China 
PLoS Medicine  2008;5(12):e251.
Background
Each year, 540 million Chinese are exposed to secondhand smoke (SHS), resulting in more than 100,000 deaths. Smoke-free policies have been demonstrated to decrease overall cigarette consumption, encourage smokers to quit, and protect the health of nonsmokers. However, restrictions on smoking in China remain limited and ineffective. Internal tobacco industry documents show that transnational tobacco companies (TTCs) have pursued a multifaceted strategy for undermining the adoption of restrictions on smoking in many countries.
Methods and Findings
To understand company activities in China related to SHS, we analyzed British American Tobacco's (BAT's) internal corporate documents produced in response to litigation against the major cigarette manufacturers to understand company activities in China related to SHS. BAT has carried out an extensive strategy to undermine the health policy agenda on SHS in China by attempting to divert public attention from SHS issues towards liver disease prevention, pushing the so-called “resocialisation of smoking” accommodation principles, and providing “training” for industry, public officials, and the media based on BAT's corporate agenda that SHS is an insignificant contributor to the larger issue of air pollution.
Conclusions
The public health community in China should be aware of the tactics previously used by TTCs, including efforts by the tobacco industry to co-opt prominent Chinese benevolent organizations, when seeking to enact stronger restrictions on smoking in public places.
Monique Muggli and colleagues study British American Tobacco (BAT) internal documents and find that from the mid 1990s BAT pursued a strategy aimed at influencing the public debate on secondhand smoke in China.
Editors' Summary
Background.
Each year, about one million people die in China from tobacco-caused diseases, including cancer, heart disease, and lung disease. Although most of these deaths occur among smokers—300 million people smoke in China, accounting for one-third of the global “consumption” of cigarettes—more than 100,000 deaths from tobacco-related causes occur annually among the 540 million Chinese people who are exposed to secondhand smoke. Tobacco smoke contains 4,000 known chemicals, 69 of which are known or probable carcinogens, and, when it is produced in enclosed spaces, both smokers and nonsmokers are exposed to its harmful effects. The only effective way to reduce tobacco smoke exposure indoors to acceptable levels is to implement 100% smoke-free environments—ventilation, filtration, and the provision of segregated areas for smokers and nonsmokers are insufficient. Importantly, as well as protecting nonsmokers from secondhand smoke, the implementation of smoke-free public places also reduces the number of cigarettes smoked among continuing smokers, increases the likelihood of smokers quitting, and reduces the chances of young people taking up smoking.
Why Was This Study Done?
Article 8 of the World Health Organization's Framework Convention on Tobacco Control (FCTC; an international public-health treaty that seeks to reduce tobacco-caused death and disease) calls on countries party to the treaty to protect their citizens from secondhand smoke exposure. China became a party to the FCTC in 2005 but restrictions on smoking in public places in China remain limited and ineffective. Previous analyses of internal tobacco industry documents have revealed that transnational tobacco companies (TTCs) have used a multifaceted approach to undermine the adoption of restrictions on smoking in many countries. TTCs have been shown to influence media coverage of secondhand smoke issues and to promote ineffective ventilation and separate smoking and nonsmoking areas in restaurants, bars, and hotels (so-called “resocalization of smoking” accommodation principles) with the aim of undermining smoke-free legislation. In addition, TTCs have created organizations interested in non-tobacco-related diseases to draw attention away from the public-health implications of secondhand smoke. In this study, the researchers ask whether TTCs have used a similar approach to undermine the adoption of restrictions on smoking in China, one of the most coveted cigarette markets in the world by the major TTCs.
What Did the Researchers Do and Find?
The researchers analyzed internal corporate documents produced by British American Tobacco (BAT; the predominant TTC in China) in response to litigation against major cigarette manufacturers stored in document depositories in Minnesota, USA and Guildford, UK. Among these documents, they found evidence that BAT had attempted to divert attention from secondhand smoke issues toward liver disease prevention by funding the Beijing Liver Foundation (BFL) from its inception in 1997 until at least 2002 (the most recent year that BAT's corporate records are available for public review). The researchers also found evidence that BAT had promoted “resocialization of smoking” accommodation principles as a “route to avoid smoking bans” and pushed ventilation and air filtration in airports and in establishments serving food and drink. Finally, the researchers found evidence that BAT had sought to “present the message that ‘tobacco smoke is just one of the sources of air polution [sic] and a very insignificant one compared with other pollutants'” through presentations given to the Chinese tobacco industry and media seminars aimed at Chinese journalists.
