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1.  Chronic disease prevention policy in British Columbia and Ontario in light of public health renewal: a comparative policy analysis 
BMC Public Health  2013;13:934.
Background
Public health strategies that focus on legislative and policy change involving chronic disease risk factors such as unhealthy diet and physical inactivity have the potential to prevent chronic diseases and improve quality of life as a whole. However, many public health policies introduced as part of public health reform have not yet been analyzed, such as in British Columbia and Ontario. The purpose of this paper is to present the results of a descriptive, comparative analysis of public health policies related to the Healthy Living Core Program in British Columbia and Chronic Disease Prevention Standard in Ontario that are intended to prevent a range of chronic diseases by promoting healthy eating and physical activity, among other things.
Methods
Policy documents were found through Internet search engines and Ministry websites, at the guidance of policy experts. These included government documents as well as documents from non-governmental organizations that were implementing policies and programs at a provincial level. Documents (n = 31) were then analysed using thematic content analysis to classify, describe and compare policies in a systematic fashion, using the software NVivo.
Results
Three main categories emerged from the analysis of documents: 1) goals for chronic disease prevention in British Columbia and Ontario, 2) components of chronic disease prevention policies, and 3) expected outputs of chronic disease prevention interventions. Although there were many similarities between the two provinces, they differed somewhat in terms of their approach to issues such as evidence, equity, and policy components. Some expected outputs were adoption of healthy behaviours, use of information, healthy environments and increased public awareness.
Conclusions
The two provincial policies present different approaches to support the implementation of related programs. Differences may be related to contextual factors such as program delivery structures and different philosophical approaches underlying the two frameworks. These differences and possible explanations for them are important to understand because they serve to contextualize the differences in health outcomes across the two provinces that might eventually be observed. This analysis informs future public health policy directions as the two provinces can learn from each other.
doi:10.1186/1471-2458-13-934
PMCID: PMC3852936  PMID: 24099140
Health policy analysis; Public health; Health promotion; Healthy eating; Physical activity; Framework for Core Functions in Public Health; Ontario Public Health Standards; Public health systems
2.  Linking public health agencies and hospitals for improved emergency preparedness: North Carolina's public health epidemiologist program 
BMC Public Health  2012;12:141.
Background
In 2003, 11 public health epidemiologists were placed in North Carolina's largest hospitals to enhance communication between public health agencies and healthcare systems for improved emergency preparedness. We describe the specific services public health epidemiologists provide to local health departments, the North Carolina Division of Public Health, and the hospitals in which they are based, and assess the value of these services to stakeholders.
Methods
We surveyed and/or interviewed public health epidemiologists, communicable disease nurses based at local health departments, North Carolina Division of Public Health staff, and public health epidemiologists' hospital supervisors to 1) elicit the services provided by public health epidemiologists in daily practice and during emergencies and 2) examine the value of these services. Interviews were transcribed and imported into ATLAS.ti for coding and analysis. Descriptive analyses were performed on quantitative survey data.
Results
Public health epidemiologists conduct syndromic surveillance of community-acquired infections and potential bioterrorism events, assist local health departments and the North Carolina Division of Public Health with public health investigations, educate clinicians on diseases of public health importance, and enhance communication between hospitals and public health agencies. Stakeholders place on a high value on the unique services provided by public health epidemiologists.
Conclusions
Public health epidemiologists effectively link public health agencies and hospitals to enhance syndromic surveillance, communicable disease management, and public health emergency preparedness and response. This comprehensive description of the program and its value to stakeholders, both in routine daily practice and in responding to a major public health emergency, can inform other states that may wish to establish a similar program as part of their larger public health emergency preparedness and response system.
doi:10.1186/1471-2458-12-141
PMCID: PMC3337284  PMID: 22361231
3.  National support to public health research: a survey of European ministries 
BMC Public Health  2009;9:203.
Background
Within SPHERE (Strengthening Public Health Research in Europe), a collaborative study funded by the European Commission, we have assessed the support for public health research at ministry level in European countries.
Methods
We surveyed the health and science ministries in 25 EU countries and 3 EEA countries, using a broad definition of public-health research at population level. We made over 600 phone calls and emails to identify respondents and to gain answers. We gained formal replies from 42 out of 56 ministries (73% response) in 25 countries. There were 22 completed questionnaires (from 25 ministries), 6 short answers and 11 contacts declaring that their ministries were not responsible for public health research, while in 14 ministries (both ministries in three countries) no suitable ministry contact could be found.
Results
In most European countries, ministries of health, or their devolved agencies, were regarded as the leading organizations. Most ministries were able to specify thematic areas for public-health research (from three to thirty), and others ministries referred to policy documents, health plans or public-health plans to define research priorities. Ministries and their agencies led on decisions for financial support of public-health research, with less involvement of other external organisations compared with the process of identifying priorities. However, the actual funds available for public health were not easily identifiable. Most ministries relied on general academic means for dissemination of results of public-health research, while ministries get information on the use of public-health research usually through informal means. Ministries made suggestions for strengthening public-health research through initiatives of their own countries and of the European Union: as well as more resources, improving coordination was most frequently suggested.
Conclusion
There is no common approach to support for public-health research across Europe, and significant gaps in organisation and funding. Health ministries and national agencies value exchange between researchers and policy-makers, civil society organizations, and academic and public authorities, and the application of public-health research results. There would be benefits from better processes of priority setting and improved coordination for research, at regional, national and European levels.
doi:10.1186/1471-2458-9-203
PMCID: PMC2713230  PMID: 19555492
4.  Public health in community pharmacy: A systematic review of pharmacist and consumer views 
BMC Public Health  2011;11:582.
Background
The increasing involvement of pharmacists in public health will require changes in the behaviour of both pharmacists and the general public. A great deal of research has shown that attitudes and beliefs are important determinants of behaviour. This review aims to examine the beliefs and attitudes of pharmacists and consumers towards pharmaceutical public health in order to inform how best to support and improve this service.
