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Workplace wellness: a piece of the pie

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madeline hermann

on 16 April 2014

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Transcript of Workplace wellness: a piece of the pie

Workplace wellness: a piece of the #globalhealth pie
What inspired the #piece of the pie?
Workplace wellness is the coordinated and comprehensive set of health promotion and protection strategies implemented at the worksite that includes programs, policies, benefits, environmental supports, and links to the surrounding community designed to encourage the health and safety of all employees. #CDC #R1
In #HSOC301 we were introduced to
the social determinants of health. Living and working conditions are an important social determinant of health and #WPW can intervene on this social determinant of health. #R32
What is #workplacewellness?
Welcome to my HSOC 591 Global Health Portfolio!

I chose to explore #WPW from a #globalhealth perspective.

Specifically how #WPW can help reduce chronic disease, furthermore hypertension, around the globe.
@maddiHSOC591 HSOC 591 Global Health Portfolio
My concentration is psychology. Throughout my psychology concentration, I have become passionate about #healthpsychology

Health psychology is devoted
to understanding psychological
influences on:
how people stay healthy
why they become ill
how they respond when they do get ill
#healthpsychology explores the influence of behaviour on health

Unhealthy behaviour is an important risk factor for chronic disease
Healthy behaviour is an important protective factor for preventing chronic disease.

How do we create healthy behaviour?
Make it easier to make healthful decisions in our environment, more specifically the #workplace through #WPW among other things aimed at intervening on the #SDOH.

Why am I passionate about #workplacewellness ?
I have previous work experience in occupational health & safety developing and managing #WPW programs.

#Ahamoment from working in occupational health and #WPW was the realization of how much benefit workplace wellness can have in creating and supporting healthy lifestyles of employees that will pay off for the employer, the city, province, and country!

With a small piece of the pie spent on population & public health, we need to develop more #upstream approaches funded by private business.
How does my concentration fit in?
FYI #R1 = reference #1, so forth, references in word document
What's up with the #pie?

In particular its #pumpkinpie - my favorite! My grandma makes the best pumpkin pie!!

In #HSOC311, we learned about the proportion of spending directed at population and public health - only ~2% #R2!! Population and public health expenditure is a small piece of the pie! This was an #ahamoment for me that the health care system is reactive and not proactive.

This made me hungry for new proactive solutions to prevent chronic disease! This is where #WPW comes in!

#WPW fits nicely into the population health promotion model #R33

#WPW is the
private sector
intervening on
working conditions
creating a supportive environment
development of personal skills
, i.e. behaviour change
Why hypertension?
Hypertension, high or raised blood pressure, is a global #public health crisis #R5
#hypertension is on the rise in #LMICs #R5
WHO reports #WPWP as 1 of the 6 important strategies to address hypertension #R5
" #workplacewellness programs are
one of the most cost-effective ways
to prevent and control non-communicable
diseases including hypertension "
- WHO global brief on hypertension #R5
Learning OBJECTIVE 1
What does #workplacewellness look like around the globe?
Learning Objective 3
What responsibility do employers have in creating employee health?
#ethics #workplacewellness

As much as #WPW is an important intervention strategy and can lead to healthy #culturechange in the workplace.I liked Nigel Marsh's TedTalk addressing the fact that we, as employees, also need to be advocates for our own health and work-life balance.
We, as employees, need to challenge the #corporateculture to create much needed #culturechange that supports healthful living. #R29
Learning objective 2
What are the barriers to #WPW? How is #WPW sustainable?
Why should this be considered?
In my occupational health experience, many people argued that health & well-being should be in the hands of the employee, as employees receive compensation that can be used to promote health and well-being.
Most people spend 1/3 of their life at work. Creating healthful work environments can have a big impact on individual's lives.
I believe employers are #responsible for employees' health.

The workplace can promote negative health behaviours, e.g. sedentary behaviour, unhealthy eating, stress, etc.

It is important that the worksite becomes a key component of chronic disease prevention and #healthpromotion, reducing risk factors like smoking, overweight, and poor diet linked to #hypertension and #CHD.
There is a necessary #culturechange that is needed in the workplace - culture change towards #worklifebalance that creates healthful living. Who creates this culture change?
Intervention ladder #ethics #workplacewellness
In HSOC 301, we learned about the intervention ladder.
The higher on the intervention ladder
you are, the more chance for intruding
on personal freedom. Interventions lower on ladder should be considered first.

Eliminating choice (e.g. removing unhealthy meal options in a worksite cafeteria) can be very effective but presents unique #ethicalconsiderations, as it restricts personal freedom in choice. #R18
Easy as pie
Often employers go for #easywins
for their #WPWP, e.g. subsidization of classes.
The easy wins may be #easyaspie but might not be aligned with employees' needs or larger needs of the community.
How do we align #workplacewellness with employees' and communities' needs?
Public-private partnerships can be an efficient and effective way to share responsibility of a population's health and wellbeing.
Utilizing #HIAs and #HNAs can align #workplacewellness with #employees' needs (expanded on in weekly seminar topic)
Example of a Successful #PPP
Public health can't do it on their own, neither can for-profit organizations do it on their own.
Public health has limited financial resources faces complex social and behavioral problems, like chronic disease.
At the same time, private for-profit organizations have come to recognize the importance of public health goals for their immediate and long-term objectives, and to accept a broader view of social responsibility as part of their corporate mandate. #R5
Why am I passionate about #sustainability and #barriers?
In #HSOC408, I conducted a systematized literature review to determine the barriers to exercise in breast cancer survivors.

My #MDSC508 thesis project studied the barriers to meditation in cancer patients.

My #healthpsychology research in HSOC has made me particularly interested in how to create a sustainable program with minimal barriers.

Additionally, my occupational health work experience has made me knowledgeable of the barriers to creating #WPW. When developing a #WPWP for the company, management buy-in was a challenge. One has to build a strong case for the #ROI for the company to justify funding expensive #WPWP.
Common #barriers
Insufficient time
Employers have to be willing to let employees have time to commit to the workplace wellness programs
Lack of interest
Incentives to participate in #WPW to generate interest
Undefined purpose
#WPW programs need clearly defined goals
Align #WPW programs with employee needs
Funding challenges
Lack of funding makes start up and maintenance of #WPW initiatives difficult
Calculating Return on Investment is important for justifying the benefits of the program
From a North American perspective,
RAND Corp reviewed North American
#WPWP and
reported the key facilitators of successful wellness programs:
Effective communication strategies with employees
Opportunities for employees to engage
Leadership engagement at all levels of the program
Use of existing relationships and resources
Continuous evaluation #R9
#lifestylediseases are on the rise
in #HICs like the US #R6
CDC reports four behaviors— inactivity, poor nutrition, tobacco use, and frequent alcohol consumption—as primary causes of chronic disease, specifically heart disease in the US #R8
#WPW in #HICs is conducted primarily by private companies that do not conduct research on the interventions.
For example,the RAND Corp, in conducting a literature review on #WPW programs in the US, relied on awards programs, newspaper articles, and experts on worksite wellness programs instead of peer-reviewed published literature. #R19
Adequate research is lacking because #WPW is rarely done in partnership with non-profits or government in #HICs and in-house evaluations of #WPWP are often inadequate for research purposes.
Government and non-profits' growing interest in #WPW will result in a growing body of literature.
Currently, #WPWP in #LMICs are primarily conducted by multidisciplinary research teams, as exemplified in the IHHP study #R14, funded by international research funding and international corporations.
This is exciting as #WPW is being guided by evidence-based practice.
#WPW in #LMICs is effectively utilizing #PPP.
Growing interest in conducting research on #WPW in #LMICs will in turn provide beneficial interventions to aid in the growing epidemic of #lifestylediseases such as #CHD in #LMICs.
#Workplacewellness in US companies
3 primary activities :
1) Screening activities to identify health risks
E.g. Health Risk Assessment, biometric screening, clinical screening, etc.
2) Preventive interventions to address health risks
E.g. educational campaigns, health counseling, etc.
3) Health Promotion Activities
On-site vaccination services, fitness benefits, healthy food options, nurse advice lines, etc.
Other activities:
Employee assistance programs, occupational health services, on-site clinics,absenteeism management
#workplacewellness in #HICs is primarily conducted by private companies that do not formally report, or if they do, reporting is done internally, within the company.
Searching for "workplace wellness" in databases yields few results. Some companies are more transparent of their #WPW activities on their website. #Workplacewellness is considered a benefit, thus some companies are not interested in publicly publishing the details of the #workplacewellness program.
Culture of competition in #WPW offered by companies in #HICs may not benefit the employee as best practice might not be conducted at all corporations.
Therefore, my portfolio outlines the common activities in #HICs #WPW from a review.
American Heart Association recommendations for #workplacewellness programs to prevent cardiovascular disease prevention:
CVD education
Tobacco cessation and prevention
#HRA for early detection and screening
Weight management
Physical activity
Stress management
Occupational health and safety
The National Worksite Health Promotion Survey conducted by #CDC in 2004 reported that of 1553 employers interviewed only 6.9% of employers provided comprehensive worksite wellness programming. #R10

