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1.  Gendered Disparities in Quality of Cataract Surgery in a Marginalised Population in Pakistan: The Karachi Marine Fishing Communities Eye and General Health Survey 
PLoS ONE  2015;10(7):e0131774.
Marine fishing communities are among the most marginalised and hard-to-reach groups and have been largely neglected in health research. We examined the quality of cataract surgery and its determinants, with an emphasis on gender, in marine fishing communities in Karachi, Pakistan, using multiple indicators of performance.
Methods and Findings
The Karachi Marine Fishing Communities Eye and General Health Survey was a door-to-door, cross-sectional study conducted between March 2009 and April 2010 in fishing communities living on 7 islands and in coastal areas in Keamari, Karachi, located on the Arabian Sea. A population-based sample of 638 adults, aged ≥ 50 years, was studied. A total of 145 eyes (of 97 persons) had undergone cataract surgery in this sample. Cataract surgical outcomes assessed included vision (presenting and best-corrected with a reduced logMAR chart), satisfaction with surgery, astigmatism, and pupil shape. Overall, 65.5% of the operated eyes had some form of visual loss (presenting visual acuity [PVA] < 6/12). 55.2%, 29.0%, and 15.9% of these had good, borderline, and poor visual outcomes based on presenting vision; with best correction, these values were: 68.3 %, 18.6%, and 13.1%, respectively. Of 7 covariates evaluated in the multivariable generalized estimating equations (GEE) analyses, gender was the only significant independent predictor of visual outcome. Women’s eyes were nearly 4.38 times more likely to have suboptimal visual outcome (PVA<6/18) compared with men’s eyes (adjusted odds ratio 4.38, 95% CI 1.96-9.79; P<0.001) after adjusting for the effect of household financial status. A higher proportion of women’s than men’s eyes had an irregular pupil (26.5% vs. 14.8%) or severe/very severe astigmatism (27.5% vs. 18.2%). However, these differences did not reach statistical significance. Overall, more than one fourth (44/144) of cataract surgeries resulted in dissatisfaction. The only significant predictor of satisfaction was visual outcome (P <0.001).
The quality of cataract surgery in this marginalised population, especially among women, falls well below the WHO recommended standards. Gender disparities, in particular, deserve proactive attention in policy, service delivery, research and evaluation.
PMCID: PMC4506126  PMID: 26186605
2.  Mechanisms underpinning interventions to reduce sexual violence in armed conflict: A realist-informed systematic review 
Conflict and Health  2015;9:19.
Sexual violence is recognised as a widespread consequence of armed conflict and other humanitarian crises. The limited evidence in literature on interventions in this field suggests a need for alternatives to traditional review methods, particularly given the challenges of undertaking research in conflict and crisis settings. This study employed a realist review of the literature on interventions with the aim of identifying the mechanisms at work across the range of types of intervention. The realist approach is an exploratory and theory-driven review method. It is well suited to complex interventions as it takes into account contextual factors to identify mechanisms that contribute to outcomes. The limited data available indicate that there are few deterrents to sexual violence in crises. Four main mechanisms appear to contribute to effective interventions: increasing the risk to offenders of being detected; building community engagement; ensuring community members are aware of available help for and responses to sexual violence; and safe and anonymous systems for reporting and seeking help. These mechanisms appeared to contribute to outcomes in multiple-component interventions, as well as those relating to gathering firewood, codes of conduct for personnel and legal interventions. Drawing on pre-existing capacity or culture in communities is an additional mechanism which should be explored. Though increasing the risk to offenders of being detected was assumed to be a central mechanism in deterring sexual violence, the evidence suggests that this mechanism operated only in interventions focused on gathering firewood and providing alternative fuels. The other three mechanisms appeared important to the likelihood of an intervention being successful, particularly when operating simultaneously. In a field where robust outcome research remains likely to be limited, realist methods provide opportunities to understand existing evidence. Our analysis identifies the important potential of building in mechanisms involving community engagement, awareness of responses and safe reporting provisions into the range of types of intervention for sexual violence in crises.