Methods
Five electronic databases were searched for articles published in English between 2001 and 2010. Titles and abstracts were screened by one researcher according to the inclusion criteria. Papers were included if they assessed pharmacy staff or consumer attitudes towards pharmaceutical public health. Full papers identified for inclusion were assessed by a second researcher and data were extracted by one researcher.
Results
From the 5628 papers identified, 63 studies in 67 papers were included. Pharmacy staff: Most pharmacists viewed public health services as important and part of their role but secondary to medicine related roles. Pharmacists' confidence in providing public health services was on the whole average to low. Time was consistently identified as a barrier to providing public health services. Lack of an adequate counselling space, lack of demand and expectation of a negative reaction from customers were also reported by some pharmacists as barriers. A need for further training was identified in relation to a number of public health services. Consumers: Most pharmacy users had never been offered public health services by their pharmacist and did not expect to be offered. Consumers viewed pharmacists as appropriate providers of public health advice but had mixed views on the pharmacists' ability to do this. Satisfaction was found to be high in those that had experienced pharmaceutical public health
Conclusions
There has been little change in customer and pharmacist attitudes since reviews conducted nearly 10 years previously. In order to improve the public health services provided in community pharmacy, training must aim to increase pharmacists' confidence in providing these services. Confident, well trained pharmacists should be able to offer public health service more proactively which is likely to have a positive impact on customer attitudes and health.
doi:10.1186/1471-2458-11-582
PMCID: PMC3146877  PMID: 21777456
5.  Reducing health inequities: the contribution of core public health services in BC 
BMC Public Health  2013;13:550.
Background
Within Canada, many public health leaders have long identified the importance of improving the health of all Canadians especially those who face social and economic disadvantages. Future improvements in population health will be achieved by promoting health equity through action on the social determinants of health. Many Canadian documents, endorsed by government and public health leaders, describe commitments to improving overall health and promoting health equity. Public health has an important role to play in strengthening action on the social determinants and promoting health equity. Currently, public health services in British Columbia are being reorganized and there is a unique opportunity to study the application of an equity lens in public health and the contribution of public health to reducing health inequities. Where applicable, we have chosen mental health promotion, prevention of mental disorders and harms of substance use as exemplars within which to examine specific application of an equity lens.
Methods/design
This research protocol is informed by three theoretical perspectives: complex adaptive systems, critical social justice, and intersectionality. In this program of research, there are four inter-related research projects with an emphasis on both integrated and end of grant knowledge translation. Within an overarching collaborative and participatory approach to research, we use a multiple comparative case study research design and are incorporating multiple methods such as discourse analysis, situational analysis, social network analysis, concept mapping and grounded theory.
Discussion
An important aim of this work is to help ensure a strong public health system that supports public health providers to have the knowledge, skills, tools and resources to undertake the promotion of health equity. This research will contribute to increasing the effectiveness and contributions of public health in reducing unfair and inequitable differences in health among population groups. As a collaborative effort between public health practitioners/decision makers and university researchers, this research will provide important understanding and insights about the implementation of the changes in public health with a specific focus on health equity, the promotion of mental health and the prevention of harms of substance use.
doi:10.1186/1471-2458-13-550
PMCID: PMC3681553  PMID: 23738840
Health inequities; Health equity tools and frameworks; Public health services; Population health interventions; Public health policy; Determinants of health; Ethics and values; Complex adaptive systems; Intersectionality; Critical social justice
6.  A qualitative study of health information technology in the Canadian public health system 
BMC Public Health  2013;13:509.
Background
Although the adoption of health information technology (HIT) has advanced in Canada over the past decade, considerable challenges remain in supporting the development, broad adoption, and effective use of HIT in the public health system. Policy makers and practitioners have long recognized that improvements in HIT infrastructure are necessary to support effective and efficient public health practice. The objective of this study was to identify aspects of health information technology (HIT) policy related to public health in Canada that have succeeded, to identify remaining challenges, and to suggest future directions to improve the adoption and use of HIT in the public health system.
Methods
A qualitative case study was performed with 24 key stakeholders representing national and provincial organizations responsible for establishing policy and strategic direction for health information technology.
Results
Identified benefits of HIT in public health included improved communication among jurisdictions, increased awareness of the need for interoperable systems, and improvement in data standardization. Identified barriers included a lack of national vision and leadership, insufficient investment, and poor conceptualization of the priority areas for implementing HIT in public health.
Conclusions
The application of HIT in public health should focus on automating core processes and identifying innovative applications of HIT to advance public health outcomes. The Public Health Agency of Canada should develop the expertise to lead public health HIT policy and should establish a mechanism for coordinating public health stakeholder input on HIT policy.
doi:10.1186/1471-2458-13-509
PMCID: PMC3665446  PMID: 23705692
Health information technology; Electronic infrastructure; Informatics; Surveillance; Public health; Canada
7.  Public Health Emergency Preparedness and Response Communications with Health Care Providers: A Literature Review 
BMC Public Health  2011;11:337.
Background
Health care providers (HCPs) play an important role in public health emergency preparedness and response (PHEPR) so need to be aware of public health threats and emergencies. To inform HCPs, public health issues PHEPR messages that provide guidelines and updates, and facilitate surveillance so HCPs will recognize and control communicable diseases, prevent excess deaths and mitigate suffering. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. Public health agencies need to know that the PHEPR messages sent to HCPs reach their target audience and are effective and informative. We conducted a literature review to investigate the systems and tools used by public health to generate PHEPR communications to HCPs, and to identify specific characteristics of message delivery mechanisms and formats that may be associated with effective PHEPR communications.