Employers pick and choose what type of #WPWP they want to offer. Although, CDC has guidelines, utilization of guidelines is variable.
#R10 #R11
The Isfahan Healthy Heart programme (IHHP) is a comprehensive community-based program for CVD prevention, designed and conducted by the Isfahan Cardiovascular Research Centre (ICRC) with the cooperation of Provincial Health Centre, both are affiliated to Isfahan University of Medical Sciences. IHHP comprises 10 projects to reduce CVD risk. Its Worksite Intervention Project has changed employee habits and helped Iranian firms show that employee health is a good investment.
The five-year Worksite Intervention Project began in 2001. Targeting offices and factories in the Central Iranian cities of Isfahan and Najafabad, it involved some 13,000 workers in factories and 7,000 employees in workplaces as diverse as advertising agencies, electricity plants, media companies, steel mills, food manufacturing plants, transport companies, and government offices. Using both health promotion and environmental/policy change, the project aimed to improve nutrition in factory restaurants, educate employees on CVD risk factors, reduce smoking, and increase workers’ physical activity. #R14
Examples of activities included:
Canteens using liquid cooking oil instead of hydrogenated oil
Increasing fish and vegetables served using less salt
Substituting mineral water or traditional yogurt drink for sodas
Some employers:
Subsidized entry to swimming pools and sports clubs or gave employees sporting gear
Purchased bicycles for use at large worksites
Organized morning exercise sessions at work
Let workers use work time to exercise elsewhere
To reduce smoking among workers they:
Enforced smoke-free policy
Referred smokers to cessation clinics
Conducted Quit & Win contests
Factories organized:
Regular health-education sessions for workers
Distributed educational leaflets on CVD risk
Included health information in work newsletters
Offered individual or group counselling on lifestyle factors
Screened workers for risk factors. #R15 #R16
#WPW in #LMICs are commonly nested in larger community-based lifestyle intervention studies.
The Isfahan Healthy Heart Program in the Islamic Republic of Iran is an example.
#R13 #R14
Facilitators of #workplacewellness #HICs
Factors of SUCCESS in IRAN
Group meetings with employers created a group dynamic, more employers bought into worksite interventions.

Involved many worksites - large impact!

Iranian employers were very willing to allow time for the interventions to really work
#R13 #R14
Creating #sustainablechange
An important lesson from the Iran Worksite Intervention project was that the interventions that changed the environment and made it easier for workers to make healthy choices, like changes in food served in canteens, were the aspects of the project that had the biggest impact. When interventions depended on workers investing energy or motivation or discipline, they were less effective: it is not easy to get people to go out of their way to make healthy choices.
This supports the population health promotion model for intervening on social determinants - need to make the healthful choice the easier choice! #R13 #R14
Thorough and systematic monitoring and evaluation enabled project staff to find approaches that work and adapt the ones that were less successful in the #WPWP. #R13 #R14
Global Public health
One health
Health Surveillance
Health Promotion
Community Health Assessment
Disease prevention
One Health - Canada North
Health protection/ Disaster Preparedness
Global health partnerships & Ethics
Capacity building
#workplacewellness is a piece of the #globalhealth pie! The #globalhealth components discussed throughout #HSOC591 are also the toolkit for global #workplacewellness.
#CDC Framework for developing #workplacewellness
Corporations in #HICs struggle with fully developing and maintaining #WPWP.
Local businesses in #LMICs would have difficulties following framework and supporting #WPWP.
International organizations have more capacity to support #WPWP.
CDC framework highlights key components for success of #WPWP.
Pepsico, a global food and beverage company, has teamed up with the Oxford Health Alliance #OxHA in a public-private partnership titled 'Community Interventions for Health' #CIH to conduct community-based health interventions and offer #WPWP in the UK, Mexico, China, and India.
The Oxford Health Alliance is also conducting research to evaluate the interventions. #R19
#WPWP Mexico CIty
#WPWP India
#WPWP China
Long-term goal of CIH is to create environments and policies that reduce exposure to the three main risk factors (tobacco use, unhealthy diet and physical inactivity) for hypertension and heart disease. #R19
The goal of the #CIH is to develop a comprehensive international database of intervention processes and outcomes and research articles to advance the global understanding of risk-factor reduction and chronic disease prevention. #R19
#CIH effectively balances research and action
A strength of the #CIH is that it does not engage the workplace in isolation but rather links it to other aspects of the community. #R19
#CIH includes intervention and control sites in
, and
health centers

Focusing on high-risk communities, the projects use
four strategies
for change:
community coalition building
health education
structural change

The studies evaluate impact at
two levels
Individual level:
measuring changes in both knowledge and behaviour together with physical/biological risk factors (blood pressure, lipid profile, hip-to-waist ratio, body mass index and glucose level).
Community level:
focusing on policy and environmental changes, measuring these by using GPS technology to conduct an environmental scan that maps neighbourhoods, worksites, health centers and schools to systematically document barriers or opportunities for healthy behaviour.

Throughout HSOC, the socio-ecological model has been presented as best practice for health promotion but I never quite understood what it might look like in practice. The #CIH is a great example of the socio-ecological model in practice #ahamoment.

The #CIH employs the socio-ecological model for intervening on the #wickedproblem of #chronicdisease like #CHD around the globe.

Specifically, intervening at the individual, organizational, and community level to hopefully influence healthier public policy that will create healthful environments, making the healthy choice the easier choice.

The #CIH is going #upstream to get at the #rootcause of this #wickedproblem.
Socio-ecological model
Dr. Sara Karrar, #CIH Intervention Coordinator at #OxHA, reports
"There is no dispute that global action is needed in tackling chronic diseases, especially as 80% of the disease burden falls on developing countries where resources are already stretched. CIH provides a solution by focusing and building on comprehensive community-based chronic disease prevention strategies."
The #CIH intervention is in 3 districts of Hangzhou, China.
Hangzhou is an industrial city of six million inhabitants. It is an important manufacturing base and logistics hub for coastal China.
There is a large population of migrant workers in Hangzhou. #R22
Worksites include a mix of public and private sectors in areas as varied as heavy machinery and administrative enforcement. Thirteen worksites are being studied, four intervention worksites and seven controls. The workplaces involved in the program vary in size, some have 1,000 employees and on-site healthcare providers. Interventions focus on:
smoke-free policy
workplace safety
physical activity
healthy diet
health knowledge
Workers receive health education, coaching, disease management and personalized health-risk assessment.
Additional activities include efforts to gain managerial support and develop policies and systems to support changes in practice, environment and behaviour. #R22
#WPW is targeting individuals who have employment. There may be some unintended consequences in #LMICs where employment rates are lower than in #HICs. Also, employment in #LMICs may be more variable. #WPW may not target a large portion of the population if unemployment is high.

This points to the fact that #WPW is a component of a larger #GH strategy.
Included a total of 10 companies from around India representing a variety of industries including electronics, aeronautics, tea, pharmaceuticals, tools and textiles with 1,500–5,000 employees. #R23
The intervention group:
Reduced salt intake
Increased fruit and vegetable consumption
Increased levels of physical activity
Decreased tobacco use
Showed a significant relative decline in mean body weight, waist circumference, blood pressure, serum cholesterol, and plasma glucose levels.#R23
Dr Goenka, co-author of Powering Health, a manual on health promotion aiming to provide a framework for multi-sectorial partnerships to address the threat of CVD in India.
“The CIH study on industrial worksites highlights the great promise of working through organized workplaces, but we have to go beyond this sector. In India over 85% of the working population works in the informal sector - people like street vendors, self-employed farmers, or those who work in their own or other peoples’ homes. Most are underprivileged and very poorly served by systems of healthcare and social security. We urgently need to find out how to reach them...If we are to achieve the healthy, powerful and prosperous India, government and non-government sectors, industries, policy makers, the media, city planners and economists all need to work together, along with the health sector, to engineer India’s growth through health.” #R23
The workplaces selected by the CIH in Tlalpan is the delegación, the municipal administration which employs about 3,021 people in work supporting sustainable development, urban planning, justice, public security, administration and culture, ranging from high-level administration to park or building maintenance.
Interventions currently being planned include:
Time for physical activity during the work day
Health screening and promotion
Improving nutritional quality of food in the canteens #R24
As a personal reflection, I completed a missions trip with #YWAM #HOH program in Ensenada, Mexico in December 2012.