PMCID: PMC4499895  PMID: 26170898
Sexual violence; Conflict and crisis-related sexual violence; Armed conflict; Humanitarian crisis; Interventions; Realist approach; Systematic review
3.  How Should the Health Community Respond to Violent Political Conflict? 
PLoS Medicine  2004;1(1):e14.
Violent political conflict is on the front pages, in Iraq, Afghanistan, and Sudan. This provocative piece discusses lessons we can learn from past conflicts in dealing with future ones
We must define better practice and promote organisational learning
PMCID: PMC523835  PMID: 15526042
4.  Policy context and narrative leading to the commissioning of the Australian Indigenous Burden of Disease study 
Burden of disease (BoD) studies have been conducted in numerous international settings since the early 1990’s. Two national BoD studies have been undertaken in Australia, in 1998 and 2003, although neither study estimated the BoD specifically for Indigenous Australians. In 2005 the Australian Government Department of Health and Ageing Office for Aboriginal and Torres Strait Islander Health formally commissioned the University of Queensland to undertake, in parallel with the second national BoD study, the “Burden of Disease and Injury in Aboriginal and Torres Strait Islander Peoples” study, drawing on available data up to 2003. This paper aims to explore the policy context and narrative in the lead up to commissioning the Indigenous BoD (IBoD) study, focusing on relevant contextual factors and insights regarding the perspectives of key stakeholders and their anticipated value of the study. It is part of a broader project that examines the uptake of evidence to policy, using the IBoD study as a case study.
A systematic review of the literature was undertaken in late 2013 and early 2014, and the findings triangulated with 38 key informant interviews with Indigenous and non-Indigenous academics, researchers, statisticians, policy advisors, and policymakers, conducted between 2011 and 2013.
Contextual features which led to commissioning the IBoD study included widespread recognition of longstanding Indigenous disadvantage, lower life expectancy than non-Indigenous Australians, and the lack of an adequate evidence base upon which to determine priorities for interventions. Several anticipated benefits and expectations of key stakeholders were identified. Most informants held at least one of the following expectations of the study: that it would inform the evidence base, contribute to priority setting, and/or inform policy. There were differing or entirely contrasting views to this however, with some sharing concerns about the study being undertaken at all.
The IBoD study, in concept, offered the potential to generate much desired ‘answers’, in the form of a quantified ranking of health risks and disease burden, and it was hoped by many that the results of the study would feed into determining priorities and informing Indigenous health policy.
PMCID: PMC4409780  PMID: 25890380
Australia; Burden of Disease; Health policy; Indigenous disadvantage; Research translation
5.  Violence: a priority for public health? (part 2) 
Violence continues to grow as a priority for public health practitioners, particularly as its causes and consequences become better understood and the potential roles for public health are better articulated. This article provides the context to “Violence: a glossary (part 1)” published in the last issue of this journal, and updates some of the data, concepts and population approaches presented in the 2002 World report on violence and health. The paper addresses the following questions: What is the magnitude and global burden of injury from violence? What causes violence? Is resilience important? What is the role for public health? What are the key challenges and opportunities? We aim to engage the general reader and to increase understanding of violence as a potentially preventable issue.
PMCID: PMC2659998  PMID: 17699529
violence; public health; prevention and control; intentional injury
6.  Violence: a glossary 
Violence has been explicitly identified as a significant public health problem. This glossary clarifies widely used definitions and concepts of violence within the public health field, building on those promoted through the 2002 World Report on Violence and Health. We provide definitions and concepts that can be usefully applied to identify points for public health intervention to prevent the social and health impacts of violence.
PMCID: PMC2652990  PMID: 17630364
violence; public health; prevention and control; intentional injury
7.  Pathways to “Evidence-Informed” Policy and Practice: A Framework for Action 
PLoS Medicine  2005;2(7):e166.
Bowen and Zwi propose a new framework that can help researchers and policy makers to navigate the use of evidence.
PMCID: PMC1140676  PMID: 15913387
8.  Policymaking ‘under the radar’: a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka 
Health Policy and Planning  2013;30(1):56-67.
Background Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined.
Methods This study was undertaken as part of a broader analysis of policy in two parts—an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews.