Methods
A systematic review of peer- and non-peer-reviewed literature focused on the following questions: 1) What public health systems exist for communicating PHEPR messages from public health agencies to HCPs? 2) Have these systems been evaluated and, if yes, what criteria were used to evaluate these systems? 3) What have these evaluations discovered about characterizations of the most effective ways for public health agencies to communicate PHEPR messages to HCPs?
Results
We identified 25 systems or tools for communicating PHEPR messages from public health agencies to HCPs. Few articles assessed PHEPR communication systems or messaging methods or outcomes. Only one study compared the effectiveness of the delivery format, device or message itself. We also discovered that the potential is high for HCPs to experience "message overload" given redundancy of PHEPR messaging in multiple formats and/or through different delivery systems.
Conclusions
We found that detailed descriptions of PHEPR messaging from public health to HCPs are scarce in the literature and, even when available are rarely evaluated in any systematic fashion. To meet present-day and future information needs for emergency preparedness, more attention needs to be given to evaluating the effectiveness of these systems in a scientifically rigorous manner.
doi:10.1186/1471-2458-11-337
PMCID: PMC3121631  PMID: 21592390
8.  Detection of events of public health importance under the international health regulations: a toolkit to improve reporting of unusual events by frontline healthcare workers 
BMC Public Health  2011;11:713.
Background
The International Health Regulations (IHR (2005)) require countries to notify WHO of any event which may constitute a public health emergency of international concern. This notification relies on reports of events occurring at the local level reaching the national public health authorities. By June 2012 WHO member states are expected to have implemented the capacity to "detect events involving disease or death above expected levels for the particular time and place" on the local level and report essential information to the appropriate level of public health authority. Our objective was to develop tools to assist European countries improve the reporting of unusual events of public health significance from frontline healthcare workers to public health authorities.
Methods
We investigated obstacles and incentives to event reporting through a systematic literature review and expert consultations with national public health officials from various European countries. Multi-day expert meetings and qualitative interviews were used to gather experiences and examples of public health event reporting. Feedback on specific components of the toolkit was collected from healthcare workers and public health officials throughout the design process.
Results
Evidence from 79 scientific publications, two multi-day expert meetings and seven qualitative interviews stressed the need to clarify concepts and expectations around event reporting in European countries between the frontline and public health authorities. An analytical framework based on three priority areas for improved event reporting (professional engagement, communication and infrastructure) was developed and guided the development of the various tools. We developed a toolkit adaptable to country-specific needs that includes a guidance document for IHR National Focal Points and nine tool templates targeted at clinicians and laboratory staff: five awareness campaign tools, three education and training tools, and an implementation plan. The toolkit emphasizes what to report, the reporting process and the need for follow-up, supported by real examples.
Conclusion
This toolkit addresses the importance of mutual exchange of information between frontline healthcare workers and public health authorities. It may potentially increase frontline healthcare workers' awareness of their role in the detection of events of public health concern, improve communication channels and contribute to creating an enabling environment for event reporting. However, the effectiveness of the toolkit will depend on the national body responsible for dissemination and training.
doi:10.1186/1471-2458-11-713
PMCID: PMC3188493  PMID: 21936937
9.  Public health economics: a systematic review of guidance for the economic evaluation of public health interventions and discussion of key methodological issues 
BMC Public Health  2013;13:1001.
Background
If Public Health is the science and art of how society collectively aims to improve health, and reduce inequalities in health, then Public Health Economics is the science and art of supporting decision making as to how society can use its available resources to best meet these objectives and minimise opportunity cost. A systematic review of published guidance for the economic evaluation of public health interventions within this broad public policy paradigm was conducted.
Methods
Electronic databases and organisation websites were searched using a 22 year time horizon (1990–2012). References of papers were hand searched for additional papers for inclusion. Government reports or peer-reviewed published papers were included if they; referred to the methods of economic evaluation of public health interventions, identified key challenges of conducting economic evaluations of public health interventions or made recommendations for conducting economic evaluations of public health interventions. Guidance was divided into three categories UK guidance, international guidance and observations or guidance provided by individual commentators in the field of public health economics. An assessment of the theoretical frameworks underpinning the guidance was made and served as a rationale for categorising the papers.
Results
We identified 5 international guidance documents, 7 UK guidance documents and 4 documents by individual commentators. The papers reviewed identify the main methodological challenges that face analysts when conducting such evaluations. There is a consensus within the guidance that wider social and environmental costs and benefits should be looked at due to the complex nature of public health. This was reflected in the theoretical underpinning as the majority of guidance was categorised as extra-welfarist.
Conclusions
In this novel review we argue that health economics may have come full circle from its roots in broad public policy economics. We may find it useful to think in this broader paradigm with respect to public health economics. We offer a 12 point checklist to support government, NHS commissioners and individual health economists in their consideration of economic evaluation methodology with respect to the additional challenges of applying health economics to public health.
doi:10.1186/1471-2458-13-1001
PMCID: PMC4015185  PMID: 24153037
Health economics; Public health; Published guidelines; Public sector policy; Inequalities in health; Outcome measurement
10.  One Health and EcoHealth in Ontario: a qualitative study exploring how holistic and integrative approaches are shaping public health practice in Ontario 
BMC Public Health  2012;12:358.
Background
There is a growing recognition that many public health issues are complex and can be best understood by examining the relationship between human health and the health of the ecosystems in which people live. Two approaches, One Health and Ecosystem Approaches to Health (EcoHealth), can help us to better understand these intricate and complex connections, and appear to hold great promise for tackling many modern public health dilemmas. Although both One Health and EcoHealth have garnered recognition from numerous health bodies in Canada and abroad, there is still a need to better understand how these approaches are shaping the practice of public health in Ontario.
The purpose of this study was to characterize how public health actors in Ontario are influenced by the holistic principles which underlie One Health and EcoHealth, and to identify important lessons from their experiences.