I vividly remember crossing the San, Diego USA border into Mexico and looking back from the van window and literally seeing the poverty line. Large, beautiful, well kept mansions to the left (San Diego, USA) and mismatched shacks and apartments to the right (Mexico).

I also remember driving along the coastal road and looking down to the ocean and seeing beautiful mansions on the water and looking up into the hills to see small shacks without electricity.

It was such a powerful juxtaposition of a healthful environment with a potentially unhealthy environment both between countries (USA and Mexico) and within the same country of Mexico.

It was an #ahamoment that addressing poverty, potentially through creating more employment opportunities, can intervene on the social determinants of health that are important risk factors for #chronicdisease #CHD #hypertension.

Higher employment rates also means increased impact of #WPW.

Dr Ramirez, the CIH lead in Mexico City emphasized the importance of extending workplace initiatives beyond formal work settings to include the unorganized or informal sector: those who are self-employed and work at home, or as street vendors.
“It is very important to reach out to this group, which is a big sector of the economy and has fewer resources and poor access to primary care services: in our neighbourhood about half of the population do not get social security insurance, for example. To reach these people you have to get out into public places: the streets, markets, parks.” #R24
Pepsico #WPWP in UK & Ireland including health check kiosks to complete ongoing assessments of employees' health
The video demonstrates employees engaged in the Health Check Kiosks. Additionally, the employees believe that Pepsico is interested in supporting their best health and well being and as an outcome their is high employee morale. #R25

Pepsico offers basic medical, disability, and life insurance and retirement benefits, at its locations around the globe.

Workplace Wellness
Healthy Living program offers:
Preventive screenings and rewards for participating in personal health assessments and for completing health improvement programs
Personalized coaching
Fitness and nutrition programs
Online tools and resources
Educational messaging
Worksite wellness initiatives
Health benefit coverage to promote healthier lifestyles

On-site health and wellness services in many countries around the world, including China, India, Mexico, South Africa, the U.K. and the U.S. These initiatives, which vary by location, include:
Routine medical care at work sites
Education programs on health
Nutrition and exercise
Programs on smoking cessation
On-site fitness centers
Organized programs to encourage exercise
Stress management and coping skills counseling and workshops
Financial education program providing tools and resources to improve the financial fitness

Occupational Health & Safety
PepsiCo Global Environmental, Health and Safety Management System (GEHSMS) conforms to the ISO 14001 and sets global standards for risk areas across the business.
Third-party audits are completed to ensure standards are met.
Often #WPW is an optional activity for employees, which can reduce its impact if few employees are engaged.

#WPW that creates a healthful environment does not intrude on employee's personal freedom but it creates a better work environment for all employees.
E.g. reducing exposure to harmful chemicals in the workplace.
We need to hold corporations responsible for the health of their employees. Corporations have a strong influence on the economic wellbeing, health of people, and the health of this planet.

Corporations based in the West often use #WPW as an attract-and-retain strategy. We need to advocate for #WPW to also be a reflection point for corporations to assess their impact on the broader wellbeing of people and this planet #corporateculture #culturechange.
Final reflection on how I achieved my learning objectives:

Lessons going forward in my academic career
The biggest thing I learned through my portfolio is that knowledge from one area can be utilized to build knowledge in another area. Knowledge sharing can be a #wickedsolution for a #wickedproblem. #onehealth and #globalhealth exemplify this by bringing together experts in various fields in a multidiscplinary, interdisciplinary, or transdisciplinary teams to address #wickedproblems, e.g. #chronicdisease. Throughout my portfolio, I explored my learnings throughout my HSOC degree, my work experience in occupational health, my international volunteer experience, my research experience, and the specific #WPW research I conducted in my portfolio. My diverse experiences have created rich knowledge of #WPW from a global perspective. Diversity in teams and projects can lead to rich #globalhealth research in action.
Going forward, in my academic and professional career, I hope to be mindful of how diversity in teams, experiences, and perspective can leverage multiple skill sets and expertise and lead to sustainable, proactive solutions to #wickedproblems.
"A steady evolution of philosophy, attitude, and practice
has led to the increased use of the term global health." Koplan (2009)
Global health is representative of #culturechange in response to the #wickedproblems facing a globalizing world #ahamoment.
Similarly, #WPW is a movement of #culturechange in the workplace. A recognition of the role of the corporation in the wellbeing of its employees.
Prior to the reading & seminar, I had thought global health was a synonym for international health, namely global health simply referred to research or practice in another country. Koplan points out that
global refers to the scope of problems, not the location.
This clarified the definition of global health for me and made me realize the breadth of global health. Additionally, the interdisciplinary or better yet transdisciplinary approach to global health makes it particularly adept to tackling #wickedproblems that are new to our globalizing, fast-paced, ever changing world.
This is exemplified in #WPW. The efforts of corporations locally has a big impact on the health and wellbeing of employees. International corporations have a unique role in creating sustainable workplace interventions tailored to the unique needs of employees at each of the company's sites.
Strategically expanding #WPW in partnership with research can have a huge impact on the bottom line of creating healthier employees and citizens, preventing #chronicdisease, and providing good return on investment to provide incentive for employers to invest in #WPW.
Dr. Hatfield's phrase: local is global, was an important learning piece for me that research and practice anywhere in the world impacts global health.

Sometimes I feel my own research and work has a limited scope but this point was empowering that the work I conduct here, there, or anywhere in the world is part of the larger whole of global health - building knowledge, best practice, and creating #culturechange that can transcend national borders.

We can all have a large impact locally and thus globally.

With power comes great responsibility!
Definition of public health
“Efforts to protect, promote and restore the people’s health. It is the combination of sciences, skills, and beliefs that is directed to the maintenance and improvement of the health of all the people through collective or social actions.”
- Prevent disease and prolong life
- Maintain and promote health
- Community intervention and partnerships
- Educating the individual
- Addressing social determinants of health
- Health as public good

History of International Health
Health work abroad, with a geographic focus on developing countries and often with a content of infectious and tropical diseases, water and sanitation, malnutrition, and maternal and child health.

Merson, Black, and Mill’s definition of international health: “the application of the principles of public health to problems and challenges that affect low and middle-income countries and to the complex array of global and local forces that influence them”.

Global health, public health, and international health all share:
• Priority on a population-based and preventive focus
• Concentration on poorer, vulnerable, and underserved populations
• Multidisciplinary and interdisciplinary approaches
• Emphasis on health as a public good and the importance of systems and structures
• Participation of several stakeholders

Globalization is an important force in shaping the health of populations around the world.

This table from Koplan (2009) paper is a great reference when thinking of the differences between #globalhealth #internationalhealth #publichealth. I will ensure to refer back to it in my future work and/or research.
General reflection on the course... Twitter was an interesting exploration of how social media can support a fruitful discussion. It was really exciting seeing all of the interesting perspectives from each of the students in #HSOC591. The discussions were rich because of all the unique perspectives each of us brings from our diverse research backgrounds, life experience, and concentrations in the program.
The seminars were helpful and interesting because they walked us through the students' learning of the topic to aid us in our own learning of the topic.
In my research, I found it difficult to find #WPWP directly aimed at #hypertension prevention but mostly I found #WPWP that focused on risk factors of multiple #chronicdiseases, among the list being #hypertension and #CHD.

This is not necessarily a problem... actually it is promising to see #WPWP being oriented around multiple risk factors to tackle prevention of multiple #chronicdiseases
#efficient #costeffective #killtwobirdswithonestone.
I've overlapped all the circles representing the different #globalhealth components to demonstrate their interconnectedness. They each feed into each other and act as important components of the #globalhealth pie.
Weekly article summary
Koplan, J.P., Bond, T.C., Merson, M.S., Reddy, K.S., Rodriguez, M.H., Sewankambo N.K., Wasserheit J.N. (2009). Global health: towards a common definition. The Lancet, 373:1993-1995.

Global health definition
• notion (the current state of global health). objective (a world of healthy people, a condition of global health), mix of scholarship, research, and practice (with many questions, issues, skills, and competencies)
• Global refers to the scope of problems, not their location
• Global health is a dialogue and partnership between developed and developing countries
• Global health is interdisciplinary encompassing many disciplines specializing in prevention, treatment, and care

Koplan’s global health definition: global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasizes transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care.

History of public health
Public Health emerged in 19th century around the globe in response to social reform and growth of medical knowledge
Four factors of public health:
1) decision making based on data and evidence (vital statistics, surveillance, and outbreak investigations, laboratory science)
2) Focus on populations rather than individuals
3) Goal of social justice and equity
4) Emphasis on prevention rather than curative care
#onehealth, like #globalhealth and #WPW, is also an evolution of #culturechange in both research and practice.
#onehealth requires a change in mindset of how we conduct research, a recognition of its value, and the development of sustainable infrastructure and funding to incentivize the application of #onehealth in research and practice.
#syndromesofglobalchange #ecohealth #wickedproblemsrequiresystemsthinking.
Prior to the seminar and readings, I had never heard of the term #onehealth before, so I was a complete novice going into the seminar.