Results A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers.
Conclusions The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place ‘under the radar’, thus avoiding policy inertia often associated with reforms in lower and middle income countries.
PMCID: PMC4287191  PMID: 24362640
Suicide; pesticides; policy analysis; evidence-based policy; health policy; agriculture; prevention; developing countries; Sri Lanka
9.  Mobile Phone–based Syndromic Surveillance System, Papua New Guinea 
Emerging Infectious Diseases  2013;19(11):1811-1818.
The health care system in Papua New Guinea is fragile, and surveillance systems infrequently meet international standards. To strengthen outbreak identification, health authorities piloted a mobile phone–based syndromic surveillance system and used established frameworks to evaluate whether the system was meeting objectives. Stakeholder experience was investigated by using standardized questionnaires and focus groups. Nine sites reported data that included 7 outbreaks and 92 cases of acute watery diarrhea. The new system was more timely (2.4 vs. 84 days), complete (70% vs. 40%), and sensitive (95% vs. 26%) than existing systems. The system was simple, stable, useful, and acceptable; however, feedback and subnational involvement were weak. A simple syndromic surveillance system implemented in a fragile state enabled more timely, complete, and sensitive data reporting for disease risk assessment. Feedback and provincial involvement require improvement. Use of mobile phone technology might improve the timeliness and efficiency of public health surveillance.
PMCID: PMC3837650  PMID: 24188144
syndromic surveillance; mobile phone; m-health; information and communication technology; ICT; early warning; fragile state; evaluation; Papua New Guinea
10.  Concurrent Outbreaks of Cholera and Peripheral Neuropathy Associated with High Mortality among Persons Internally Displaced by a Volcanic Eruption 
PLoS ONE  2013;8(9):e72566.
In October 2004, Manam Island volcano in Papua New Guinea erupted, causing over 10 000 villagers to flee to internally displaced person (IDP) camps, including 550 from Dugulaba village. Following violence over land access in March 2010, the IDPs fled the camps, and four months later concurrent outbreaks of acute watery diarrhea and unusual neurological complaints were reported in this population.
Materials and Methods
A retrospective case-control study was conducted to identify the risk factors for peripheral neuropathy. Rectal swabs were collected from cases of acute watery diarrhea. Hair and serum metals and metalloids were analyzed by Inductively Coupled Plasma-Mass Spectrometry (ICP-MS).
There were 17 deaths among the 550 village inhabitants during the outbreak period at a crude mortality rate 21-fold that of a humanitarian crisis. Vibrio cholerae O1 El Tor Ogawa was confirmed among the population. Access to community-level rehydration was crucial to mortality. Peripheral neuropathy was diagnosed among cases with neurological symptoms. A balanced diet was significantly protective against neuropathy. A dose-response relationship was seen between peripheral neuropathy and a decreasing number of micronutrient- rich foods in the diet. Deficiencies in copper, iron, selenium and zinc were identified among the cases of peripheral neuropathy.
Cholera likely caused the mostly preventable excess mortality. Peripheral neuropathy was not caused by cholera, but cholera may worsen existing nutritional deficiencies. The peripheral neuropathy was likely caused by complex micronutrient deficiencies linked to non-diversified diets that potentially increased the vulnerability of this population, however a new zinc-associated neuropathy could not be ruled out. Reoccurrence can be prevented by addressing the root cause of displacement and ensuring access to arable land and timely resettlement.
PMCID: PMC3759368  PMID: 24023752
11.  Changing the malaria treatment protocol policy in Timor-Leste: an examination of context, process, and actors’ involvement 
In 2007 Timor-Leste, a malaria endemic country, changed its Malaria Treatment Protocol for uncomplicated falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. The change in treatment policy was based on the rise in morbidity due to malaria and perception of increasing drug resistance. Despite a lack of nationally available evidence on drug resistance, the Ministry of Health decided to change the protocol. The policy process leading to this change was examined through a qualitative study on how the country developed its revised treatment protocol for malaria. This process involved many actors and was led by the Timor-Leste Ministry of Health and the WHO country office. This paper examines the challenges and opportunities identified during this period of treatment protocol change.