Methods
Ten semi-structured interviews were conducted with ten participants from the public health sphere in Ontario. Participants encompassed diverse perspectives including infectious disease, food systems, urban agriculture, and environmental health. Interviews were recorded, transcribed and analyzed using qualitative content analysis to identify major themes and patterns.
Results
Four major themes emerged from the interviews: the importance of connecting human health with the environment; the role of governance in promoting these ideas; the value of partnerships and collaborations in public health practice; and the challenge of operationalizing holistic approaches to public health. Overall study participants were found to be heavily influenced by concepts couched in EcoHealth and One Health literature, despite a lack of familiarity with these fields.
Conclusions
Although One Health and EcoHealth are lesser known approaches in the public health sphere, their holistic and systems-based principles were found to influence the thoughts, values and experiences of public health actors interviewed in this study. This study also highlights the critical role of governance and partnerships in facilitating a holistic approach to health. Further research on governance and partnership models, as well as systems-based organizational working practices, is needed to close the gap between One Health and EcoHealth theory and public health practice.
doi:10.1186/1471-2458-12-358
PMCID: PMC3676168  PMID: 22591618
Public health practice; One Health; EcoHealth; Governance; Sustainability; Cross-sectoral partnerships
11.  Public health preparedness in Alberta: a systems-level study 
BMC Public Health  2006;6:313.
Background
Recent international and national events have brought critical attention to the Canadian public health system and how prepared the system is to respond to various types of contemporary public health threats. This article describes the study design and methods being used to conduct a systems-level analysis of public health preparedness in the province of Alberta, Canada. The project is being funded under the Health Research Fund, Alberta Heritage Foundation for Medical Research.
Methods/Design
We use an embedded, multiple-case study design, integrating qualitative and quantitative methods to measure empirically the degree of inter-organizational coordination existing among public health agencies in Alberta, Canada. We situate our measures of inter-organizational network ties within a systems-level framework to assess the relative influence of inter-organizational ties, individual organizational attributes, and institutional environmental features on public health preparedness. The relative contribution of each component is examined for two potential public health threats: pandemic influenza and West Nile virus.
Discussion
The organizational dimensions of public health preparedness depend on a complex mix of individual organizational characteristics, inter-agency relationships, and institutional environmental factors. Our study is designed to discriminate among these different system components and assess the independent influence of each on the other, as well as the overall level of public health preparedness in Alberta. While all agree that competent organizations and functioning networks are important components of public health preparedness, this study is one of the first to use formal network analysis to study the role of inter-agency networks in the development of prepared public health systems.
doi:10.1186/1471-2458-6-313
PMCID: PMC1779785  PMID: 17194305
12.  Prioritising public health: a qualitative study of decision making to reduce health inequalities 
BMC Public Health  2011;11:821.
Background
The public health system in England is currently facing dramatic change. Renewed attention has recently been paid to the best approaches for tackling the health inequalities which remain entrenched within British society and across the globe. In order to consider the opportunities and challenges facing the new public health system in England, we explored the current experiences of those involved in decision making to reduce health inequalities, taking cardiovascular disease (CVD) as a case study.
Methods
We conducted an in-depth qualitative study employing 40 semi-structured interviews and three focus group discussions. Participants were public health policy makers and planners in CVD in the UK, including: Primary Care Trust and Local Authority staff (in various roles); General Practice commissioners; public health academics; consultant cardiologists; national guideline managers; members of guideline development groups, civil servants; and CVD third sector staff.
Results
The short term target- and outcome-led culture of the NHS and the drive to achieve "more for less", combined with the need to address public demand for acute services often lead to investment in "downstream" public health intervention, rather than the "upstream" approaches that are most effective at reducing inequalities. Despite most public health decision makers wishing to redress this imbalance, they felt constrained due to difficulties in partnership working and the over-riding influence of other stakeholders in decision making processes. The proposed public health reforms in England present an opportunity for public health to move away from the medical paradigm of the NHS. However, they also reveal a reluctance of central government to contribute to shifting social norms.
Conclusions
It is vital that the effectiveness and cost effectiveness of all new and existing policies and services affecting public health are measured in terms of their impact on the social determinants of health and health inequalities. Researchers have a vital role to play in providing the complex evidence required to compare different models of prevention and service delivery. Those working in public health must develop leadership to raise the profile of health inequalities as an issue that merits attention, resources and workforce capacity; and advocate for central government to play a key role in shifting social norms.
doi:10.1186/1471-2458-11-821
PMCID: PMC3206485  PMID: 22014291
13.  Perceived challenges to public health in Central and Eastern Europe: a qualitative analysis 
BMC Public Health  2012;12:311.
Background
There is a major gradient in burden of disease between Central and Eastern Europe compared to Western Europe. Many of the underlying causes and risk factors are amenable to public health interventions. The purpose of the study was to explore perceptions of public health experts from Central and Eastern European countries on public health challenges in their countries.
Methods
We invited 179 public health experts from Central and Eastern European countries to a 2-day workshop in Berlin, Germany. A total of 25 public health experts from 14 countries participated in May 2008. The workshop was structured into 8 sessions of 1.5 hours each, with the topic areas covering coronary heart disease, stroke, prevention, obesity, alcohol, tobacco, tuberculosis, and HIV/AIDS. The workshop was recorded and the proceedings transcribed verbatim. The transcripts were entered into atlas.ti for content analysis and coded according to the session headings. After analysis of the content of each session discussion, a re-coding of the discussions took place based on the themes that emerged from the analysis.
Results
Themes discussed recurred across disease entities and sessions. Major themes were the relationship between clinical medicine and public health, the need for public health funding, and the problems of proving the effectiveness of disease prevention. Areas for action identified included the need to engage with the public, to create a better scientific basis for public health interventions, to identify “best practices” of disease prevention, and to implement registries/surveillance instruments. The need for improved data collection was seen throughout all areas discussed, as was the need to harmonize data across countries.