What Do These Findings Mean?
These findings indicate that, beginning in the mid 1990s and continuing until at least 2002, BAT has followed an intensive, multi-pronged strategy designed to undermine the health policy agenda on secondhand smoke in China. Given their findings, the researchers suggest that BFL and other charitable organizations in China must be wary of accepting tobacco money and that measures must be taken to improve the transparency and accountability of these and other public organizations. To meet FCTC obligations under Article 5.3 (industry interference), policy makers in China, they suggest, must be made aware of how BAT and other TTCs have repeatedly sought to influence health policy in China by focusing attention toward the adoption of ineffective air filtration and ventilation systems in hospitality venues rather than the implementation of 100% smoke-free environments. Finally, Chinese policy makers and the media need to be better informed about BAT's long-standing attempts to communicate misleading messages to them about the health effects of secondhand smoke.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050251.
The World Health Organization's Regional Office for the Western Pacific provides smoking statistics for China and other countries in the region
The World Health Organization provides information on the health problems associated with secondhand smoke, about its Tobacco Free Initiative (available in several languages), and about the Framework Convention on Tobacco Control (also available in several languages)
MedlinePlus provides links to information about the dangers of secondhand smoke (available in English and Spanish)
The UK National Health Service Smokefree Web site provides information about the advantages of giving up smoking, how to give up smoking, and the dangers associated with secondhand smoke
British American Tobacco documents stored in the Minnesota and Guildford Depositories, including those analyzed in this study, can be searched through the British American Tobacco Documents Archive
doi:10.1371/journal.pmed.0050251
PMCID: PMC2605899  PMID: 19108603
20.  Research Productivity of Members of IADR Behavioral Sciences and Health Services Research Group: Relationship to Professional and Personal Factors 
Journal of dental education  2008;72(10):1142-1148.
This report describes the research productivity of the members of the International Association for Dental Research (IADR) Behavioral Sciences and Health Services Research Group and examines personal and professional factors related to greater productivity. The findings from previous studies suggested there might be gender discrimination in opportunities for women faculty. Members on the active membership list for this IADR group were surveyed by email. Most were dentists, and three-quarters had external funding for their research. The primary outcome measure was the number of self-reported published articles in PubMed in the preceding twenty-four months. The mean number of these publications was 4.9 (SD=5.1). Gender and time in research were the best predictors of research productivity of this population. There was no difference in time for research between the men and women in this study. Controlling for gender, the best single predictor of research productivity remained percent time spent in research. Overall, the members of the IADR group spent almost three times as much time in research and were more than twice as productive as faculty members as a whole as described in earlier studies. In view of the current emphasis in many countries on addressing the social and behavioral determinants of oral health disparities, the productivity of this area of dental research is very important. Trends toward clinically oriented, non-research-intensive dental schools in the United States and reductions in time and funding available to conduct research should be of concern.
PMCID: PMC2754570  PMID: 18923094
dental faculty; research; research funding; publishing; productivity; gender
21.  A Health Department’s Collaborative Model for Disease Surveillance Capacity Building 
Objective
Highlight one academic health department’s unique approach to optimizing collaborative opportunities for capacity development and document the implications for chronic disease surveillance and population health.
Introduction
Public Health departments are increasingly called upon to be innovative in quality service delivery under a dwindling resource climate as highlighted in several publications of the Institute of Medicine. Collaboration with other entities in the delivery of core public health services has emerged as a recurring theme. One model of this collaboration is an academic health department: a formal affiliation between a health professions school and a local health department. Initially targeted at workforce development, this model of collaboration has since yielded dividends in other core public health service areas including community assessment, program evaluation, community-based participatory research and data analysis.
The Duval County Health Department (DCHD), Florida, presents a unique community-centered model of the academic health department. Prominence in local informatics infrastructure capacity building and hosting a CDC-CSTE applied public health informatics fellowship (APHIF) in the Institute for Public Health Informatics and Research (IPHIR) in partnership with the Center for Health Equity Research, University of Florida & Shands medical center are direct dividends of this collaborative model.
Methods
We examined the collaborative efforts of the DCHD and present the unique advantages these have brought in the areas of entrenched data-driven public health service culture, community assessments, program evaluation, community-based participatory research and health informatics projects.
Results
Advantages of the model include a data-driven culture with the balanced scorecard model in leadership and sub-departmental emphases on quality assurance in public health services. Activities in IPHIR include data-driven approaches to program planning and grant developments, program evaluations, data analyses and impact assessments for the DCHD and other community health stakeholders.