PMCID: PMC3665480  PMID: 23672371
Evidence; Malaria treatment; Policy formulation; Policy process; Timor-Leste; Treatment protocol
12.  Addressing the human resources crisis: a case study of Cambodia’s efforts to reduce maternal mortality (1980–2012) 
BMJ Open  2013;3(5):e002685.
To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries.
Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors (‘House Model’; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR).
Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners.
A total of 49 interviewees, who were identified through a snowball sampling technique.
Main outcome measures
Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction.
The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment.
Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.
PMCID: PMC3657637  PMID: 23674446
Public Health
13.  Did the first Global Fund grant (2003–2006) contribute to malaria control and health system strengthening in Timor-Leste? 
Malaria Journal  2012;11:237.
In 2003, Timor-Leste successfully obtained its first Global Fund grant for a three-year programme for malaria control. The grant aimed to reduce malaria-related morbidity and mortality by 30 % by the end of the implementation.
A mixed-methods approach was used to assess the impact of the grant implementation. Fifty-eight in-depth interviews, eight group interviews, 16 focus group discussions, and on-site observations were used. Morbidity data reported to the Ministry of Health were also examined to assess trends.
The National Malaria Programme with funding support from the Global Fund grant and other development partners contributed considerably to strengthening malaria control and the general health system. It also brought direct and indirect benefits to pregnant women and to the community at large. However, it failed to achieve the stated objective of reducing malaria morbidity and mortality by 30 %. The implementation was hampered by inadequate human resources, the rigidity of Global Fund rules, weak project management and coordination, and inadequate support from external stakeholders.
Despite limitations, the grant was implemented until the agreed closing date. Considerable contributions to malaria control, health system, and the community have been made and the malaria programme was sustained.
PMCID: PMC3502152  PMID: 22823965
Global Fund to fight HIV/AIDS; Tuberculosis and malaria; Malaria control; Capacity building; Health system; Additionality; Timor-Leste
14.  Brain Gains: a literature review of medical missions to low and middle-income countries 
Healthcare professionals’ participation in short-term medical missions to low and middle income countries (LMIC) to provide healthcare has become common over the past 50 years yet little is known about the quantity and quality of these missions. The aim of this study was to review medical mission publications over 25 years to better understand missions and their potential impact on health systems in LMICs.
A literature review was conducted by searching Medline for articles published from 1985–2009 about medical missions to LMICs, revealing 2512 publications. Exclusion criteria such as receiving country and mission length were applied, leaving 230 relevant articles. A data extraction sheet was used to collect information, including sending/receiving countries and funding source.
The majority of articles were descriptive and lacked contextual or theoretical analysis. Most missions were short-term (1 day – 1 month). The most common sending countries were the U.S. and Canada. The top destination country was Honduras, while regionally Africa received the highest number of missions. Health care professionals typically responded to presenting health needs, ranging from primary care to surgical relief. Cleft lip/palate surgeries were the next most common type of care provided.
Based on the articles reviewed, there is significant scope for improvement in mission planning, monitoring and evaluation as well as global and/or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training in such areas as cross-cultural communication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy, harmonisation with existing government programming and transparency are needed.
PMCID: PMC3474169  PMID: 22643123
medical missions; low- and middle-income countries; volunteer; human resources
15.  Analysis of policy implications and challenges of the Cuban health assistance program related to human resources for health in the Pacific 
Cuba has extended its medical cooperation to Pacific Island Countries (PICs) by supplying doctors to boost service delivery and offering scholarships for Pacific Islanders to study medicine in Cuba. Given the small populations of PICs, the Cuban engagement could prove particularly significant for health systems development in the region. This paper reviews the magnitude and form of Cuban medical cooperation in the Pacific and analyses its implications for health policy, human resource capacity and overall development assistance for health in the region.
We reviewed both published and grey literature on health workforce in the Pacific including health workforce plans and human resource policy documents. Further information was gathered through discussions with key stakeholders involved in health workforce development in the region.