Conclusions
To reduce the burden of disease across Europe, closer collaboration of countries across Europe seems important in order to learn from each other. A more credible scientific basis for effective public health interventions is urgently needed. The monitoring of health trends is crucial to evaluate the impact of public health programmes.
doi:10.1186/1471-2458-12-311
PMCID: PMC3370990  PMID: 22537389
14.  pH1N1 - a comparative analysis of public health responses in Ontario to the influenza outbreak, public health and primary care: lessons learned and policy suggestions 
BMC Public Health  2013;13:687.
Background
Ontario’s 36 Public Health Units (PHUs) were responsible for implementing the H1N1 Pandemic Influenza Plans (PIPs) to address the first pandemic influenza virus in over 40 years. It was the first under conditions which permitted mass immunization. This is therefore the first opportunity to learn and document what worked well, and did not work well, in Ontario’s response to pH1N1, and to make recommendations based on experience.
Methods
Our objectives were to: describe the PIP models, obtain perceptions on outcomes, lessons learned and to solicit policy suggestions for improvement. We conducted a 3-phase comparative analysis study comprised of semi-structured key informant interviews with local Medical Officers of Health (n = 29 of 36), and Primary Care Physicians (n = 20) and in Phase 3 with provincial Chief-Medical Officers of Health (n = 6) and a provincial Medical Organization. Phase 2 data came from a Pan-Ontario symposium (n = 44) comprised leaders representing: Public Health, Primary Care, Provincial and Federal Government.
Results
PIPs varied resulting in diverse experiences and lessons learned. This was in part due to different PHU characteristics that included: degree of planning, PHU and Primary Care capacity, population, geographic and relationships with Primary Care. Main lessons learned were: 1) Planning should be more comprehensive and operationalized at all levels. 2) Improve national and provincial communication strategies and eliminate contradictory messages from different sources. 3) An integrated community-wide response may be the best approach to decrease the impact of a pandemic. 4) The best Mass Immunization models can be quickly implemented and have high immunization rates. They should be flexible and allow for incremental responses that are based upon: i) pandemic severity, ii) local health system, population and geographic characteristics, iii) immunization objectives, and iv) vaccine supply.
Conclusion
“We were very lucky that pH1N1 was not more severe.” Consensus existed for more detailed planning and the inclusion of multiple health system and community stakeholders. PIPs should be flexible, allow for incremental responses and have important decisions (E.g., under which conditions Public Health, Primary Care, Pharmacists or others act as vaccine delivery agents.) made prior to a crisis.
doi:10.1186/1471-2458-13-687
PMCID: PMC3726397  PMID: 23890226
pH1N1; Pandemic influenza plans; Influenza responses; Public health; Primary care; Mass immunization; Public health policy
15.  Validation of public health competencies and impact variables for low- and middle-income countries 
BMC Public Health  2014;14:55.
Background
The number of Master of Public Health (MPH) programmes in low- and middle-income countries (LMICs) is increasing, but questions have been raised regarding the relevance of their outcomes and impacts on context. Although processes for validating public health competencies have taken place in recent years in many high-income countries, validation in LMICs is needed. Furthermore, impact variables of MPH programmes in the workplace and in society have not been developed.
Method
A set of public health competencies and impact variables in the workplace and in society was designed using the competencies and learning objectives of six participating institutions offering MPH programmes in or for LMICs, and the set of competencies of the Council on Linkages Between Academia and Public Health Practice as a reference. The resulting competencies and impact variables differ from those of the Council on Linkages in scope and emphasis on social determinants of health, context specificity and intersectoral competencies. A modified Delphi method was used in this study to validate the public health competencies and impact variables; experts and MPH alumni from China, Vietnam, South Africa, Sudan, Mexico and the Netherlands reviewed them and made recommendations.
Results
The competencies and variables were validated across two Delphi rounds, first with public health experts (N = 31) from the six countries, then with MPH alumni (N = 30). After the first expert round, competencies and impact variables were refined based on the quantitative results and qualitative comments. Both rounds showed high consensus, more so for the competencies than the impact variables. The response rate was 100%.
Conclusion
This is the first time that public health competencies have been validated in LMICs across continents. It is also the first time that impact variables of MPH programmes have been proposed and validated in LMICs across continents. The high degree of consensus between experts and alumni suggests that these public health competencies and impact variables can be used to design and evaluate MPH programmes, as well as for individual and team assessment and continuous professional development in LMICs.
doi:10.1186/1471-2458-14-55
PMCID: PMC3899921  PMID: 24438672
Public health competencies; Impact; Low- and middle-income countries; Master of Public Health
16.  Projection scenarios of body mass index (2013–2030) for Public Health Planning in Quebec 
BMC Public Health  2014;14(1):996.
Background
Projection analyses can provide estimates of the future health burden of increasing BMI and represent a relevant and useful tool for public health planning. Our study presents long-term (2013–2030) projections of the prevalence and numbers of individuals by BMI category for adult men and women in Quebec. Three applications of projections to estimate outcomes more directly pertinent to public health planning, as well as an in-depth discussion of limits, are provided with the aim of encouraging greater use of projection analyses by public health officers.
Methods
The weighted compositional regression method is applied to prevalence time series derived from sixteen cross-sectional survey cycles, for scenarios of linear change and deceleration. Estimation of the component of projected change potentially amenable to intervention, future health targets and the projected impact on type 2 diabetes, were done.
Results
Obesity prevalence in Quebec is projected to rise steadily from 2013 to 2030 in both men (from 18.0-19.4% to 22.2-30.4%) and women (from 15.5-16.3% to 18.2-22.4%). Corresponding projected numbers of obese individuals are (579,000-625,000 to 790,000-1,084,000) in men and (514,000-543,000 to 661,000-816,000) in women. These projected increases are found to be primarily an ‘epidemiologic’ rather than ‘demographic’ phenomenon and thus potentially amenable to public health intervention. Assessment of obesity targets for 2020 illustrates the necessity of using projected rather than current prevalence; for example a targeted 2% drop in obesity prevalence relative to 2013 translates into a 3.6-5.4% drop relative to 2020 projected levels. Type 2 diabetes is projected to increase from 6.9% to 9.2-10.1% in men and from 5.7% to 7.1-7.5% in women, from 2011–2012 to 2030. A substantial proportion of this change (25-44% for men, and 27-43% for women) is attributable to the changing BMI distribution.
