Month: February 2019

Introduction

History of modern society is riddled with public health breakthroughs. Advances based on the notion of prevention of disease and promotion of good health allowed for better living conditions, safe transportation, diverse and nourishing diets, and numerous other standards of developed societies most of us take for granted.

In retrospect, we praise much of those advances as prototypal public health measures. Did ingenious minds behind those actions perceive themselves as public health pioneers? One might even argue that they needn’t identify as such (1). John Snow, Louis Pasteur and Robert Koch transformed the world through their work and for that they only had to subscribe to the ideal of public health – not to the profession. They were inventors that spawned a health revolution. But times have changed. We are faced with globalised world, global warming and regular political tantrums with possibly perilous consequences (2). Nations of the world are putting health high on the agenda with concerted actions such as Millennium Development Goals and Sustainable Development Goals (3). Further advancement of public health demands a different toolset and approaches from those of past eras. This holds true for public health practice on international as well as on an national or even local level (4). Modern challenges of public health require a workforce with capacities to address and overcome them (5,6). Public health practitioners of today and tomorrow need to be leaders as much as scientists and inventors (7). Development of such a workforce is the common theme of following reflections provided by a group of professionals with deep insight into education and training practices in public health.

The collection of reflections starts with an overview of current status and recent initiatives in public health workforce development in the European region written by Robert Otok, Katarzyna Czabanowska, and John Middleton who are all active in Association of Schools of Public Health in the European Region, a key independent European organisation dedicated to strengthening the role of public health by improving education and training of public health professionals for both practice and research.

Alberto Mateo, president of the European Network of Medical Residents in Public Health, further reflects on the topic of international cooperation and on importance of internationally harmonised curricula in public health education. Afterwards authors focus on analysing and reflecting on public health workforce development in Slovenia. Tit Albreht from National Institute of Public Health addresses the challenge of diversification of public health workforce in Slovenia. In his commentary, he stresses the importance of standard education as well as continuous professional development. Recognising the importance of having a modern and comprehensive public health educational programme for medical residents, Lijana Zaletel Kragelj from Faculty of Medicine at University of Ljubljana provides us with a summary of the transformation of Slovenian public health specialty training programme from its conception and offers us with a glimpse of what we can expect in near future. Ivan Eržen from National Institute of Public Health completes the overview of graduate and postgraduate programmes which offer public health topics in their curriculums. Acknowledging the limitations of current landscape of educational opportunities in public health he points out the need for a school of public health which has yet to be established in Slovenia. In the following commentary, Marjan Premik, one of the main protagonists of establishment of school of public health in Slovenia, introduces arguments for school of public health as an integral part of health care system. Putting the emphasis on the wider public health workforce, Mitja Vrdelja from National Institute of Public Health, gives his view on working in public health in Slovenia from a communications expert perspective and complements reflections on workforce developments from previous authors with challenges that could be solved with appropriate education and training of public health workforce. Current Perspectives are rounded up with a playful note by a discussion I had with Damir Ivanković, a former public health resident from Croatia who is presently a researcher at the Academic Medical Center in Amsterdam. Since both of us are a young public health professionals from relatively small countries we take a look at benefits and drawbacks of starting a career in such an environment.

Matej Vinko
National Institute of Public Health of Slovenia, Ljubljana, Slovenia

Keep reading the article at:
http://www.nijz.si/sites/www.nijz.si/files/uploaded/vinko_jz_03-06.pdf

References

1. Nijhuis HG, van der Maesen LJ. The philosophical foundations of public health: an invitation to debate. J Epidemiol Community Health. februar 1994.;48(1):1–3.
2. Lomazzi M, Jenkins C, Borisch B. Global public health today: connecting the dots. Glob Health Action. 2016.;9:28772.
3. Sachs JD. From Millennium Development Goals to Sustainable Development Goals. The Lancet. 9. junij 2012.;379(9832):2206–11.
4. Birt CA, Foldspang A, Otok R. Meeting the population health challenge: what should you know, and what should you be able to do? Eur J Public Health. oktober 2018.;28(5):789–90.
5. Bjegovic-Mikanovic V, Foldspang A, Jakubowski E, Müller-Nordhorn J, Otok R, Stjernberg L. Developing the public health workforce. Eurohealth Inc Eur Obs. 2015.;21(1):24–7.
6. Collyer TA. Three Metaphors to Aid Interdisciplinary Dialogue in Public Health. Am J Public Health. 25. september 2018.;e1–4.
7. Czabanowska K, Rethmeier KA, Lueddeke G, Smith T, Malho A, Otok R, in sod. Public health in the 21st century: working differently means leading and learning differently. Eur J Public Health. december 2014.;24(6):1047–52.