Cuba formalised its relationship with PICs in September 2008 following the first Cuba-Pacific Islands ministerial meeting. Some 33 Cuban health personnel work in Pacific Island Countries and 177 Pacific island students are studying medicine in Cuba in 2010 with the most extensive engagement in Kiribati, the Solomon Islands, Tuvalu and Vanuatu. The cost of the Cuban medical cooperation to PICs comes in the form of countries providing benefits and paying allowances to in-country Cuban health workers and return airfares for their students in Cuba. This has been seen by some PICs as a cheaper alternative to training doctors in other countries.
The Cuban engagement with PICs, while smaller than engagement with other countries, presents several opportunities and challenges for health system strengthening in the region. In particular, it allows PICs to increase their health workforce numbers at relatively low cost and extends delivery of health services to remote areas. A key challenge is that with the potential increase in the number of medical doctors, once the local students return from Cuba, some PICs may face substantial rises in salary expenditure which could significantly strain already stretched government budgets. Finally, the Cuban engagement in the Pacific has implications for the wider geo-political and health sector support environment as the relatively few major bilateral donors, notably Australia (through AusAID) and New Zealand (through NZAID), and multilaterals such as the World Bank will need to accommodate an additional player with whom existing links are limited.
PMCID: PMC3447691  PMID: 22558940
16.  The implementation of a new Malaria Treatment Protocol in Timor-Leste: challenges and constraints 
Health Policy and Planning  2012;27(8):677-686.
Background Timor-Leste changed its malaria treatment protocol in 2007, replacing the first-line for falciparum malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine. This study explored the factors affecting the implementation of the revised treatment protocol, with an emphasis on identifying key constraints.
Methods A mixed method approach drew on both qualitative and quantitative data. The study included data from District Health Services in seven districts, community health centres in 14 sub-districts, four hospitals, five private clinics, one private pharmacy and the country's autonomous medical store. In-depth interviews with 36 key informants, five group interviews and 15 focus group discussions were conducted. A survey was also undertaken at community health centres and hospitals to assess the availability of a physical copy of the Malaria Treatment Protocol, as well as the availability and utilization of artemether-lumefantrine and sulphadoxine-pyrimethamine.
Results Many factors impeded the implementation of the new malaria protocol. These included: inadequate introduction and training around the revised treatment protocol; unclear phasing out of sulphadoxine-pyrimethamine and phasing in of the revised treatment, artemether-lumefantrine, and the rapid diagnostic test (RDT); lack of supervision; lack of adherence to the revised guidelines by foreign health workers; lack of access to the new drug by the private sector; obstacles in the procurement process; and the use of trade names rather than generic drug description. Insufficient understanding of the rapid diagnostic test and the untimely supply of drugs further hampered implementation.
Conclusion To effectively implement a revised malaria treatment protocol, barriers should be identified during the policy formulation process and those emerging during implementation should be recognized promptly and addressed.
PMCID: PMC3513764  PMID: 22460007
Malaria; treatment protocol; malaria treatment; plasmodium falciparum; sulphadoxine-pyremethamine (SP); artemether-lumefantrine (AL); policy implementation; implementation science; Timor-Leste
17.  A Comprehensive Framework for Human Resources for Health System Development in Fragile and Post-Conflict States 
PLoS Medicine  2011;8(12):e1001146.
Noriko Fujita and colleagues offer a comprehensive framework for human resource system development, based upon experiences in three fragile and post-conflict health systems: Afghanistan, the Democratic Republic of Congo, and Cambodia.
PMCID: PMC3243715  PMID: 22205886
18.  Global Protection and the Health Impact of Migration Interception 
PLoS Medicine  2011;8(6):e1001038.
In the fourth article in a six-part PLoS Medicine series on Migration & Health, Zachary Steel and colleagues discuss the interception phase of migration and the specific health risks and policy needs associated with this phase.
PMCID: PMC3114866  PMID: 21695084
19.  Malaria control in Timor-Leste during a period of political instability: what lessons can be learned? 
Conflict and Health  2009;3:11.
Malaria is a major global health problem, often exacerbated by political instability, conflict, and forced migration.