Conclusions
Obesity in Quebec is projected to increase and should therefore continue to be a public health priority. Application of projections to estimate the proportion of change potentially amenable to intervention, feasible health targets, and future chronic disease prevalence are demonstrated. Projection analyses have limitations, but represent a pertinent tool for public health planning.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-996) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-996
PMCID: PMC4196088  PMID: 25253196
Projections; Forecasting; Obesity; Body mass index; Type 2 diabetes; Health targets; Public health; Public health planning; Health burden
17.  Public health management of antiviral drugs during the 2009 H1N1 influenza pandemic: a survey of local health departments in California 
BMC Public Health  2012;12:82.
Background
The large-scale deployment of antiviral drugs from the Strategic National Stockpile during the 2009 H1N1 influenza response provides a unique opportunity to study local public health implementation of the medical countermeasure dispensing capability in a prolonged event of national significance. This study aims to describe the range of methods used by local health departments (LHDs) in California to manage antiviral activities and to gain a better understanding of the related challenges experienced by health departments and their community partners.
Methods
This research employed a mixed-methods approach. First, a multi-disciplinary focus group of pandemic influenza planners from key stakeholder groups in California was convened in order to generate ideas and identify critical themes related to the local implementation of antiviral activities during the H1N1 influenza response. These qualitative data informed the development of a web-based survey, which was distributed to all 61 LHDs in California for the purpose of assessing the experiences of a representative sample of local health agencies in a large region.
Results
Forty-four LHDs participated in this study, representing 72% of the local public health agencies in California. While most communities dispensed a modest number of publicly purchased antivirals, LHDs nevertheless drew on their previous work and engaged in a number of antiviral activities, including: acquiring, allocating, distributing, dispensing, tracking, developing guidance, and communicating to the public and clinical community. LHDs also identified specific antiviral challenges presented by the H1N1 pandemic, including: reconciling multiple sources and versions of antiviral guidance, determining appropriate uses and recipients of publicly purchased antivirals, and staffing shortages.
Conclusions
The 2009 H1N1 influenza pandemic presented an unusual opportunity to learn about the role of local public health in the management of antiviral response activities during a real public health emergency. Results of this study offer an important descriptive account of LHD management of publicly purchased antivirals, and provide practitioners, policy makers, and academics with a practice-based assessment of these events. The issues raised and the challenges faced by LHDs should be leveraged to inform public health planning for future pandemics and other emergency events that require medical countermeasure dispensing activities.
doi:10.1186/1471-2458-12-82
PMCID: PMC3323435  PMID: 22276659
Public health preparedness and response; Public health systems research; Influenza
18.  Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework 
BMC Public Health  2014;14(1):1195.
Background
Countries across Europe have introduced a wide variety of policies to improve nutrition. However, the sheer diversity of interventions represents a potentially bewildering smorgasbord.
We aimed to map existing public health nutrition policies, and examine their perceived effectiveness, in order to inform future evidence-based diet strategies.
Methods
We created a public health nutrition policy database for 30 European countries . National nutrition policies were classified and assigned using the marketing "4Ps" approach Product (reformulation, elimination, new healthier products); Price (taxes, subsidies); Promotion (advertising, food labelling, health education) and Place (schools, workplaces, etc.).
We interviewed 71 senior policy-makers, public health nutrition policy experts and academics from 14 of the 30 countries, eliciting their views on diverse current and possible nutrition strategies.
Results
Product Voluntary reformulation of foods is widespread but has variable and often modest impact. Twelve countries regulate maximum salt content in specific foods.
Denmark, Austria, Iceland and Switzerland have effective trans fats bans.
Price EU School Fruit Scheme subsidies are almost universal, but with variable implementation.
Taxes are uncommon. However, Finland, France, Hungary and Latvia have implemented ‘sugar taxes’ on sugary foods and sugar-sweetened beverages. Finland, Hungary and Portugal also tax salty products.
Promotion Dialogue, recommendations, nutrition guidelines, labelling, information and education campaigns are widespread. Restrictions on marketing to children are widespread but mostly voluntary.
Place Interventions reducing the availability of unhealthy foods were most commonly found in schools and workplace canteens.
Interviewees generally considered mandatory reformulation more effective than voluntary, and regulation and fiscal interventions much more effective than information strategies, but also politically more challenging.
Conclusions
Public health nutrition policies in Europe appear diverse, dynamic, complex and bewildering. The "4Ps" framework potentially offers a structured and comprehensive categorisation.
Encouragingly, the majority of European countries are engaged in activities intended to increase consumption of healthy food and decrease the intake of "junk" food and sugary drinks. Leading countries include Finland, Norway, Iceland, Denmark, Hungary, Portugal and perhaps the UK. However, all countries fall short of optimal activities. More needs to be done across Europe to implement the most potentially powerful fiscal and regulatory nutrition policies.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1195) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1195
PMCID: PMC4251675  PMID: 25413832
Public health nutrition; Public health policy; Europe; Food policy mapping; Qualitative
19.  The epidemiology and surveillance response to pandemic influenza A (H1N1) among local health departments in the San Francisco Bay Area 
BMC Public Health  2013;13:276.
Background
Public health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. Very little is known about how these functions are conducted at the local level. The purpose of the Epidemiology Networks in Action (EpiNet) Study was to describe the epidemiology and surveillance response to the 2009 pandemic influenza A (H1N1) by city and county health departments in the San Francisco Bay Area in California. The study also documented lessons learned from the response in order to strengthen future public health preparedness and response planning efforts in the region.