As published in Revija Javno zdravje

“Proudly by ourselves” – this was a Portuguese nationalist slogan advertised before April 25th 1974 revolution. However, globalization changed the paradigm of international relationships and communication technologies connected the whole world by a simple click. We no longer live in a place where our actions have no consequences, but rather influence people and the environment around us – both as individuals and through organizations.

As you know, Public Health was defined by Acheson as “the science and art of preventing disease, prolonging life and promoting health through organized community efforts” and Ottawa Charter for Health Promotion called for “community health partnerships, health alliances or socio-ecological approaches to prevention and health promotion”.

Therefore, non-governmental organizations (NGO) play an interesting role in promoting community development while remaining independent from governments. Currently, some of the most important European NGOs in Public Health area are ASPHER (Association of School of Public Health in Europe), EHMA (European Health Management Association) and EUPHA (European Public Health Association)¹. The aim of most of these kind of organizations is to bring together experts to develop innovative health research and implement it through effective policy making.

Another perfect example of cooperation between European public health professionals is the European Network of Medical Residents in Public Health (EuroNet MRPH), which gathers 10 national based Public Health associations training programs.

Following its mission, EuroNet MRPH aims to promote the sharing of educational opportunities, facilitate exchange internships and develop international scientific research. Euronet-like networks are keen on knowledge transferring, research collaboration and they create a unique environment for ideas to develop, encouraging the rapid spread of information in Europe.

The lack of bureaucracy (but not organizational anarchy) among networks is one of its strengths when comparing to governments and institutions, which makes it so useful in creating knowledge, exchanging information and spreading good practice². Individuals from different organizations and areas can collaborate free from the constraints that exist in more hierarchical models³. Also, collaborative papers tend to get cited more often, which is an important “bonus”⁴.

Summing up, networks should focus on five specific pillars:

• A common purpose that promote a sense of belonging of its members and a commitment in moving in the same direction;
• A cooperative structure that allows people to work together across organizations;
• A critical mass that increases value for members and society;
• Collective intelligence, as members share and learn from each other and;
• A sense of community built through relationships.

Figure 1. The 5C Wheel, including core features of an effective network⁴

Right now, in my opinion, EuroNet MRPH follows the main essentials for a successful network. That is amazing in such a short period of time, while having room for development, especially regarding partnerships and cooperation. Networks are just the bottom level of a collaboration hierarchy, gathering a huge potential for development and expansion for the following years, until they achieve a full collaboration status⁵.

Partnerships can be defined as “contextually relevant peer-to-peer collaborations which offer a platform for sharing knowledge and growing expertise globally, working towards a common goal, across disciplines and perspectives”⁶. This allows organizations to explore their differences and find solutions beyond their limited visions⁷.

Similar to networks’ main pillars, partnerships also need⁶:

• Focus: a common goal that keeps partners focused on their objectives;
• Values: a commitment and trust between partners;
• Equity: adequate sharing of resources and respect for different capacities;
• Mutual benefits: based on knowledge exchange and skills development;
• Communication: through meetings, agendas and reports sharedon time;
• Leadership: accountability and delegation of roles to organize common efforts and;
• Resolution: determination and mediation in conflict resolution between partners.

As discussed in 2018’s Winter Meeting, communication and partnerships are fields where Euronet MRPH needs to invest some workforce and time, in order to develop proper foundations for the future. As referred by Rahman, EUPHA added value to members association through contact to other European Public Health Associations and more ideas for research and collaboration, among others¹. Therefore, members of both organizations in a partnership also expect to develop future collaborations through existing ones.