To examine the impact of political upheaval and population displacement in Timor-Leste (2006) on malaria in the country.
Case study approach drawing on both qualitative and quantitative methods including document reviews, in-depth interviews, focus group discussions, site visits and analysis of routinely collected data.
The conflict had its most profound impact on Dili, the capital city, in which tens of thousands of people were displaced from their homes. The conflict interrupted routine malaria service programs and training, but did not lead to an increase in malaria incidence. Interventions covering treatment, insecticide treated nets (ITN) distribution, vector control, surveillance and health promotion were promptly organized for internally displaced people (IDPs) and routine health services were maintained. Vector control interventions were focused on IDP camps in the city rather than on the whole community. The crisis contributed to policy change with the introduction of Rapid Diagnostic Tests and artemether-lumefantrine for treatment.
Although the political crisis affected malaria programs there were no outbreaks of malaria. Emergency responses were quickly organized and beneficial long term changes in treatment and diagnosis were facilitated.
PMCID: PMC2802356  PMID: 20003539
20.  Increasing the use of evidence in health policy: practice and views of policy makers and researchers 
Better communication is often suggested as fundamental to increasing the use of research evidence in policy, but little is known about how researchers and policy makers work together or about barriers to exchange. This study explored the views and practice of policy makers and researchers regarding the use of evidence in policy, including: (i) current use of research to inform policy; (ii) dissemination of and access to research findings for policy; (iii) communication and exchange between researchers and policy makers; and (iv) incentives for increasing the use of research in policy.
Separate but similar interview schedules were developed for policy makers and researchers. Senior policy makers from NSW Health and senior researchers from public health and health service research groups in NSW were invited to participate. Consenting participants were interviewed by an independent research company.
Thirty eight policy makers (79% response rate) and 41 researchers (82% response rate) completed interviews. Policy makers reported rarely using research to inform policy agendas or to evaluate the impact of policy; research was used more commonly to inform policy content. Most researchers reported that their research had informed local policy, mainly by increasing awareness of an issue. Policy makers reported difficulty in accessing useful research syntheses, and only a third of researchers reported developing targeted strategies to inform policy makers of their findings. Both policy makers and researchers wanted more exchange and saw this as important for increasing the use of research evidence in policy; however, both groups reported a high level of involvement by policy makers in research.
Policy makers and researchers recognise the potential of research to contribute to policy and are making significant attempts to integrate research into the policy process. These findings suggest four strategies to assist in increasing the use of research in policy: making research findings more accessible to policy makers; increasing opportunities for interaction between policy makers and researchers; addressing structural barriers such as research receptivity in policy agencies and a lack of incentives for academics to link with policy; and increasing the relevance of research to policy.
PMCID: PMC2739528  PMID: 19698186
21.  Community perceptions of mental health needs: a qualitative study in the Solomon Islands 
Psychosocial and mental health needs in the aftermath of conflict and disaster have attracted substantial attention. In the Solomon Islands, the conceptualisation of mental health, for several decades regarded by policy makers as primarily a health issue, has broadened and been incorporated into the national development and social policy agendas, reflecting recognition of the impact of conflict and rapid social change on the psychosocial wellbeing of the community as a whole. We sought to understand how mental health and psychosocial wellbeing were seen at the community level, the extent to which these issues were identified as being associated with periods of 'tension', violence and instability, and the availability of traditional approaches and Ministry of Health services to address these problems.
This article reports the findings of qualitative research conducted in a rural district on the island of Guadalcanal in the Solomon Islands. Key informant interviews were conducted with community leaders, and focus groups were held with women, men and young people. Wellbeing was defined broadly.
Problems of common concern included excessive alcohol and marijuana use, interpersonal violence and abuse, teenage pregnancy, and lack of respect and cooperation. Troubled individuals and their families sought help for mental problems from various sources including chiefs, church leaders and traditional healers and, less often, trauma support workers, health clinic staff and police. Substance-related problems presented special challenges, as there were no traditional solutions at the individual or community level. Severe mental illness was also a challenge, with few aware that a community mental health service existed. Contrary to our expectations, conflict-related trauma was not identified as a major problem by the community who were more concerned about the economic and social sequelae of the conflict.