Methods
In order to characterize the epidemiology and surveillance response, we conducted key informant interviews with public health professionals from twelve local health departments in the San Francisco Bay Area. In order to contextualize aspects of organizational response and performance, we recruited two types of key informants: public health professionals who were involved with the epidemiology and surveillance response for each jurisdiction, as well as the health officer or his/her designee responsible for H1N1 response activities. Information about the organization, data sources for situation awareness, decision-making, and issues related to surge capacity, continuity of operations, and sustainability were collected during the key informant interviews. Content and interpretive analyses were conducted using ATLAS.ti software.
Results
The study found that disease investigations were important in the first months of the pandemic, often requiring additional staff support and sometimes forcing other public health activities to be put on hold. We also found that while the Incident Command System (ICS) was used by all participating agencies to manage the response, the manner in which it was implemented and utilized varied. Each local health department (LHD) in the study collected epidemiologic data from a variety of sources, but only case reports (including hospitalized and fatal cases) and laboratory testing data were used by all organizations. While almost every LHD attempted to collect school absenteeism data, many respondents reported problems in collecting and analyzing these data. Laboratory capacity to test influenza specimens often aided an LHD’s ability to conduct disease investigations and implement control measures, but the ability to test specimens varied across the region and even well-equipped laboratories exceeded their capacity. As a whole, the health jurisdictions in the region communicated regularly about key decision-making (continued on next page) (continued from previous page) related to the response, and prior regional collaboration on pandemic influenza planning helped to prepare the region for the novel H1N1 influenza pandemic. The study did find, however, that many respondents (including the majority of epidemiologists interviewed) desired an increase in regional communication about epidemiology and surveillance issues.
Conclusion
The study collected information about the epidemiology and surveillance response among LHDs in the San Francisco Bay Area that has implications for public health preparedness and emergency response training, public health best practices, regional public health collaboration, and a perceived need for information sharing.
doi:10.1186/1471-2458-13-276
PMCID: PMC3681650  PMID: 23530722
Influenza A (H1N1); Epidemiology; Surveillance; Public health preparedness; Public health emergency response
20.  Media actors’ perceptions of their roles in reporting food incidents 
BMC Public Health  2014;14(1):1305.
Background
Previous research has shown that the media can play a role in shaping consumer perceptions during a public health crisis. In order for public health professionals to communicate well-informed health information to the media, it is important that they understand how media view their role in transmitting public health information to consumers and decide what information to present. This paper reports the perceptions of media actors from three countries about their role in reporting information during a food incident. This information is used to present ideas and suggestions for public health professionals working with media during food incidents.
Methods
Thirty three semi-structured interviews with media actors from Australia, New Zealand and the United Kingdom were conducted and analysed thematically. Media actors were recruited via purposive sampling using a sampling strategy, from a variety of formats including newspaper, television, radio and online.
Results
Media actors said that during a food incident, they play two roles. First, they play a role in communicating information to consumers by acting as a conduit for information between the public and the relevant authorities. Second, they play a role as investigators by acting as a public watchdog.
Conclusion
Media actors are an important source of consumer information during food incidents. Public health professionals can work with media by actively approaching them with information about food incidents; promoting to media that as public health professionals, they are best placed to provide the facts about food incidents; and by providing angles for further investigation and directing media to relevant and correct information to inform such investigations. Public health professionals who adapt how they work with media are more likely to influence media to portray messages that fit what they would like the public to know and that are in line with public health recommendations and enable consumers to engage in safe and health promoting behaviours in response to food incidents.
doi:10.1186/1471-2458-14-1305
PMCID: PMC4301931  PMID: 25524217
Food; Food incident; Media; Public health; Public health professional
21.  Planning ahead in public health? A qualitative study of the time horizons used in public health decision-making 
BMC Public Health  2008;8:415.
Background
In order to better understand factors that influence decisions for public health, we undertook a qualitative study to explore issues relating to the time horizons used in decision-making.
Methods
Qualitative study using semi-structured interviews. 33 individuals involved in the decision making process around coronary heart disease were purposively sampled from the UK National Health Service (national, regional and local levels), academia and voluntary organizations. Analysis was based on the framework method using N-VIVO software. Interviews were transcribed, coded and emergent themes identified.
Results
Many participants suggested that the timescales for public health decision-making are too short. Commissioners and some practitioners working at the national level particularly felt constrained in terms of planning for the long-term. Furthermore respondents felt that longer term planning was needed to address the wider determinants of health and to achieve societal level changes. Three prominent 'systems' issues were identified as important drivers of short term thinking: the need to demonstrate impact within the 4 year political cycle; the requirement to 'balance the books' within the annual commissioning cycle and the disruption caused by frequent re-organisations within the health service. In addition respondents suggested that the tools and evidence base for longer term planning were not well established.
Conclusion
Many public health decision and policy makers feel that the timescales for decision-making are too short. Substantial systemic barriers to longer-term planning exist. Policy makers need to look beyond short-term targets and budget cycles to secure investment for long-term improvement in public health.
doi:10.1186/1471-2458-8-415
PMCID: PMC2649072  PMID: 19094194
22.  The use of syndromic surveillance for decision-making during the H1N1 pandemic: A qualitative study 
BMC Public Health  2012;12:929.
Background
Although an increasing number of studies are documenting uses of syndromic surveillance by front line public health, few detail the value added from linking syndromic data to public health decision-making. This study seeks to understand how syndromic data informed specific public health actions during the 2009 H1N1 pandemic.
Methods
Semi-structured telephone interviews were conducted with participants from Ontario’s public health departments, the provincial ministry of health and federal public health agency to gather information about syndromic surveillance systems used and the role of syndromic data in informing specific public health actions taken during the pandemic. Responses were compared with how the same decisions were made by non-syndromic surveillance users.
