Toward a Broader Notion of Community

Purpose To analyze information needs of the Russian public health professionals Methods Statistical, sociological, bibliometrics and content analysis Objectives To analyze results of a survey of information needs of public health professionals; To analyze requests by public health professionals; To present topics and types of information resources needed by public health professionals Results public health professionals usually prepare informational and analytical reports and reviews for decision-makers. Therefore, it is important to understand what issues this group of information consumers is interested in, as well as what information resources they may need. To address this purpose, the authors have surveyed this group of specialists and analyzed their requests for information submitted to WHO Documentation Center in the Russian Federation. The results obtained made it possible to define major information needs of Russian public health professionals. By topics, they are arranged as follows: analysis and trends in mortality by age and cause of death; analysis and trends in fertility; analysis of information resources on healthy lifestyles, physical activity, healthy diet an risk factors, as well as analysis of international experience and comparisons. Distribution by information resources used by the public health professionals: Russian collections of statistical data, National report on health; articles from Russian journals on public health and nutrition; statistical databases of the World Health Organization; Eurostat; WHO reports on different public health issues (tobacco control, excessive alcohol consumption, obesity and unhealthy diet, etc.); WHO/Europe reports on health and well-being; WHO evidence reports on public health problems; PubMed - articles on public health questions; Cochrane library, etc. Key messages This poster presents the results of a study of the information needs of public health professionals. The study was conducted by interviewing these specialists at conferences and seminars.

This chapter aims to answer two questions: first, whether intra-family psychological – or emotional – abuse of children fulfils the criteria to be considered a question of social justice, and second, if it entails an issue of public (mental) health per se in light of the recent debate on the British Cinderella Law project. In order to answer these questions, I will firstly focus on the current debate, pointing out how psychological abuse has generally only been tackled if it co-occurs with other types of maltreatment or if it is the consequence of those other types. Secondly, I will try to shed light on the different attitudes towards mental and physical health and, in turn, towards physical and emotional abuse, also in relation to parental duties. Thirdly, I will explore the open questions on the nature of emotional abuse that could help to understand the disagreements and to analyze whether it is a corrosive disadvantage to children in terms of health and justice. In my conclusion I will finally advocate for the need of specific legal recognition of emotional abuse as a threat to children’s health and well-being and, as such, as a question of public health and social justice that should receive much more attention.

Moving from awareness to action on preventing patient exposure to toxic environmental chemicals

This article describes how the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and strength of recommendations considers the Bradford Hill criteria for...

Knowing how to inquire strong and well-developed questions is a critical skill in discovering new alternatives that may be equivalent or better than existing modalities/treatments/clinical guidelines. Thorough understanding of the existing literature is essential in formulating addressable questions within public health and sports medicine. This is especially important for public-health-focused sports medicine since the historical focus of sports medicine has been on care over outcomes. To identify these addressable issues, researchers can use formulation framework tools to help organize key points and outcome measures that are essential to effective study design and strong conclusions to their inquiry.

The evaluation of the burden of job stress on both the number of cases of diseases (morbidity and mortality) and the resulting economic costs are key questions in public health. However, work in this area remains only very sparse. We here underline the importance of such a calculation, and briefly present a feasible estimation method (that of attributable fractions) and its limitations. This method uses epidemiological data on the relative risk of disease associated with a given job stress risk factor, and the prevalence of exposure to this factor. The associated difficulties revolve around the need for robust and consistent epidemiological data from prospective large-sample etiological studies. The resulting estimates of the evaluation of the burden of job stress provide useful information for decision-making regarding the allocation of resources for prevention purposes.