Addressing the big elephant in the room, there are hundreds of public health related institutes and NGOs in Europe. Many of them are already connected but it’s crucial to align most important NGOs agendas in Public Health, strengthening integration policies and influence⁸. While integrating activities in a single network is already a complicated task, integration of activities between different organizations it’s even more problematic – but when well coordinated, they have a bigger impact.

Challenges in Public Health collaboration will be hard to tackle, but young professionals willingness to act and innovate play a crucial role. Today, in my opinion, Euronet MPRH is a successful network with a clear direction, encouraging innovation and quality improvement. There is a potential in advocacy for Public Health residents and promoting community driven initiatives which still remains on hold, while a broader influence in European Public Health can also be addressed through more meaningful and structured partnerships.

In the Velika Planina winter meeting, Euronet MRPH members discussed the role of partnerships for the future of the network and there was a call for reviewing Euronet MRPH partnerships in an objective way, highlighting the need for meaningful and relevant benefits for enrolled public health residents, like scholarships, reduced fees and opportunities for research collaboration. But most of all, is crucial to gather feedback from residents and understand what they expect from partnerships.

In the Velika Planina winter meeting, Euronet MRPH members discussed the role of partnerships for the future of the network and there was a call for reviewing Euronet MRPH partnerships in an objective way, highlighting the need for meaningful and relevant benefits for enrolled public health residents, like scholarships, reduced fees and opportunities for research collaboration.

But most of all, is crucial to gather feedback from residents and understand what they expect from partnerships. There will be many challenges in the future and it’s up to us to prepare and embrace the opportunities that they will bring.

Duarte Brito

Public Health Resident
Public Health Unit Lisboa Central, Portugal

References

1. Rahman, SG. Public Health in Europe: the role of Non-Governmental Public Health associations in public health policy development. Karolinska Institutet.
2. Cunningham, FC; Ranmuthugala, G; Plumb, J; Georgiou, A; Westbrook, JI; Braithwaite, J. Health professional networks as a vector for improving healthcare quality and safety: a systematic review. BMJ Quality & Safety. 2011
3. The Health Foundation. Effective networks for improvement. The Health Foundation. 2014
4. Adams, J. The rise of research networks. Nature. 2012
5. Sommervile, M; Kumaran, K; Anderson, R. Public Health and Epidemiology at a Glance. Wiley-Blackwell. 2012
6. Larkan, F; Uduma, O; Lawal, SA; van Bavel, B. Developing a framework for successful research partnerships in global health. Globalization and Health. 2016
7. Axelsson, R; Axelsson SB. Integration and collaboration in public health – a conceptual framework. International Journal of Health Planning and Management. 2006
8. Lang, PB; Gouveia, FC; Leta, J. Cooperation in Health: mapping collaborative networks on the web. PLOS One. 2013

Nowadays many people die from weight related diseases, these can normally be prevented by improving eating habits and lifestyle choices. But, how easy is it for people to choose better?

As a dietitian and public health professional I find myself promoting healthy eating very often.  However, I have realised that it is not just up to the people to try to get healthier. It is the government’s job to make it easier for everyone to make these changes.

A year ago, I found myself moving to Barcelona, a city full of life and full of bars and restaurants. Asking for tap water in Barcelona is impossible as waiters argue that tap water is not drinkable in Spain. In fact, Barcelona’s water is safe to drink as it follows EU regulations and the company in charge of water in Barcelona has many ISO certifications that secure the water’s innocuousness. In addition to this, a bottle of water in Barcelona is sometimes either the same price or more expensive than a beer or sugary drinks. In contrast, countries in the European Union like the UK and France make it mandatory for bars and restaurants to give free tap water to customers, making it easier for people to choose healthier.

By the same token, in consultation, I always suggest patients to choose whole meal bread and pastas over white ones. Many of them stick to refined grains given that wholemeal products are normally more expensive. It is a fact that eating refined carbs lead to increased risk of obesity and type 2 diabetes, such as it is a fact that it is cheaper to make wholemeal products than to make heavily processed ones, and still people need to pay more for getting the healthier option.

The idea that to eat better is necessary to spend lots of money is a problem I have encountered many times. The current trend of organic foods makes it seem like eating healthily is only for those who can actually afford it. People from a low socioeconomic status find it impossible to eat the so-called organic products. Showing people that healthier does not necessarily mean organic or more expensive should be a public health priority.