Communities identify and are responding to a wide range of mental health challenges; the health system generally can do more to learn about how this is being done, and build more comprehensive services and policy on this foundation. The findings underscore the need to promote awareness of those services which are available, to extend mental health care beyond urban centres to rural villages where the majority of the population live, and to promote community input to policy so as to ensure that it 'fits' the context.
PMCID: PMC2667440  PMID: 19284638
22.  Towards enhancing national capacity for evidence informed policy and practice in falls management: a role for a "Translation Task Group"? 
There has been a growing interest over recent years, both within Australia and overseas, in enhancing the translation of research into policy and practice. As one mechanism to improve the dissemination and uptake of falls research into policy and practice and to foster the development of policy-appropriate research, a "Falls Translation Task Group" was formed as part of an NHMRC Population Health Capacity Building grant. This paper reports on the group's first initiative to address issues around the research to policy and practice interface, and identifies a continuing role for such a group.
A one day forum brought together falls researchers and decision-makers from across the nation to facilitate linkage and exchange. Observations of the day's proceedings were made by the authors. Participants were asked to complete a questionnaire at the commencement of the forum (to ascertain expectations) and at its completion (to evaluate the event). Observer notes and the questionnaire responses form the basis of analysis.
Both researchers and decision-makers have a desire to bridge the gap between research and policy and practice. Significant barriers to research uptake were highlighted and included both "health system barriers" (for example, a lack of financial and human resources) as well as "evidence barriers" (such as insufficient economic data and implementation research). Solutions to some of these barriers included the identification of clinical champions within the health sector to enhance evidence uptake, and the sourcing of alternative funding to support implementation research and encourage partnerships between researchers, decision-makers and other stakeholders.
Participants sought opportunities for ongoing networking and collaboration. Two activities have been identified as priorities: establishing a "policy-sensitive" research agenda and partnering researchers and decision-makers in the process; and establishing a National Translation Task Group with a broad membership.
PMCID: PMC1892562  PMID: 17537272
23.  Reconstructing Tuberculosis Services after Major Conflict: Experiences and Lessons Learned in East Timor 
PLoS Medicine  2006;3(10):e383.
Tuberculosis (TB) is a major public health problem in developing countries. Following the disruption to health services in East Timor due to violent political conflict in 1999, the National Tuberculosis Control Program was established, with a local non-government organisation as the lead agency. Within a few months, the TB program was operational in all districts.
Methods and Findings
Using the East Timor TB program as a case study, we have examined the enabling factors for the implementation of this type of communicable disease control program in a post-conflict setting. Stakeholder analysis was undertaken, and semi-structured interviews were conducted in 2003 with 24 key local and international stakeholders. Coordination, cooperation, and collaboration were identified as major contributors to the success of the TB program. The existing local structure and experience of the local non-government organisation, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. This success was achieved despite major impediments, including mass population displacement, lack of infrastructure, and the competing interests of organisations working in the health sector.
Five years after the conflict, the TB program continues to operate in all districts with high notification rates, although the lack of a feeling of ownership by government health workers remains a challenge. Lessons learned in East Timor may be applicable to other post-conflict settings where TB is highly prevalent, and may have relevance to other disease control programs.
A qualitative study of re-introduction of tuberculosis services in East Timor in 1999, after a period of civil conflict, concluded coordination, cooperation, and collaboration contributed to the success achieved.
Editors' Summary
Tuberculosis is an infectious disease and one of the world's most serious health problems. It causes between 2 million and 3 million deaths every year, most of them in developing countries. The success of national control programs has varied considerably between countries. In times of war or other emergencies, control efforts are considerably hampered. East Timor is a former Portuguese colony in Southeast Asia annexed by Indonesia in 1975. It is a small country of about 1 million people situated some 500 miles northwest of Australia. In 1999, following a referendum on independence from Indonesia, violent civil conflict led to the destruction of much of East Timor's health-care system. As tuberculosis was known to be one of the country's biggest health problems, efforts to improve treatment were launched during the transition to independence in 2002. Several organizations, led by a local non-government organization (NGO), Caritas East Timor, collaborated in the new program. Many difficulties had to be overcome, including the forced movement of people away from their homes during the fighting, the departure of many health-care workers from the country, and the destruction of health-care facilities. Nevertheless, in its first three years the program diagnosed and commenced treatment on 10,722 patients. The rate of treatment success reached 81% in 2003, which—in international terms—is regarded as very high.