Interactions among multiple infectious agents are increasingly recognized as a fundamental issue in the understanding of key questions in public health regarding pathogen emergence, maintenance, and evolution. The full description of host-multipathogen systems is, however, challenged by the multiplicity of factors affecting the interaction dynamics and the resulting competition that may occur at different scales, from the within-host scale to the spatial structure and mobility of the host population. Here we study the dynamics of two competing pathogens in a structured host population and assess the impact of the mobility pattern of hosts on the pathogen competition. We model the spatial structure of the host population in terms of a metapopulation network and focus on two strains imported locally in the system and having the same transmission potential but different infectious periods. We find different scenarios leading to competitive success of either one of the strain or to the codominance of both strains in the system. The dominance of the strain characterized by the shorter or longer infectious period depends exclusively on the structure of the population and on the the mobility of hosts across patches. The proposed modeling framework allows the integration of other relevant epidemiological, environmental and demographic factors, opening the path to further mathematical and computational studies of the dynamics of multipathogen systems.

Following the SARS outbreak, large gaps in the public health workforce have been identified. This study sought to understand the perceptions and attitudes of Canadian medical students with regard to public health to determine how this impacted their choice towards a career in Community Medicine (CM). Five focus groups of 11-12 medical students from all years were recruited at McMaster University, Université de Sherbrooke, University of Toronto, University of Manitoba and the University of British Columbia. A professional facilitator was hired to conduct the focus groups using a unique computer-based facilitation system. Questions in both the focus group and an accompanying survey sought to determine medical students' understanding and exposure to public health and how this impacted their attitude and choice towards a career in community medicine. The transcripts were independently reviewed and analyzed by each of the authors to identify themes. Four major themes related to choosing Community Medicine as a career were identified: 1) poor understanding of the role of Community Medicine specialists in public health practice, 2) perceived lack of clinical work and relevance of public health to clinical practice, 3) perceived lack of exclusivity of Community Medicine specialty, 4) incentives and disincentives to pursuing Community Medicine. Better education of students on the role of CM specialists through increasing exposure to role models and demystifying inaccurate perceptions of CM through integration of public health with clinical medicine may potentially increase medical student entry into Community Medicine.

The implementation of the Affordable Care Act (ACA) provides an opportunity for undergraduate students to observe and experience first-hand changing social policies and their impacts for individuals and communities. This article overviews an action research and teaching project developed at an undergraduate liberal arts university and focused on providing ACA enrollment assistance as a way to support student engagement with community health. The project was oriented around education, enrollment and evaluation activities in the community, and students and faculty together reflected on and analyzed the experiences that came from the research and outreach project. Student learning centered around applying concepts of diversity and political agency to health policy and community health systems. Students reported and faculty observed an unexpected empowerment for students who were able to use their university-learned critical thinking skills to explain complex systems to a wide range of audiences. In addition, because the project was centered at a university with no health professions programs, the project provided students interested in community and public health with the opportunity to reflect on how health and access to health care is conditioned by social context. The structure and pedagogical approaches and implications of the action research and teaching project is presented here as a case study for how to engage undergraduates in questions of community and public health through the lens of health policy and community engagement.

The Question of Immigration and Public Health — The Medical Press — Boston Floating Hospital — Medical Notes