Reports developed by IPHIR have impacted policy formulation by highlighting the need for sub county level data differentiation to address health disparities. Unique community-based mapping of Duval County into health zones based on health risk factors correlating with health outcome measures have been published. Other reports highlight chronic disease surveillance data and health scorecards in special populations.
Partnerships with regional higher institutions (University of Florida, University of North Florida and Florida A&M University) increased public health service delivery and yielded rich community-based participatory research opportunities.
Cutting edge participation in health IT policy implementation led to the hosting of the fledgling community HIE, the Jacksonville Health Information Network, as well as leadership in shaping the landscape of the state HIE. This has immense implications for public health surveillance activities as chronic disease surveillance and public health service research take center stage under new healthcare payment models amidst increasing calls for quality assurance in public health services.
DCHD is currently hosting a CDC-funded fellowship in applied public health informatics. Some of the projects materializing from the fellowship are the mapping of the current public health informatics profile of the DCHD, a community based diabetes disease registry to aid population-based management and surveillance of diabetes, development of a proposal for a combined primary care/general preventive medicine residency in UF-Shands Medical Center, Jacksonville and mobilization of DCHD healthcare providers for the roll-out of the state-built electronic medical records system (Florida HMS-EHR).
Conclusions
Academic health centers provide a model of collaboration that directly impacts on their success in delivering core public health services. Disease surveillance is positively affected by the diverse community affiliations of an academic health department. The academic health department, as epitomized by DCHD, is also better positioned to seize up-coming opportunities for local public health capacity building.
PMCID: PMC3692891
Academic Health Departments; collaborative model; health informatics projects
22.  An exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds: a protocol paper for Teeth Tales 
BMJ Open  2014;4(3):e004260.
Introduction
Inequalities are evident in early childhood caries rates with the socially disadvantaged experiencing greater burden of disease. This study builds on formative qualitative research, conducted in the Moreland/Hume local government areas of Melbourne, Victoria 2006–2009, in response to community concerns for oral health of children from refugee and migrant backgrounds. Development of the community-based intervention described here extends the partnership approach to cogeneration of contemporary evidence with continued and meaningful involvement of investigators, community, cultural and government partners. This trial aims to establish a model for child oral health promotion for culturally diverse communities in Australia.
Methods and analysis
This is an exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds. Families from an Iraqi, Lebanese or Pakistani background with children aged 1–4 years, residing in metropolitan Melbourne, were invited to participate in the trial by peer educators from their respective communities using snowball and purposive sampling techniques. Target sample size was 600. Moreland, a culturally diverse, inner-urban metropolitan area of Melbourne, was chosen as the intervention site. The intervention comprised peer educator led community oral health education sessions and reorienting of dental health and family services through cultural Competency Organisational Review (CORe).
Ethics and dissemination
Ethics approval for this trial was granted by the University of Melbourne Human Research Ethics Committee and the Department of Education and Early Childhood Development Research Committee. Study progress and output will be disseminated via periodic newsletters, peer-reviewed research papers, reports, community seminars and at National and International conferences.
Trial registration number
Australian New Zealand Clinical Trials Registry (ACTRN12611000532909).
doi:10.1136/bmjopen-2013-004260
PMCID: PMC3963385  PMID: 24622949
PUBLIC HEALTH; ORAL HEALTH; CULTURAL COMPETENCY; INEQUALITIES; CHILD; COMMUNITY-BASED PARTICIPATORY RESEARCH
23.  Programme guidelines for promoting good oral health for children in Nigeria: a position paper 
BMC Oral Health  2014;14(1):128.
Background
The objective of this paper is to draw attention to the oral health needs of children in Nigeria, and promote the use of appropriate interventions for disease prevention in the population. It also evaluates the value of the ongoing twice-daily tooth brushing campaign, which focuses on promoting good periodontal health and its relevance for children in Nigeria.
Discussion
The main oral health burden for children in Nigeria is untreated dental caries, attributable to low utilization of oral health facilities. While there is a strong association between oral hygiene status and caries occurrence, no research had established an association between frequency of tooth brushing and caries in children in Nigeria. Prevalence of caries and gingivitis is low, despite the fact that a majority of children brush once a day and most of them have fair oral hygiene. Campaigns that promote twice daily brushing to prevent chronic periodontitis in children are not driven by evidences supporting the local epidemic, and therefore cannot be considered as efficient use of the limited resources available.