After the seminar and reflecting back on the Nathan Wolfe Ted Talk "The Jungle Search for Viruses", the term #onehealth really clicked for me.
Although the Nathan Wolfe Ted Talk "The jungle search for viruses" was introduced in the #globalhealth seminar, I thought the video really helped enhance my understanding of #onehealth. #R31
In particular, Nathan Wolfe's research demonstrated the interconnectedness of animal and human health and the benefits of going #upstream to monitor the entry of viruses from animals into humans. This really contextualized #onehealth for me and helped me understand the role of #onehealth in research and practice.
This evolution of #culturechange is exemplified in Zinsstag et al. (2011) paper:
"Despite all efforts of cooperation between human and animal health, isolated silo thinking persists,
particularly in the public health sector...Demonstrating evidence of an added value of “one health” compared to conventional separated sectoral approaches is the major task that lies ahead, and represents the unfinished agenda of “one health” in view of further systemic conceptual developments."
Health is a human right and needs to be protected!
Health is a resource for everyday life and is not the objective of life!
Health for all by the year 2000!
From Dr. Hatfield's lecture on Global Health, I was introduced to the Millennium Development Goals and the overarching vision of #globalhealth.
Corporations can have a large, positive impact on the #MDGs. Specifically, corporation's philanthropy (e.g. Bill and Melinda Gates Foundation) supports projects around the globe. Furthermore, their own #WPW and #HSE has huge potential to directly benefit employees health and well being. We have to hold corporations responsible as a #teamplayer in the health of employees and people around the globe. But sustainable solutions are created through shared responsibility in partnerships. Partnership between the private, public,and not-for-profit sectors. #R30
#R http://www.un.org/millenniumgoals/
Also from Zinsstag et al (2011). This is an
evolution towards a modern theory of health, namely #nonlinear #systemsthinking to better understand the interdependence of humans, animals, and their environments.

Zinsstag et al (2009)
"we need to change our 'us versus them' perspective towards a perspective of 'shared risk' between humans and animals...what is required now is a radical paradigm shift in our approach to global public health with practical approaches and 'hands-on' examples to facilitate its application and accelerating necessary leverage of 'One Health'".
An important reflection point in the video for me was when Nathan mentioned that we cannot place all the responsibility on the individual for the behaviours that cause the spread of viruses or particular to my portfolio, the development of #chronicdisease. For me this was an #ahamoment because I've always struggled, as a psychology concentration and a Health & Society major, as to how to balance the responsibility of health issues between the individual, government, corporations, etc. The psychological lens often focuses on the individual. Similarly, #WPW often relies on the autonomy of individuals and human agency but as we see in new community-based interventions with #WPW embedded in the intervention, guided by multidisciplinary teams, there is sharing of responsibility in tackling #wickedproblems like #chronicdisease.
Min et al. (2013)
"Both #OH and #TD approaches call for integrative, systemic health research methods that will facilitate the
of academic, institutional, disciplinary, stakeholder, and government silos."
They say a picture tells a thousand words...I liked this picture because it encapsulates the ongoing evolution of #culturechange in the workplace. A juxtaposition of what has been accomplished in #HSE and what is yet to be accomplished in #HSE and #WPW. #R20
This picture shows the adoption of safety practices, e.g. wearing a hard hat, but the need to address other unhealthy behaviours like smoking in the workplace. It has taken many years to establish safety practices as mandatory in the workplace and it will take many more years for #WPW to become widely established in the workplace #evolution #culturechange.
Culture change in the workplace
Zinsstag J, Schelling E. Waltner-Toews D, Tanner M. (2011). From ‘one medicine to ‘one health’ and systematic approaches to health and wellbeing. Preventative Veterinary Medicine, 101(3-4): 148-156.

Interconnections between humans, pet animals, livestock, wildlife, social, and ecological environment necessitates the integrated approaches to human and animal health in the social and environmental context

History of integrative thinking on human and animal health. Virchow linked animal and human health as a comparative medicine based on similar disease processes.

One Medicine
- William Osler coined the term One Medicine
- Calvin Schwabe’s recognized the close links between human and animal health, conceptualized by Schwabe’s work with Dinka pastoralists
- no difference in paradigm between animal and human health
- both sciences (veterinarian medicine and human medicine) share a common body of knowledge in anatomy, physiology, pathology, and origins of disease
- integrated approach to health of all species

One Health
Ecosystem health – extends one medicine to the whole ecosystem, including wildlife

Sustainable development – mutual health and well-being of humans, animals, and the ecosystems in which they co-exist

How can the public health sector perceive advantages of using “one health”?
- systemic conceptual developments
- major task for the future of one health

Ecosystem approaches to health
- considers the linkages and interdependence between ecosystems, society, and health of animals and humans
- contemporary problems cannot be solved with reductionist thinking, require systems thinking
Towards a systems approach to health of animals and humans
systems thinking
- non-linear relationships
- feed-back loops
- understand societal structures and functions influence on health, socio-ecological systems
- Needs to take into consideration social contact networks, socio-political and cultural context

Health in social-ecological systems (HSES)
- systemic approach to health of humans and animals
- approach to health determines social, cultural, economic, and political outcomes and these same things impact health and well-being in human and animal health
- social and ecological are intertwined
- interdisciplinary systemic research required to understand all these factors
- addresses social and ecological determinants of health and the consequences of health interventions

Challenges ahead
- faced with wicked problems
- need cross-sectoral collaboration
- enhance North-South and South-South cooperation
- find high-leverage determinants of health for humans and animals, alike
Zinsstag J, Schelling E, Bonfoh B, Fooks AR, Kasymbekov J, Waltner-Toews D, Tanner M. (2009). Towards a ‘one health’ research and application tool box. Veterinaria Italiana, 45(1): 121-133.

‘One Health’ thinking
emphasizes epidemiology and public health
emerged out of ‘One Medicine’ based on the close genomic relationships between animals and humans, e.g. cancer genetics
integrated approach to health - all species at the levels of pathogens, patients, populations, and cultural and natural environments
Shared risk between human and animals, change ‘us versus them’ perspective
Need more dialogue between medicine and veterinary medicine
dualistic, reductionist thinking must stop; overspecialization of disciplines
comparative pathology, cooperation to recognize infectious disease outbreaks
link animal and human surveillance
recognize health effects within complex social and environmental interactions
systems thinking

Open tool box – translating One Health into practical methods and approaches in the field
Integrated surveillance
joint veterinary medicine and human medicine databases
obstacles: support in lower to middle-income countries without infrastructure, culturally and gender sensitive, participatory – communities play an essential role at the first level of any surveillance system, requires multiple disciplines to create culturally and gender sensitive, participatory approaches
transdisciplinary approach – work in partnership with the local community

Animals as sentinels for human disease, vice versa
Epidemiological study designs: potential
Incidence and control of specific disease in humans and animals
Longitudinal and cross-sectional research to study animal-human transmission and interfaces
Joint human and animal surveillance systems, reduction in costs
Aim at high-risk populations exposed to exposure of interest

Epidemiological study designs: pitfalls
difficult to prove animal-human outcome linkages
• Mobility, heterogeneity, and diverse exposure
• Assessing non-transmission as difficult as transmission between humans and animals
• Broader ecological and societal considerations
Joint health and social services development
Joint delivery of health care services to both humans and animals, e.g. joint animal and human vaccination programs

Take a shared risk approach. Optimize human-environment interactions, minimize health hazards for humans and animals, and preserve a balanced ecosystem.
For things that cannot be changed or reversed, study resilience and adaptive management in socio-ecological systems.
Min B, Allen-Scott LK, Buntain B. (2013) Transdisciplinary research for complex One Health issues: A scoping review of key concepts. Preventive Veterinary Medicine, 112: 222–229.