Results
Findings from 56 interviews (82% response) show that syndromic data were most used for monitoring virus activity, measuring impact on the health care system and informing the opening of influenza assessment centres in several jurisdictions, and supporting communications and messaging, rather than its intended purpose of early outbreak detection. Syndromic data had limited impact on decisions that involved the operation of immunization clinics, school closures, sending information letters home with school children or providing recommendations to health care providers. Both syndromic surveillance users and non-users reported that guidance from the provincial ministry of health, communications with stakeholders and vaccine availability were driving factors in these public health decisions.
Conclusions
Syndromic surveillance had limited use in decision-making during the 2009 H1N1 pandemic in Ontario. This study provides insights into the reasons why this occurred. Despite this, syndromic data were valued for providing situational awareness and confidence to support public communications and recommendations. Developing an understanding of how syndromic data are utilized during public health events provides valuable evidence to support future investments in public health surveillance.
doi:10.1186/1471-2458-12-929
PMCID: PMC3539916  PMID: 23110473
Decision making; Pandemic influenza; Public health; Surveillance; Syndromic surveillance
23.  Pain as a global public health priority 
BMC Public Health  2011;11:770.
Background
Pain is an enormous problem globally. Estimates suggest that 20% of adults suffer from pain globally and 10% are newly diagnosed with chronic pain each year. Nevertheless, the problem of pain has primarily been regarded as a medical problem, and has been little addressed by the field of public health.
Discussion
Despite the ubiquity of pain, whether acute, chronic or intermittent, public health scholars and practitioners have not addressed this issue as a public health problem. The importance of viewing pain through a public health lens allows one to understand pain as a multifaceted, interdisciplinary problem for which many of the causes are the social determinants of health. Addressing pain as a global public health issue will also aid in priority setting and formulating public health policy to address this problem, which, like most other chronic non-communicable diseases, is growing both in absolute numbers and in its inequitable distribution across the globe.
Summary
The prevalence, incidence, and vast social and health consequences of global pain requires that the public health community give due attention to this issue. Doing so will mean that health care providers and public health professionals will have a more comprehensive understanding of pain and the appropriate public health and social policy responses to this problem.
doi:10.1186/1471-2458-11-770
PMCID: PMC3201926  PMID: 21978149
24.  A knowledge management tool for public health: health-evidence.ca 
BMC Public Health  2010;10:496.
Background
The ultimate goal of knowledge translation and exchange (KTE) activities is to facilitate incorporation of research knowledge into program and policy development decision making. Evidence-informed decision making involves translation of the best available evidence from a systematically collected, appraised, and analyzed body of knowledge. Knowledge management (KM) is emerging as a key factor contributing to the realization of evidence-informed public health decision making. The goal of health-evidence.ca is to promote evidence-informed public health decision making through facilitation of decision maker access to, retrieval, and use of the best available synthesized research evidence evaluating the effectiveness of public health interventions.
Methods
The systematic reviews that populate health evidence.ca are identified through an extensive search (1985-present) of 7 electronic databases: MEDLINE, EMBASE, CINAHL, PsycINFO, Sociological Abstracts, BIOSIS, and SportDiscus; handsearching of over 20 journals; and reference list searches of all relevant reviews. Reviews are assessed for relevance and quality by two independent reviewers. Commonly-used public health terms are used to assign key words to each review, and project staff members compose short summaries highlighting results and implications for policy and practice.
Results
As of June 2010, there are 1913 reviews in the health-evidence.ca registry in 21 public health and health promotion topic areas. Of these, 78% have been assessed as being of strong or moderate methodological quality. Health-evidence.ca receives approximately 35,000 visits per year, 20,596 of which are unique visitors, representing approximately 100 visits per day. Just under half of all visitors return to the site, with the average user spending six minutes and visiting seven pages per visit. Public health nurses, program managers, health promotion workers, researchers, and program coordinators are among the largest groups of registered users, followed by librarians, dieticians, medical officers of health, and nutritionists. The majority of users (67%) access the website from direct traffic (e.g., have the health-evidence.ca webpage bookmarked, or type it directly into their browser).
Conclusions
Consistent use of health-evidence.ca and particularly the searching for reviews that correspond with current public health priorities illustrates that health-evidence.ca may be playing an important role in achieving evidence-informed public health decision making.
doi:10.1186/1471-2458-10-496
PMCID: PMC2936422  PMID: 20718970
25.  A systematic review of barriers to data sharing in public health 
BMC Public Health  2014;14(1):1144.
Background
In the current information age, the use of data has become essential for decision making in public health at the local, national, and global level. Despite a global commitment to the use and sharing of public health data, this can be challenging in reality. No systematic framework or global operational guidelines have been created for data sharing in public health. Barriers at different levels have limited data sharing but have only been anecdotally discussed or in the context of specific case studies. Incomplete systematic evidence on the scope and variety of these barriers has limited opportunities to maximize the value and use of public health data for science and policy.
Methods
We conducted a systematic literature review of potential barriers to public health data sharing. Documents that described barriers to sharing of routinely collected public health data were eligible for inclusion and reviewed independently by a team of experts. We grouped identified barriers in a taxonomy for a focused international dialogue on solutions.
Results
Twenty potential barriers were identified and classified in six categories: technical, motivational, economic, political, legal and ethical. The first three categories are deeply rooted in well-known challenges of health information systems for which structural solutions have yet to be found; the last three have solutions that lie in an international dialogue aimed at generating consensus on policies and instruments for data sharing.
Conclusions
The simultaneous effect of multiple interacting barriers ranging from technical to intangible issues has greatly complicated advances in public health data sharing. A systematic framework of barriers to data sharing in public health will be essential to accelerate the use of valuable information for the global good.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1144) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1144
PMCID: PMC4239377  PMID: 25377061
Data sharing; Public health; Surveillance

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