Given these points, it is evident that support from the government is essential in order to make it easier for people to choose the healthier option.

José Carlos Flores

Masters in Public health student at the Universitat Pompeu Fabra in Barcelona

References:

• Certificaciones de calidad – www.aiguesdebarcelona.cat [Internet]. Aiguesdebarcelona.cat. 2018. Available from: http://www.aiguesdebarcelona.cat/garantia-de-calidad
• Aigües de Barcelona, Sustainability report 2017. [Internet]  Available from: http://www.aiguesdebarcelona.cat/documents/4176268/4286604/AiguesdeBarcelona_InformeSostenibilitat_2017_eng.pdf
• Drinking Water – Environment – European Commission [Internet]. Ec.europa.eu. 2018. Available from: http://ec.europa.eu/environment/water/water-drink/regulation_en.html
• Sun Q, Spiegelman D. White Rice, Brown Rice, and Risk of Type 2 Diabetes in US Men and Women. 2010.

Access to health services in the prison system is conditioned by legal barriers, social marginalization and stigma which can increase infectious diseases among the prison population¹.

The prison population is different from other populations and it’s in a situation of increased vulnerability. There are several factors that contribute to this, mainly: more exposure to violence; transmission of infectious diseases; increased unprotected sexual, confinement and overpopulation; difficulties in the patients flow up¹.

The number of prisoners in Portugal is about 14.000 on 2017, for a theoretical capacity of approximately 13.000, generating, thus, a panorama of indisputable overcrowding of the prison system. In addition there is also a high turn-over of inmates². The most relevant characteristics of Portuguese prisoners are summarized in Table 1 and Figure 1.

Figure 1. Prisoners, by age. Portugal 2017²

In order to achieve the goals to 2020 outlined on Onusida/Unaids and reduce the morbimortality of viral hepatitis, the General Directorate for Reinsertion and Prisional Services (Direção-Geral da Reinserção e dos Serviços Prisionais) and 28 hospitals of the National Health Service (SNS) will sign a protocol for the treatment of human immunodeficiency virus (HIV) and viral hepatitis infections in the prison population, extending to the whole country the pilot project that runs between the Hospital de São João in Porto and the prison of Custóias.

This pilot project started on january 2017, in order to promote appropriate diagnostic procedures and to provide medication to cure hepatitis C.

This initiative enabled the elimination of Hepatitis C in prisons in Custóias and Santa Cruz do Bispo and is now being expanded geographically and to include other viral hepatitis and HIV⁴.

Table 1. Characteristics of the Portuguese Prison Population, Portugal, 2017^2,3

Up until now, prisoners were subject to security procedures when traveling to healthcare facilities, which caused constraints to clinical observation. From now on they will be treated in the prison itself. This new model will allow physicians – infecciologists, gastroenterologists and internists – to move to prisons to care for the HIV-infected, hepatitis B and C prison population of 45 prison facilities across the continent. In addition, screening will be done at the entrance, during and at the end of the sentence.

Thus, it is expected that this protocol will shape a new approach to health care for infectious diseases in prisons.

Tiago Carvalho

Public Health Resident, Portugal

José Rodrigues

Public Health Resident, Portugal

References:

1. Sousa KAA, Araújo TME, Teles SA, Rangel EML, Nery IS, Sousa KAA, et al. Fatores associados à prevalência do vírus da imunodeficiência humana em população privada de liberdade. Rev da Esc Enferm da USP. 2017 Dec 18 [cited 2018 Aug 24];51(0)
2. PORDATA- Justiça e Segurança: Prisões [Internet]. [cited 2018 Aug 14]. Available from: https://www.pordata.pt/Subtema/Portugal/Pris%C3%B5es-60
3. Direção-Geral de Saúde. Infeção VIH e Sida- Desafios e estratégias. Lisboa: Direção Geral da Saúde; 2018
4. Hospital de São João- Projeto do São João de eliminação da Hepatite C nas prisões replicado a todo o país [Internet]. [cited 2018 Aug 31]. Available from: http://portal-chsj.min-saude.pt/frontoffice/pages/16?news_id=537