One health research is conducted to solve complex health challenges at the animal-human-ecosystem interface.
Transdisciplinary research is more holistic, critical for solving complex health issues
TD goes beyond ID by including multiple levels of stakeholders, focus on the health issue through a unified lens

Evolution of TD research
ID → collaboration among different disciplines, transfer methods from one discipline to another
- Extent of collaboration varies with context
- Members of the team still approach the issue from their discipline
TD → holistic approach to health research, researchers from many disciplines work together to create a shared conceptual framework used to address a common problem
• Focus on interactions between, across, and beyond disciplines with a shared conceptual framework
• Successfully address complex OH challenges
• Facilitate knowledge translation

One Health/ Ecohealth convergence
TD focuses on ecosystem approaches to health, brings together disciplines and stakeholders
- Improve health at the animal-social-ecological interfaces

“Researchers work jointly using shared conceptual framework drawing together disciplinary-specific theories, concepts, and approaches to address a common problem”
Research that creates a common conceptual framework by combining disciplines and blending the expertise from each discipline, community-based and participatory approaches, ecosystem approaches
TD approaches necessary to solve complex health problems at the human-animal-environmental interface
Interconnection between human, animal, and environmental health, integration of multiple disciplines
“The collaborative efforts of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and our environment”

Important elements of TD OH research:
1) Education
- Increase TD education
2) Conflict amongst disciplines
- TD training will reduce conflict among disciplines and increase collaboration
3) Effective communication
- TD research is an iterative process, requires continual dialog between all stakeholders
- Team members must be familiar with each other’s discipline’s terminology and methods
4) Shared conceptual frameworks
- Effective communication critical for developing shared conceptual frameworks
5) Leadership
- Central leader needed to maintain team’s focus on the bigger picture
6) Perceived power differentials
- Deemphasize status and power between university and community members
- Participatory approaches empower communities and community members
7) Community-based methodologies
- Various levels of community-involvement in study design, data collection, analysis, and implications
- Collaboration among stakeholders
- Development of culturally appropriate health policies
8) Support for TD research
- Lack of academic structure to encourage and support TD research
- Focus on individual academic achievement does not support TD research
- Funding structures do not support TD research
9) Time and effort required for maintaining and establishing TD research teams
- TD research is time consuming; extend timeframes to allow for successful TD research

1) Tailored training
2) Early establishment of a conceptual framework through effective communication
3) TD roadmap to guide management of teams, leadership
4) Increase participatory and community-based research and strategies
5) Collaborative funding opportunities for TD research
6) Systematic evaluation of timeframes and evaluation of the added value of TD OH research
#onehealth is inherently transdisciplinary.

Collaborative Research Approaches:
Multidisciplinary -> fruit, each member of the team comes with their own training and their own conceptual framework
Interdisciplinary -> fruit salad, each perspective informs the other, mixed methods
Transdisciplinary -> smoothie, each perspective is mixed together, do not lose disciplinary expertise, but each member of the team operates under a unified conceptual framework
Prior to the seminar, I was unaware of the distinction between multidisciplinary, interdisciplinary, and transdisciplinary teams. Now I understand the distinction thanks to Dr. Lisa Allen's fruit-fruit salad-smoothie analogy.
In our #T2 twitter discussion, we explored the difference between #equity and #equality.
Ilana posted an excellent photo on twitter that helped illustrate the difference between #equality and #equity.
#equality is the same outcome for each individual, not taking into consideration each individual's particular situation or circumstance. #equity is matching resources with needs to ensure an equitable outcome.
Also, Jade tweeted a neat blog post explaining that
"equity means everyone gets the same quality of outcome - shoes that fit their individual needs."
Unfortunately, often #WPW operates on a principle of equality, all employees receive the same intervention, instead of equity.
#HNAs can target #WPW interventions to meet the needs of employees and #HIAs can evaluate the effectiveness of #WPWP to meet employees' needs.
Although Cody tweeted this for #T4, I thought it was relevant to the topic of equity vs. equality.
Cody expressed concern that business models may create inequity. #PPP can create equitable solutions by ensuring that workplaces are not only focused on the bottom-line. #PPP have been effective in creating equitable solutions through community-based interventions with #WPW nested in the intervention, as demonstrated in #CIH community-based intervention.
There are many psychological theories aiming to explain behaviour modification and the barriers that arise in the process, namely the Theory of Planned Behaviour, the Transtheoretical Model, the Health Belief Model, etc.
My favorite health psychology theory to explain behaviour modification is Tiny Habits by Dr. Fogg.
Dr. Fogg has studied behaviour modification out of Stanford University for 20 years and he argues that only 3 things will change behaviour in the long term.
1) Have an epiphany
2) Change your environment
3) Take baby steps
#WPW is directed at helping individual's change their behaviour through baby steps but most importantly by intervening on the #SDOH through changing the environment, ideally creating a more healthful environment where the healthful choice is the easy choice.
In order to incentivize #WPW, better research on #ROI is needed. Outcomes from intervening on #chronicdisease are often not seen for decades into the future making it difficult to provide data on #ROI. #R9
Return on investment
To increase sustainability of #WPW, management must be invested in the project. Better yet, if #WPW is nested in a larger community-based #PPP, the responsibility is shared by multiple stakeholders.
#chronicdisease in Iran #R12
Prior to this seminar, I was unaware of the potential benefit of utilizing website hits on google as a useful way to conduct health surveillance.
I think it is really fascinating that we can utilize these technologies to better inform our health research and practice.
In my own research for my learning objectives, I came across a similar health surveillance method - using twitter to observe health trends in populations.
In HSOC 311, we had a whole lecture on #healthpromotion and we were introduced to the Ottawa Charter, so coming into the seminar I was familiar with the concept of #healthpromotion.
#WPW is a form of #healthpromotion intervening on the #SDOH, particularly working conditions. Indeed, #WPW can be an excellent form of #healthpromotion as explored throughout my learning objectives; however, if #WPW can be better aligned with individual and community needs, this will improve the impact of #WPW.
Prior to the seminar, my exposure to #HNAs was through my work experience conducting #HNAs in different countries where the company operated. At the company I was working at, #HNAs were common practice in the workplace but did not guide the development and roll out of #WPW. Moreover, #HIAs are done less often. Utilizing #HNAs would guide the development of #WPWP to match the needs of employees and the community. Furthermore, utilizing #HIAs would allow for better evaluation of the impact and #ROI of #WPWP.
Prior to this seminar, I was unaware of the term syndemics. However, throughout the HSOC degree we often spoke about the interconnectedness of #SDOH and the #wickedproblems complicated by the interconnectedness of the #SDOH. Now, I have a term to better understand this phenomenon. The study of syndemics is important to understand the #wickedproblems, like the ever increasing prevalence of #lifestylediseases, facing our globalizing world.
The workplace is an important yet singular variable among the many variables in a syndemic. This highlights the importance of #PPP to tackle syndemics through multi-level interventions.
Prior to the seminar, I did not realize how disconnected I was from my food source. I realized this after watching a video clip from the documentary Samsara posted by Cynthia on twitter (although it was posted for Disease Prevention, I found it helped in my learning of health protection). #R36
The discussion in the seminar was very rich and explored the logistics of food safety and the ethical considerations of privacy and restricting information from consumers, workers, and citizens in a country.
One thing that stood out for me in the discussion was the importance of not relying on the individual worker to be responsible for food safety, rather this is the responsibility of the management operating under strict guidelines, policies, and processes that ensure food safety standards are met.
Can't blame the individual - like Nathan Wolfe mentioned in the "jungle search for viruses". #R31
Dr. Mark Dredze and Michael J. Paul at John Hopkins University are tracking the flu in the U.S. using twitter. #R41
Billion of tweets analyzed together can unlock insights to our public health.
For me, the most exciting thing about #WPW is the fact that #diseaseprevention can be tackled by multiple stakeholders, one of those stakeholders being the private sector.
There is an acute crisis that our health care system will not be able to support the increase in #NCDs within each country and around the globe. We need to act fast to prevent #NCDs to reduce premature morbidity and mortality. #R5
The cost of prevention of #NCDs should be shared by the public and private sectors.
Today, I could not tell you where the banana that I ate for breakfast came from. This reflection on my disconnect from my food source made me realize that I place a lot of trust in the governing bodies to protect my food source.
Ngom, P., Binka, F. N., Phillips, J. F., Pence, B., & Macleod, B. (2001). Demographic surveillance and health equity in sub-Saharan Africa. Health Policy and Planning, 16(4), 337-344.