Summary
Existing evidences show that the main oral health need of children in Nigeria is the management of untreated caries. Promoting the treatment of caries should be the primary focus of oral health programmes for children in Nigeria, as this would reduce further risks of developing new carious lesions. Public health campaigns should focus efforts at creating demand for oral health care services, for both preventive and curative purposes.
doi:10.1186/1472-6831-14-128
PMCID: PMC4216911  PMID: 25331086
Nigeria; Children; Caries; Campaign; Evidence; Oral health promotion
24.  Dental Status of New Caledonian Children: Is There a Need for a New Oral Health Promotion Programme? 
PLoS ONE  2014;9(11):e112452.
Background
Before implementing a new oral health promotion program in the French overseas territory of Nouvelle Calédonie, the health authorities needed recent data about dental status of the New Caledonian child population.
Objectives
This study aimed to describe the dental status of 6, 9 and 12-yr-old New Caledonian children and to investigate the environmental and behavioural risk factors related to oral health.
Methods
A randomly selected sample of 2734 children (744 6-yr-olds, 789 9-yr-olds, and 1201 12-yr-olds) was examined clinically by seven calibrated investigators and participants responded to a questionnaire. The main variables were objective criteria about dental status and subjective criteria about experience of dental care, dental fear, self-perception of oral health, cultural or ethnic identity and environmental and behavioural risk factors.
Results
Overall, most of the children had infectious oral diseases: more than 50% had gingivitis, and 60% of 6- and 9 yr-olds had at least one deciduous or permanent tooth with untreated caries. The mean 12-yr-old number of decayed missing and filled teeth (DMFT) was 2.09±2.82. The number of carious lesions was related to the unfavourable lifestyle, deprived social status and no preventive dental care. Kanak, Polynesians and Caledonians (respectively 27%, 18% and 45% of the study sample) were more affected by caries than metropolitan French and Asian children. Children with many untreated carious lesions had negative perceptions of their oral health; they complained of chewing difficulty and had higher scores for dental anxiety.
Conclusion
This study highlights the need for new strategies aimed at improving oral health and at reducing inequalities in New Caledonia. An oral health promotion program would need to be developed in connection with other health programmes using the common risk factor approach within the context of the local environment.
doi:10.1371/journal.pone.0112452
PMCID: PMC4224488  PMID: 25380304
25.  The Impact of eHealth on the Quality and Safety of Health Care: A Systematic Overview 
PLoS Medicine  2011;8(1):e1000387.
Aziz Sheikh and colleagues report the findings of their systematic overview that assessed the impact of eHealth solutions on the quality and safety of health care.
Background
There is considerable international interest in exploiting the potential of digital solutions to enhance the quality and safety of health care. Implementations of transformative eHealth technologies are underway globally, often at very considerable cost. In order to assess the impact of eHealth solutions on the quality and safety of health care, and to inform policy decisions on eHealth deployments, we undertook a systematic review of systematic reviews assessing the effectiveness and consequences of various eHealth technologies on the quality and safety of care.
Methods and Findings
We developed novel search strategies, conceptual maps of health care quality, safety, and eHealth interventions, and then systematically identified, scrutinised, and synthesised the systematic review literature. Major biomedical databases were searched to identify systematic reviews published between 1997 and 2010. Related theoretical, methodological, and technical material was also reviewed. We identified 53 systematic reviews that focused on assessing the impact of eHealth interventions on the quality and/or safety of health care and 55 supplementary systematic reviews providing relevant supportive information. This systematic review literature was found to be generally of substandard quality with regards to methodology, reporting, and utility. We thematically categorised eHealth technologies into three main areas: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. We found that despite support from policymakers, there was relatively little empirical evidence to substantiate many of the claims made in relation to these technologies. Whether the success of those relatively few solutions identified to improve quality and safety would continue if these were deployed beyond the contexts in which they were originally developed, has yet to be established. Importantly, best practice guidelines in effective development and deployment strategies are lacking.