For decades there has been a consistent public health message about the use of calcium supplements in healthy adults: they prevent fracture and have no serious side effects. Although there is disagreement about the populations that are most likely to benefit and the magnitude of antifracture benefits, the best evidence pooled from multiple placebo-controlled trials suggests that supplementation with calcium plus vitamin D reduces fracture risk about 12%.1 Some populations, such as the institutionalized elderly and those with inadequate dietary intake, may benefit from supplements to a greater degree than independent-living individuals with adequate calcium intake. The potential nonskeletal benefits of calcium supplementation remain controversial.2 In addition to mild and often self-limited gastrointestinal intolerance, the most important confirmed side effect of supplementation is a 17% increase in nephrolithiasis.3 The calcium supplement landscape, however, has changed considerably since the publication of two meta-analyses by Bolland and colleagues in 20104 and 2011,5 concluding that calcium supplements increase the risk of both coronary and cerebrovascular events. The first meta-analysis pooled 15 placebo-controlled trials of calcium supplements without vitamin D and found a statistically significant 31% increased risk of myocardial infarction (p = 0.04) and a nonsignificant 20% increased risk of stroke (p = 0.11) among calcium-treated individuals.4 The study received considerable attention in the lay press, but was also criticized for excluding calcium plus vitamin D trials, inconsistent validation of cardiovascular endpoints, and the lack of a dose-response. In fact, analyses stratified on baseline calcium intake revealed significant supplement-related increases in myocardial infarction among those with higher pretreatment dietary calcium intake (above the median of 805 mg/d) but not among those with lower pretreatment calcium intake (interaction p = 0.01). A follow-up meta-analysis by Bolland and colleagues5 addressed at least some of these criticisms by including calcium plus vitamin D trials, and the results were similar: after pooling eight placebo-controlled trials, randomization to calcium alone or calcium plus vitamin D was associated with a statistically significant 24% increase in myocardial infarction (p = 0.004) and a nonsignificant 15% increase in stroke (p = 0.06). Although Bolland and colleagues included the Women's Health Initiative (WHI) Calcium Plus Vitamin D Supplementation Trial, which rigorously adjudicated thousands of cardiovascular outcomes and had previously reported no increase in vascular events among the calcium plus D group,6 in their second meta-analysis Bolland and colleagues5 excluded the 46% of WHI participants taking personal calcium supplements at baseline. The rationale offered for excluding women taking personal calcium supplements was that it allowed a pure comparison of supplement use versus no supplement use. Unfortunately, analysis of a subset of trial participants does not preserve the full benefits of initial randomization,7 and those taking and not taking personal supplements at baseline might have differed in subtle but important ways. Given the size of the WHI trial and the overall null effect on cardiovascular endpoints, it is not surprising that two other meta-analyses of the same topic which included all of the WHI trial participants found no increase in cardiovascular risk with supplementation.8, 9 If calcium supplements do increase the risk of cardiovascular events, the mechanism is not known. Calcium supplements, but not dietary calcium, transiently increase serum calcium,10 which might lead to arrhythmias in susceptible individuals, but evidence linking calcium supplements to mechanisms that clearly cause vascular disease, such as accelerated atherosclerosis, intimal plaque instability, or altered coagulation, are lacking. In addition, several studies of coronary artery calcium, a surrogate vascular measurement that is able to identify subclinical atherosclerosis and is associated with future vascular events,11 have found no relationship to calcium supplement use. For example, neither the prospective Framingham Heart Study12 nor the WHI trial13 found a relationship between use of calcium supplements and coronary calcium score. In this regard, a high-quality ancillary study of the Calcium Intake Fracture Outcomes Study (CAIFOS) reported in this issue of the Journal of Bone and Mineral Research by Lewis and colleagues14 is of interest. CAIFOS was a 5-year placebo-controlled trial of calcium carbonate (1.2 gm per day of elemental calcium) that enrolled nearly 1500 older women with a mean baseline calcium intake of 970 mg/day, and previously reported a nonsignificant reduction in fracture risk (relative risk [RR] = 0.86; 95% confidence interval [CI], 0.87–1.12)15 and no significant effect on atherosclerotic events or death (RR = 0.94; 95% CI, 0.69–1.28).16 The current report by Lewis and colleagues14 details the effects of 3 years of calcium supplements on two accepted surrogate measurements of cardiovascular risk: carotid artery intimal medial thickness and the presence or absence of atherosclerotic carotid plaque, both assessed by B-mode ultrasonography.17 The reported intention-to-treat results are solidly null: there were no significant differences in either of the two