Definition of equity and equality: equity is about fairness and justice, and implies that every one should have an opportunity to attain their full potential for health. Equality is about comparisons between the level of health, or ability to obtain access to health care, of individuals and communities

- coordinates efforts among these field sites and facilitates multi-site research into health equity issues
- Sites in sub-Saharan Africa, Asia, Middle East
Demographic surveillance
- define risk and correspond dynamics in demographic rates of birth, death, and migration in a population over time
Demographic surveillance in Africa
- sites linked to Ministry of Health address health inequity
- field-testing of health interventions
- ongoing demographic surveillance
- Phoelela Health Centre – prevention and treatment of diseases in Natal to inform health policy
- Collected demographic information as well
- Niakhar Project – assess feasibility of civil registration system, independent of Ministry of health
- Have not addressed the social determinants of health – homogenous population
- Demographic surveillance as a research tool to address health inequities

- provides accurate population-based information to inform health policy in developing countries
- aim to increase interactions between member sites through multi-site research, build capacity for research institutions in resource-poor settings, strengthen interface between research and policy
- testing primary health care strategies, appropriate health technologies to address diseases in developing countries
- improvement in demographic dynamics and disease profiles
- Household Registration System
- Potential for accurately measuring equity in health status and health care
- INDEPTH can provide accurate information on mortality in developing world
- Understand if improvements in health care in resource-poor settings result in better equity in health status
- Longitudinal data from DSS data in INDEPTH answer how health equity varies over time in developing countries
- Potential to use DSS data from INDEPTH to estimate DALY
- INDEPTH can measure distribution of health care resources, finding reasonable proxies to measure inequalities in distribution of health resources, household costs of illness not readily available
- Higher overall coverage or utilization of services does not imply greater equity or less inequality
- Search for a better way to achieve health equity in developing countries
- Track individuals – conduct population-based controlled experiments on the effect of a health intervention
- Field-testing of primary health care settings can lead to health sector reform
- Demographic surveillance provides accurate information on mortality and morbidity as social determinants of health intervene in longitudinal processes

ICDDR, B. (2008). Health and Demographic Surveillance System-Matlab: Volume Forty Two. Registration of health and demographic events.

Case study of health surveillance in Matlab, Bangladesh
- accurately updating health statistics
- more knowledge you have the better decisions you can make and the better you can deliver health care
- vital registration and maternal and child health data gathered from Matlab, Bangladesh
- Collected by the Health and Demographic Surveillance system of ICDDR
- Implemented in 1963 - health research programme
- recognized worldwide by population experts and health scientists as one of the longest continuing demographic surveillance sites in a developing country
- maintains the registration of births, deaths, and migrations, and periodic censuses
- community health research workers visit each household bi-monthly to collect data
- Collect data on child and reproductive health, delivered maternal health care, provided information on contraception and contraceptives, administered immunizations to mothers
- Example of a success story for a health surveillance system in a developing country

Christakis, N., Fowler, J. (2010) “Social Network Sensors for Early Detection of Contagious Outbreaks” PLoS ONE, 5(9): pp. e12948 , 1 – 8

• Monitoring contagious outbreaks is difficult and require new strategies.
• Christakis & Fowler developed a new strategy for contagious outbreak monitoring involving monitoring the friends of randomly selected individuals.
• The researchers observed a flu outbreak in Harvard in 2009 and followed 744 students that were either randomly selected or a group of their friends.
• The epidemic in the friend group was shifted forward 13.9 days.
• The high in-degree group is composed of individuals who have a higher-than-average number of other people in the network who name them as a friend. The low transitivity group is composed of individuals with below-average probability that any two of their friends are friends with one another.
• The high centrality group is composed of individuals with a higher-than-average betweenness, which is the number of shortest paths connecting all individuals in a network that pass through a given person.
• The high coreness group is composed of individuals with a higher-than-average coreness, which is the number of friends a person has once all individuals with fewer friends have been eliminated from the network.
• The results show that flu outbreaks occur up to two weeks earlier in each of these groups.
• The authors identified the new strategy as beneficial to understand contagious disease outbreaks and inform policy makers and public health
• Additionally, a sensory method may include observing online searching behaviour in friend group or group known to be central in network

Cliff A, Haggett P. (2004). Time travel and infection. British Medical Bulletin, 69: 87-99.
Soleman N, Chandramohan D, Shibuya K. (2006). Verbal Autopsy: current practices and challenges. Bulletin of the World Health Organization, 84(3): 239 – 245.

• Human population has grown exponentially
• Geographical space is becoming smaller because of growth in the world population
• Human travel and immigration has changed infectious disease outbreak patterns
• Three case studies are explored to understand the changing dynamics of disease transmission
• Improvements in boat and air travel changed disease patterns:
o improvements in ship technologies resulted in an increase in chance of infections surviving on board
o air travel resulted in an exponential increase in infection potential due to shorter travel times and increase in carrying capacity
o increase in personal spatial mobility
• Contraction and disease spread

1) Switch from sail to steamships in importing measles into Fiji over a 40-year period
• intercontinental spread of measles by ship
• Indian immigrant ships, measles endemic in India
• Documented cases of measles when ship left, longer ship rides
• Improvements in technology resulted in shorter travel by boat, measles survived on boat
• Led to the disastrous 1875 measles epidemic in Fiji
2) Changes in measles epidemic behaviour in Iceland over a 150-year period
• epidemics of measles caused by infectious individuals travel by boat along the coast
• Iceland population too small to maintain epidemic
• More encounters with virus, population grew, outside contact increased leading to subsequent waves of measles epidemics
3) Changes in spread of cholera within the US over 35-year period
• Increase in railroad travel, cholera spread less dependent on local and regional contact, driven by intercity links in the urban city centers
General implications for travel and disease
• Air travel is increasing the spread of zoonotic agents and infectious disease
• Airplanes are opportunistic environment to spread diseases from around the world

World Health Organization. (n.d.). Development of Verbal Autopsy Standards. Retrieved from World Health Organization website: http://www.who.int/healthinfo/statistics/verbal_autopsy_standards1.pdf

Need for standardization in VA methods
- VA good way to assess COD at a population level, not the best at the individual level
VA used in 3 main ways:
1) research tool in the context of longitudinal population studies, intervention research, epidemiological studies, usually in children or to determine maternal cause(s) of death
2) source of COD statistics to meet demand for population-level disease burden estimates to be used in policy planning and priority setting
3) Data from Vas gaining acceptance as a source of COD statistics to be used for monitoring progress
Currently no standard procedures for VAs
VA data used as a source of comparative population health outcome statistics
Systematically collected data is preferred but not available in many lower income countries
VA data to target progress on MDGs
Evidence-based planning and priority setting
Consensus on a core set of technical standards and guidelines for VA
Reliable and free of human bias

Soleman, N., Chandramohan, D., Shibuya, K. (2006). Verbal autopsy: current practices and challenges. World Health Organization Bulletin, 84(3): 239-245

VA – indirect method of collecting biomedical information regarding symptoms, sings, and circumstances preceding death obtained from deceased’s caretakers
- also used to investigate infectious disease outbreaks

Standard VA tool
- VA questionnaire
- COD or mortality classification system
- diagnostic criteria
- diversity of tools → difficult to compare VA data
VA questionnaires
- high variability in questionnaires
- key filter questions on symptoms and signs were not substantially different
- variation may lead to different sensitivities and specifities of the tools
COD classification
- variations in the COD on classification – some tied to ICD-10
Algorithms to derive cause of death
- map diagnostic criteria in order to provide a systematic means of deriving COD from VA
- increase reliability of VA tool
- automation of COD coding process
Use physician panels to determine COD

Some sites use medical professionals and others use individuals with secondary education, many do not report the characteristics of VA interviewers
Well-trained lay people can obtain accurate information when using culturally and linguistically appropriate questionnaires
Standardization in one site beneficial

Identify a relative who had taken care of the deceased during the final illness
This process is not formalized
Accuracy of VA tool increases if respondent took care of deceased in final illness
Culturally and socially sensitive

Recall period
Wide range of recall periods, sometimes VA interview happens soon after death or quite a while later
Impair recollection, decrease accuracy of VA tool

VA tool should be written in the local language
Multiple translators to improve accuracy of VA tool to be translated into proper local language
Field-tested to optimize the VA tool (layout, language, biomedical concepts)

Analytical Challenges (deriving COD from VA results)
Physician review, predefined expert algorithms, data-driven algorithms
Expert Algorithms more sensitive to multiple COD, physician review often results in single COD
Expert Algorithms reduce cost and time needed for VA result review
Validity of algorithms lower than physician review

Data-derived algorithms
- relative low cost, potentially high reliability and consistency over time and between sites
- comparable to physician review
- only use closed-ended questions, physicians would use closed and open-ended questions and medical charts

Single or multiple CODs
Cause-specific mortality fraction should be primarily based on underlying COD defined in ICD-10
Classifications on VA are all different – need to harmonize VA categories with ICD-10 categories

Accuracy of the mortality data from VA systems
VA considered to have an acceptable level of diagnostic accuracy at the individual level, specificity and sensitivity of at least 90%
Improper classification leads to inaccurate reporting
Not recommended to adjust for misclassifications using sensitivities and specificities from validation studies

Measuring trends
Difficult because of the heterogeneous VA tools used – difficult to standardize

The way forward
Uniform and reliable method to derive COD and standardize the VA questionnaire and field-operating procedures
Standardize COD classifications to the ICD-10 classifications
VA data used to track progress of MDGs

International Conference on Primary Health Care. (1978). Declaration of Alma-Ata. Presented at Alma-Ata, USSR.