Why Was This Study Done?
The researchers wanted to find out from the people involved with the program how well they thought it was performing, what its strengths were, and what remained to be achieved. The lessons learned could be of use in other countries, particularly those recovering from civil conflict and other emergencies.
What Did the Researchers Do and Find?
In 2003, the researchers reviewed all available documents that had been written about the tuberculosis program. They also carried out interviews with 24 senior people involved with the program. Some of them were East Timorese, and some were from international organizations. The questions asked in the interviews were semi-structured. In other words, the researchers wanted to make sure that certain topics were covered but also wanted the people they questioned to have freedom in the way they gave their answers; they were not restricted to answering only “yes” or “no.” This kind of approach, where there is no gathering of precise figures that can be mathematically analyzed, is known as qualitative research.
The national tuberculosis program was considered to be working well in 2003. The researchers concluded that good coordination, cooperation, and collaboration were the most important factors contributing to the successes that had been achieved. The existing local structure and experience of the local NGO, the commitment among local personnel and international advisors to establishing an effective program, and the willingness of international advisers and local counterparts to be flexible in their approach were also important factors. The feeling among some government health workers that they lacked “ownership” of the program was one problem that still needed to be overcome.
What Do These Findings Mean?
Even after a major conflict, it was possible to launch an effective tuberculosis program in East Timor. Other countries in similar situations might be able to achieve success by applying the same approach. Unfortunately, renewed conflict broke out in East Timor in 2006. It will again be necessary to restore services, putting to use the lessons already learned.
Additional Information.
Please access these Web sites via the online version of this summary at
Basic information about tuberculosis can be found on the Web site of the US National Institute of Allergy and Infectious Diseases
The Web site of the World Health Organization's Stop TB department describes the recommended strategies for tuberculosis control
TB Alert, a UK-based charity that promotes tuberculosis awareness worldwide, has information on tuberculosis in several European, African, and Asian languages
A country profile of East Timor is available on the BBC Web site
PMCID: PMC1550733  PMID: 16933956
24.  Getting by on credit: how district health managers in Ghana cope with the untimely release of funds 
District health systems in Africa depend largely on public funding. In many countries, not only are these funds insufficient, but they are also released in an untimely fashion, thereby creating serious cash flow problems for district health managers. This paper examines how the untimely release of public sector health funds in Ghana affects district health activities and the way district managers cope with the situation.
A qualitative approach using semi-structured interviews was adopted. Two regions (Northern and Ashanti) covering the northern and southern sectors of Ghana were strategically selected. Sixteen managers (eight directors of health services and eight district health accountants) were interviewed between 2003/2004. Data generated were analysed for themes and patterns.
The results showed that untimely release of funds disrupts the implementation of health activities and demoralises district health staff. However, based on their prior knowledge of when funds are likely to be released, district health managers adopt a range of informal mechanisms to cope with the situation. These include obtaining supplies on credit, borrowing cash internally, pre-purchasing materials, and conserving part of the fourth quarter donor-pooled funds for the first quarter of the next year. While these informal mechanisms have kept the district health system in Ghana running in the face of persistent delays in funding, some of them are open to abuse and could be a potential source of corruption in the health system.
Official recognition of some of these informal managerial strategies will contribute to eliminating potential risks of corruption in the Ghanaian health system and also serve as an acknowledgement of the efforts being made by local managers to keep the district health system functioning in the face of budgetary constraints and funding delays. It may boost the confidence of the managers and even enhance service delivery.
PMCID: PMC1563463  PMID: 16916445
25.  Complex political emergencies  
BMJ : British Medical Journal  2002;324(7333):310-311.
PMCID: PMC1122252  PMID: 11834543

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