measurements among calcium-treated or placebo-treated women. Results were similar in a per protocol analysis among women who were at least 80% compliant. Although reassuring, the study did not collect carotid measurements prior to randomization and did not assess coronary atherosclerosis directly. Nonetheless, the Lewis and colleagues14 study strongly suggests that up to 3 years of daily calcium supplementation in older women does not have an adverse effect on carotid atherosclerosis. Thus, at this point we are left with a clinical conundrum: post hoc analyses of some, but not all, placebo-controlled trials have found that randomization to calcium or calcium plus vitamin D increases the risk of cardiovascular events, and no obvious biologic mechanism exists to account for such an adverse effect. Observational data are also inconsistent.18 What could explain these apparently discordant results? One potential explanation for the inconsistent relationship between calcium supplement use and cardiovascular events is that the association is real but is obscured in some studies by a threshold effect; ie, even low doses of supplemental calcium increase vascular risk and higher doses do not further increase risk. This explanation appears to be favored by Bolland and colleagues5 because they use it as the primary rational for excluding WHI participants taking personal calcium supplements in their second meta-analysis of calcium trials with and without vitamin D, but this line of reasoning is not compelling without a credible mechanism or at least some supportive data from surrogate outcomes such as coronary artery calcium or intimal medial thickness. Importantly, WHI investigators recently reanalyzed the WHI trial and extended cohort data and have concluded that calcium supplementation had no effects on the risk of myocardial infarction, coronary heart disease, or stroke.19 Another potential but increasingly unlikely explanation for the inconsistent association between calcium supplement use and vascular events is that vitamin D may reduce coronary heart disease, and therefore the cardiovascular harms of calcium supplements are negated when administered with vitamin D from any source. Although a number of observational studies have suggested a beneficial cardiovascular effect of vitamin D supplementation, the most rigorous review recently summarized for the U.S. Preventive Services Task Force concludes that there is little quality evidence that vitamin D is cardioprotective.2 A final potential and increasingly likely explanation for the inconsistent relationship between calcium supplementation and cardiovascular disease is that there is no true association and the apparent relationship has resulted from chance or bias. The probability that an observed relationship between calcium supplement use and vascular events is due to chance alone is quantified by the p value, and in the first Bolland and colleagues4 meta-analysis the p values were 0.04 for myocardial infarction and 0.11 for stroke, making chance a reasonable explanation for the observed findings. Bias as a potential explanation for positive results is often more difficult to detect, assess, and quantify than chance, even in controlled trials, particularly if there is differential ascertainment of endpoints by treatment group, selective publication or pooling of results, or post hoc analysis of subgroups identified after randomization. Is there a way forward? Clearly the issue needs to be resolved because both calcium supplement use and cardiovascular disease are very common in the elderly and even a weak causal relationship would have a substantial public health impact and require a change to clinical practice. Although time-consuming and expensive, large pragmatic trials with multiple clinical endpoints and objective collection and adjudication of cardiovascular events will be needed to definitively answer the question. Concerns that it would be impractical or unethical to randomize older adults to calcium plus vitamin D supplements or placebo are unfounded because there appears to be true clinical equipoise. Additional studies, both observational and randomized, of potential mechanisms are needed, particularly those related to the effects of transient hypercalcemia as well as novel imaging and other biomarkers for atherosclerosis. In summary, adequate calcium intake remains an important bone health concern in older adults and clarification of the population-specific antifracture benefits and cardiovascular safety of calcium supplements are important clinical and public health questions. Currently, we know that calcium supplements modestly increase the risk of nephrolithiasis and may cause mild gastrointestinal symptoms, but the evidence supporting a causal relationship between supplementation and cardiovascular events remains inconsistent and inconclusive. Indiscriminate discontinuation of calcium supplements is not necessary, but until additional data are available clinicians should promote adequate dietary calcium as a means to achieve the daily intake recommended by the Institute of Medicine,20 and reserve supplements for those who are unable or unwilling to achieve adequate dietary intake. Reassuringly, randomized trials have confirmed that clinician-based efforts to increase dietary calcium are feasible and often successful.21 The author states that he has no conflicts of interest.

Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future

On the African continent, Uganda, South Africa, Zimbabwe and Kenya were among the earliest to develop palliative care. Almost two decades later, only Uganda treats palliative care as a public health matter; but even in Uganda challenges remain. Across Africa governments inhibit scale up through insufficient support. Limited numbers of adequately skilled health and social care professionals, inadequate funding, recurrent drug shortages, and endemic concerns regarding drug use constrain progress, and encumber the mainstreaming of palliative care into African governments' national health policy agendas. Although scattered islands of excellence exist, unmet need remains on a scale that is well captured in the prevalence data presented by Webster et al. These observations gave birth to the African Palliative Care Association (APCA) at a November zooz meeting in Cape Town, South Africa. Registered in zoo3, APCA opened its headquarters in Uganda in zoo5 as a non-governmental organisation with a regional mandate to promote and scale-up culturally appropriate and affordable palliative care for people with progressive, life-limiting illnesses. APCA's programme of technical assistance supports education, efforts to influence policy, the development of care standards, monitoring, evaluation, and research. Already active in 17 African countries, APCA has made significant inroads. In just the last few months, it provided palliative care training to 109 health profes-

EUPHA's sister association in the multidisciplinary field of public health, the Association of Schools of Public Health in the European Region, is celebrating its 40th anniversary. ASPHER has served the European public health community during a period of dramatic and demanding change—unprecedented expansion, increasing complexity and growing unity as well as diversity. ASPHER has contributed to the development of a European public health. As this year's president of EUPHA I am honoured to thank and congratulate our ASPHER colleagues and friends very warmly. The two Associations share responsibility for capacity building in European public health and for providing the European public health community and the general public with a clear vision and perspective of the public's health. Both ASPHER and EUPHA share responsibility for developing two of the most basic resources for public health capacities in the 21th century. ASPHER's raison d'etre and mission is to advice and assist academic institutions to offer high-quality education and training programmes for public health professionals working in policy development, practice and research. EUPHA's remit, on the other hand, is to guide and support the development of an adequate knowledge base serving the needs both of policy and practice through multidisciplinary research. Both associations will serve the European public health best if their share a common value and knowledge base grounded in sound research and scientific discourse. During the last years public health leaders, scientists and practitioners have entered a debate on the values and principles guiding policy making, scientific research and organisational practice.1 It centres on value-related themes such as health and health improvement, equity and social justice, social cohesion and solidarity, responsiveness to health and disease-related needs, acceptability and efficiency of health services, governance and financial sustainability. We have learned that the values and principles underlying these themes tend to be …

The threat of bioterrorism has led to a reinvestment in public health, but not necessarily in a manner that ensures efficient, reliable and cost-effective improvement in services. Public health officials fear that homeland security is distorting the priorities of public health and diverting resources from the essential work they are already doing. They fear that homeland security requirements may have erosive effects on confidentiality and in compromising their core mission of health promotion and disease prevention. Specific issues include cutbacks in promised support, diversion of funding to single-purpose projects, concerns over maintaining confidentiality of client services, abuse of the extensive police powers given by state legislation to public health authorities, and lack of integration with existing public health systems. The reasons for these concerns are deeply rooted in the history of public health, in which the legal authority of health agencies included police powers and even detention. Public health leaders would prefer a policy of dual use or dual in which capacity is added to enhance the operation of the public health system in general while adding new capability in emergency response. Such a policy would ensure benefit from the investment even if no bioterrorism event ever occurred locally and would enhance the reliability of the system. For example, a single-purpose surveillance program for bioterrorism is likely to have an unacceptably a high risk of failure and unreliability in a bioterrorism event if it is not regularly tested by the type of outbreak that occurs many times a week in every metropolitan health department. A small but articulate group of public health leaders, led by Victor W. Sidel, have even questioned the ethics of collaboration between public health and police or intelligence services. This article suggests that such cooperation is actually necessary and recommends advance guidelines and policies, legal clarification, combined multidisciplinary training, and mutual trust and understanding among public health, law enforcement, and intelligence professionals, in order to protect the integrity of essential services and the valid concerns of the public health system.