Health is a state of complete physical, mental, and social wellbeing, and not merely the absence of disease or infirmity, and is a fundamental human right.
• The attainment of the highest possible level of health is a world-wide social goal that requires the action of many sectors, in addition to the health sector
• Inequality in health status of the people in developed and developing countries is unacceptable and concern for all countries
• Economic and social development is necessary for the fullest attainment of health
• People have the right and duty to plan and implement their health care
• Governments are responsible for the health of their people, by the year 2000 all peoples of the world should attain health that permits socially and economically productive life

• Primary health care needs to be self-determined and accessible to people, the first element of a continuing health care process
o evolves from economic, sociocultural and political conditions of a community, guided by research
o Addresses main issues in community, provides health care services
o education on prevention and control of health problems, adequate nutrition, food supply, safe water, basic sanitation, maternal and child health care, family planning, immunization, prevention and control of endemic diseases, appropriate treatment of disease and injury, access to pharmaceuticals
o Involves various sectors outside the health sector
o Community and individual self-reliance and participation in planning, organization, operation, and control of primary health care
o Integrated, functional, and mutually supportive referral systems
o Health professionals operate as a health team to respond to health needs of community

• National policies and strategies to sustain primary health care, requires political will to mobilize country’s resource and integrate external resources
• Countries operate in partnership to ensure primary health care for all people
• Better use of world’s resources, moving resources away from military conflicts and towards better health for all

Multiple stakeholder approach to increase technical and financial support of primary health care around the globe, and particularly in developing countries

World Health Organization. (n.d.). The Ottawa Charter for Health Promotion [Fact sheet]. Retrieved from World Health Organization website: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/.

Health Promotion
• process of enabling people to increase control over, and to improve, their health
• goal is to reach a state of complete physical, mental, social well being but individuals and groups must have the resources to achieve this
• Health is a resource for everyday life
Prerequisites for Health
• peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, equity
1) Advocate
• Health promotion advocates for health to increase the favourable economic, social, and cultural factors for good health
2) Enable
• Health promotion aims for equity in health by creating equal opportunities for and resources to enable individuals to achieve their fullest health potential
3) Mediate
• Health promotion mediates coordinated action by governments, health, social, and economic sectors

Health Promotion Action
1) Build healthy public policy
• healthy public policy should be on the agenda of all policy makers
• Make the healthier choice the easier choice for policy makers
2) Create supportive environments
• socioecological approach to health
• encourage reciprocal maintenance of communities and natural environment
• Work and leisure should be structured in society to promote health
• Protection of natural and built environments and the conservation of natural resources

3) Strengthen Community Actions
• effective community action in setting priorities, making decisions, planning strategies, and implementing them to achieve better health
• Empower communities

4) Develop personal skills
• personal and social development through education and enhancing life skills
• Empower individual to exercise control over their own health and environments, make choices that are conducive to health

5) Reorient Health Services
• health promotion is the shared responsibility of individuals, communities, health professionals, health service institutions and government
• Work together to create a health care system that contributes to the pursuit of health
• Reorientation of health services towards the total needs of the individual as a whole person

#HIA and #HNA are only as effective as the individuals or teams using them. #HIA and #HNA should be backed by interdisciplinary teams utilizing these tools effectively to assess roll out and completion of interventions.
If #WPW collects important information on non-communicable disease and health of employees and is embedded in larger community-based interventions, this will help in the collection of community health intervention (if consent is received to use health and medical information from employees). Health surveillance is important for measuring the impact of #WPW and larger community-based interventions.
Sudbury & District Health Unit. (2011). 10 promising practices to guide local public health practice to reduce social inequities in health: Technical briefing. Sudbury, ON.

1) Targeting with universalism
- universalism → entire population is beneficiary
- targeting → means-testing used to determine eligibility for the benefit
- targeting within universalism → ensures that extra benefit are directed to poorer groups and acts to fine-tune essentially universal policies
- To reduce health inequities, public health practice must balance selective or targeted approaches with universal strategies
- Within framework of universal access, special attention must be provided to socially disadvantaged groups – equity-based epidemiological information required, monitor impact of programs
2) Purposeful reporting
- report on the relationship between health and social inequities in all health status reporting
- health inequity must be measured
- stratified analysis by SES – effect of social inequities in health is understood
3) Social marketing
- systematic application of marketing alongside other concepts and techniques to achieve specific behavioural goals for a social good
- target audience segmentation and tailored interventions
- tailoring behaviour change interventions to more disadvantaged populations
- use social marketing to change the understanding and ultimate behaviour of decision makers and the public to take or support action to improve inequities in SDOH (combined with individual behaviour change approaches to increase impact)

4) Health equity target setting
- good evidence on levels of health and its distribution and the SDOH is essential to understanding the problem, assess the outcomes, and monitor progress
- target setting is a necessary strategy – time-based outcomes not as beneficial as objective-based targets
- concrete targets to drive action
- directing resources appropriately towards targets to address inequities in health
5) Equity-focused health impact assessment
- Health Impact Assessment (HIA) is a structured method to assess the potential health impacts of proposed policies and practices
- also promising method to address underlying social and economic determinants of health and resulting health inequities
- participatory approach builds capacity and reduces social inequities in health
- public health sector best to use HIAs
- resources, professional competencies, institutional nature of public health agencies are challenges for public health sector to effectively undertake an HIA
6) Competencies/ organizational standards
- important skill sets – community planning and partnership and coalition building – shift in/ culture change in public health staff → paradigm shift for public health
- public health staff need to act in accordance with social justice values and beliefs → PHAC 36 core competencies for public health encompassing essential knowledge, attitudes, and skills

7) Contribution to evidence base
- better evidence base for the outcomes from public health interventions
- intentional dissemination of knowledge through publications and reports to build a better evidence base
8) Early childhood development
- investments in early child development is a powerful equalizer
- early childhood development, nurturing environments, and quality childhood experiences critical for positive human development and health
- policies, programs, and services designed through intersectoral collaboration based on target universalism
9) Community engagement
- community engagement is a key cross-cutting strategy in reducing social inequities in health
- shared power and control
10) Intersectoral action
- build strong, durable relationships with health sector and other sectors to create effective action
- complex problems require complex solutions that are generated through governments and sectors working together to identify problems, share resources, and evaluate outcomes
- public health might not be the best evaluators of intersectoral action

Cavenagh S, Chadwick K. (2005). Health Needs Assessment. Health Development Agency.

Health Needs Assessment → systematic method for reviewing the health issues facing a population, leading to agreed priorities and resources allocation that will improve health and reduce inequalities
- HNA is a public health tool to provide evidence about a population on service planning
- targeted service planning and resource allocation
- cross-sectoral partnership
Vital tool to meet objective of reducing health inequities.
- strengthen community involvement
- improve team and partnership
- professional development
- improved communication
- better use of resources

- professional boundaries preventing information sharing
- shared language between sectors → common terms for HNA: health, inequities in health, health needs, determinants of health, population, HNA selection criteria, levels of prevention of ill health, diseases and health conditions, health functioning, health triangle
- obtaining commitment from top
- accessing relevant data
- accessing target population
- maintaining team commitment
- translating findings into action

Step 1 – Getting started → make sure resources and capacity is available for HNA
- what population?
- What are you trying to achieve?
- who needs to be involved?
- What resources are required?
- What are the risks?
Step 2 – Identifying health priorities
- population profiling
- gathering data – health functioning score → high score = priority for action (health triangle)
- perceptions of needs
- identifying and assessing health
- conditions and determinant factors
Step 3 – Assessing a health priority for action
- choosing health conditions and determinant factors with the most significant size and severity impact
- Determining effective, acceptable, and cost-efficient interventions and actions
Step 4 – Planning for change
- clarifying aims of intervention
- action planning
- monitoring and evaluation strategy – evaluation tool
- risk-management strategy
Step 5 – Moving on review
- learning from project – what went well? how effective was it?
- measuring impact
- choosing the next priority
HNAs skills – project management, team building, partnership working, community engagement, population profiling, data collection, monitoring/ setting indicators
Case studies

Montgomery CM, Mwengee W, Kong’ong’o M, Pool R. (2006). “To health them is to educate them”: power and pedagogy in the prevention and treatment of malaria in Tanzania. Tropical Medicine and International Health, 11(11): 1661-1669.