Conclusions
There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. In addition, there is a lack of robust research on the risks of implementing these technologies and their cost-effectiveness has yet to be demonstrated, despite being frequently promoted by policymakers and “techno-enthusiasts” as if this was a given. In the light of the paucity of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, it is vital that future eHealth technologies are evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle. Such evaluation should be characterised by careful attention to socio-technical factors to maximise the likelihood of successful implementation and adoption.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
There is considerable international interest in exploiting the potential of digital health care solutions, often referred to as eHealth—the use of information and communication technologies—to enhance the quality and safety of health care. Often accompanied by large costs, any large-scale expenditure on eHealth—such as electronic health records, picture archiving and communication systems, ePrescribing, associated computerized provider order entry systems, and computerized decision support systems—has tended to be justified on the grounds that these are efficient and cost-effective means for improving health care. In 2005, the World Health Assembly passed an eHealth resolution (WHA 58.28) that acknowledged, “eHealth is the cost-effective and secure use of information and communications technologies in support of health and health-related fields, including health-care services, health surveillance, health literature, and health education, knowledge and research,” and urged member states to develop and implement eHealth technologies. Since then, implementing eHealth technologies has become a main priority for many countries. For example, England has invested at least £12.8 billion in a National Programme for Information Technology for the National Health Service, and the Obama administration in the United States has committed to a US$38 billion eHealth investment in health care.
Why Was This Study Done?
Despite the wide endorsement of and support for eHealth, the scientific basis of its benefits—which are repeatedly made and often uncritically accepted—remains to be firmly established. A robust evidence-based perspective on the advantages on eHealth could help to suggest priority areas that have the greatest potential for benefit to patients and also to inform international eHealth deliberations on costs. Therefore, in order to better inform the international community, the authors systematically reviewed the published systematic review literature on eHealth technologies and evaluated the impact of these technologies on the quality and safety of health care delivery.
What Did the Researchers Do and Find?
The researchers divided eHealth technologies into three main categories: (1) storing, managing, and transmission of data; (2) clinical decision support; and (3) facilitating care from a distance. Then, implementing methods based on those developed by the Cochrane Collaboration and the NHS Service Delivery and Organisation Programme, the researchers used detailed search strategies and maps of health care quality, safety, and eHealth interventions to identify relevant systematic reviews (and related theoretical, methodological, and technical material) published between 1997 and 2010. Using these techniques, the researchers retrieved a total of 46,349 references from which they identified 108 reviews. The 53 reviews that the researchers finally selected (and critically reviewed) provided the main evidence base for assessing the impact of eHealth technologies in the three categories selected.
In their systematic review of systematic reviews, the researchers included electronic health records and picture archiving communications systems in their evaluation of category 1, computerized provider (or physician) order entry and e-prescribing in category 2, and all clinical information systems that, when used in the context of eHealth technologies, integrate clinical and demographic patient information to support clinician decision making in category 3.
The researchers found that many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence. The evidence base in support of eHealth technologies was weak and inconsistent and importantly, there was insubstantial evidence to support the cost-effectiveness of these technologies. For example, the researchers only found limited evidence that some of the many presumed benefits could be realized; importantly, they also found some evidence that introducing these new technologies may on occasions also generate new risks such as prescribers becoming over-reliant on clinical decision support for e-prescribing, or overestimate its functionality, resulting in decreased practitioner performance.
What Do These Findings Mean?
The researchers found that despite the wide support for eHealth technologies and the frequently made claims by policy makers when constructing business cases to raise funds for large-scale eHealth projects, there is as yet relatively little empirical evidence to substantiate many of the claims made about eHealth technologies. In addition, even for the eHealth technology tools that have proven to be successful, there is little evidence to show that such tools would continue to be successful beyond the contexts in which they were originally developed. Therefore, in light of the lack of evidence in relation to improvements in patient outcomes, as well as the lack of evidence on their cost-effectiveness, the authors say that future eHealth technologies should be evaluated against a comprehensive set of measures, ideally throughout all stages of the technology's life cycle, and include socio-technical factors to maximize the likelihood of successful implementation and adoption in a given context. Furthermore, it is equally important that eHealth projects that have already been commissioned are subject to rigorous, multidisciplinary, and independent evaluation.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000387.
The authors' broader study is: Car J, Black A, Anandan C, Cresswell K, Pagliari C, McKinstry B, et al. (2008) The Impact of eHealth on the Quality and Safety of Healthcare. Available at: http://www.haps.bham.ac.uk/publichealth/cfhep/001.shtml
More information is available on the World Health Assembly eHealth resolution
The World Health Organization provides information at the Global Observatory on eHealth, as well as a global insight into eHealth developments
The European Commission provides Information on eHealth in Europe and some examples of good eHealth practice
More information is provided on NHS Connecting for Health
doi:10.1371/journal.pmed.1000387
PMCID: PMC3022523  PMID: 21267058

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