• Qualitative methods explored why households make certain decisions relating to malaria and how this is connected to the household’s SES and economic situation
• grounded theory
• 415 interviews conducted with 79 parents or caretakers of children under 5 years of age
• Multiple interviews with each individual
• In-depth interviews with 55 health care practitioners
• Most individuals identified mosquitoes as the source of malaria, signs and symptoms of malaria were well identified, many new the available treatments, corresponded with health care providers interviews
• Treatment decisions are made by males, males have control over finances
• HCP referred to mothers as low intelligence, lazy, neglectful, and willfully deceptive
• Women are disempowered into believing that they cannot make decisions for themselves
• Staff fail to recognize men’s role in controlling decision making
• power relations between HCP and patients like the teacher-pupil relationship in schools
• Mutual participation in health education, moving away from existing model of health education, health education should empower the patient
• training for HCP, patient education added to medical curriculum

Snow RW, Marsh K. (2010). Malaria in Africa: progress and prospects in the decade since the Abuja Declaration. The Lancet, 376: 137-39.

1998, WHO launches the Roll Back Malaria program at the Abuja meeting. The goal of Roll Back Malaria was to ensure that 60% of continent’s at-risk population was protected and treated for Malaria.
In 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria was established to fund health-related MDGs.
Funds makes it possible to run various interventions in high risk African countries including insectiside-treated nets, selective use of indoor residual spraying, reduction of maternal and neonatal consequences of infection during pregnancy, replacing of inactive drugs with artemisinin-based combination therapy (ACT), and improved diagnostics at point of care with rapid tests.
Increase in global funding for malaria prevention programs. There is global and local excitement and energy around improving malaria outcomes and preventing malaria.
The efforts have been beneficial resulting in reduction of diagnosed malaria cases and reduction in malaria transmission.
Malaria is no longer a major childhood disease in certain countries but this situation cannot be generalized across all African countries.
A reduction in malarial cases has also reduced comorbidities such as bacterial disease.
Governments and ministries are on board with WHO Roll Back Malaria plan to control and eventually eradicate malaria.
Although malaria programs have been well funded in the past, there is still a funding gap.
In order to achieve eradication of malaria, an entirely new approach is needed including surveillance and massive investment.
Donors are stretched thin when it comes to funding health prevention and this is a real concern for the future funding of programs.
Current funding and prevention programs will reduce malaria. Malaria prevention is critical to reducing comorbidities that burden countries. Controlling malaria, although less ideal than eradication, will have multiple benefits.

Mushi AK, Armstrong Schellenberg JRM, Mponda H, Lengeler C. (2003). Targeted subsidy for malaria control with treated nets using discount voucher system in Tanzania. Health Policy and Planning, 18(2): 163-171.

• Mushi et al. conducted a mixed methods study assessing a voucher system for a targeted subsidy of treated nets in young children and pregnant women in two rural districts in Tanzania
• Qualitative: 22 focus group discussions with community leaders, male and female parents of children under 5 years, unmarried and married women, 4 in-depth interviews with MCH staff and retail agents
• Quantitative: household-level cluster sample survey of child health
• Goal of voucher program was to 1) increase use of treated nets in pregnant women and young children, most vulnerable to malaria; 2) reduce the price of treated nets 3) promote increase equity in pregnant women and young children
• Uptake was high but awareness was not very high, takes several years to create widespread awareness
• Voucher use was higher among least poor households compared to poorest households because cash payment is required when using the voucher which was a barrier for the poorest households
• The voucher system highlighted the importance of the role of public health services in the context of social marketing and developing an IEC tool to demonstrate the group at the highest risk for malaria

One thing that I have always struggled with in #HSOC is the practical, on-the-ground solutions to real problems. I find often we discuss a lot of theory. But what does it look like on the ground?
I really liked this video shown in the #diseaseprevention seminar because it demonstrated an on-the-ground, practical solution for real problems. This really clicked for me that we can start top-down and work from a framework to the field site, or we can start from the bottom, the field site, and work up to a framework. #R34
The picture shown in the #diseaseprevention seminar of the floating slum in Lagos, Nigeria helped me see how each concentration (i.e. psychology, sociology, geography, economics, political science, and anthropology) can provide a unique perspective to intervening on complex problems like the floating slums in Lagos, Nigeria. An economist might wonder why these people are living in the slum? Are there no job opportunities? A psychologist might be interested in the psychological impact of living in a slum on child development? A political scientist might wonder about the government's role in intervening in this situation? An anthropologist might be interested of the culture in the slum that impacts on the health and wellbeing of children?
When the concentrations work together in an interdisciplinary team, a holistic approach to #diseaseprevention is possible. #R35
Prior to the seminar, I was quite bitter about research in the First Nations community and I had sort of lost all hope of how we could rectify what appears to be such a hopeless situation. In the seminar, I realized that I had bought into a paternalistic view of how to conduct First Nations Research.
OCAP is #culturechange away from the past paternalistic way of conducting First Nations research and a shift towards self-determined research that can empower the community. Hearing from Dr. Kutz was exciting that this new way of going about research is already in practice and is continuing to grow.
In asking questions to Dr.Kutz, I realized how much impact employers have on the livelihood and lifestyle and ultimately health of workers in the north and how #WPW could have a large impact on this population. The biggest concern going forward with #WPW is the need to be culturally-relevant and guided by needs of the community.
Brook, R.K., Kutz, S.J., Veith, A.M., Popko, R.A., Elkin, B.T., Guthrie, G. (2009). Fostering community based wildlife health monitoring and research in the Canadian north. EcoHealth, 6(2):266-278.

Livelihood of northern Canadians is being jeopardized by climate change and northern Canadians still strongly rely on wildlife as principle food source and self-employment
Research must adequately incorporate local ecological knowledge – this will help ensure buy-in from community and scientists
Co-management boards are beneficial for co-managing wildlife and renewable resources
Community-based monitoring is an approach to environmental observation that incorporates local people, government agencies, academia, community groups, and local institutions to monitor, track, and respond to issues of common concern
- interdisciplinary methods and collaboration

Workshop on wildlife research and monitoring needs
- wildlife priority, local subsistence hunters involved in wildlife monitoring and research
- youth need to receive enhanced education in science and wildlife biology
- Sahtu Wildlife Health outreach and monitoring program – collaboration and ongoing information exchange among hunters, academics, and wildlife managers
Integrated approach
- initial monitoring program included community workshops and classroom visits and evolved to incorporate traditional knowledge, community-based wildlife health monitoring, graduate and undergraduate student education, and targeted research projects
Cultivating the next generation of scientists
- interaction with grade school children
- education on wildlife topics, student involvement in wildlife monitoring, promoted careers in science, vet med, and renewable resource management
- active learning experience for grad students in northern research
- conducted interviews to evaluate program
- Positive feedback from school visits, students interested in future careers in biology, vet med, etc.

Local Ecological Knowledge
- gain LEK in conversations with local people at workshops, schools, meetings, etc.
- formal documentation of LEK – interviews with community members
- Local ecological knowledge shared between both groups was very beneficial in creating knowledge sharing and knowledge translation
harvester partnerships in wildlife monitoring
- trained local wildlife health monitors to collect samples and record health and condition data on animals harvested for subsistence
- Regular interactions between hunters as WHMs and scientists – foundation for hunter-based monitoring program in Canada
Targeted empirical research
- evaluation of the effectiveness of blood filter strips for caribou disease surveillance, dental enamel development and lesions in caribou, etc.
- Many students conducting projects
Community workshops
- variable attendance but provided a meaningful two-way sharing of information, meetings discontinued due to “meeting fatigue”, critical meetings held

Participatory action research
1) responding to needs of communities
2) fostering collaboration among scientists, managers, and local people through the research process
3) promoting a shared knowledge and increased community awareness

“Stool model”
- champion needed to manage diverse aspects of team
- collaboration essential
- long-term funding
- education opportunities
- information and analysis

Snarch, B. (2004). Ownership, control, access and possession (OCAP) or self-determination applied to research: a critical analysis of contemporary First Nations research and some options for first nations communities. Journal of Aboriginal Health, 80- 95.

O – Ownership
- relationship of a First Nations community to its cultural knowledge/data/information
- community owns information in the same way an individual owns their personal information
C – Control
- First Nations control all aspects of research and information management processes which impact them
A – Access
- First nations have access to their information and data no matter where it is currently held
P – Possession
- ownership is asserted over data and protected
Self-determination applied to research
Response to colonialism and paternalistic research
Past research has not done a good job to involve the First Nations and allow them to direct the research.
Researched to death

New ethical guidelines for work with First Nations highlights the importance of community involvement and respect for culture. Lessen the power differential between researchers and subjects.
Tri-Council Policy statement (TCPS): ethical conduct for research involving humans – section on research involving Aboriginal Peoples
Participatory research, community involvement, incorporation of traditional knowledge, culturally-appropriate, community-based research are actively being used in First Nations and Inuit research → needs to be a more respectful and ethical approach to research in Aboriginal communities, education of researchers, and personality of researchers

New ethical guidelines
- ongoing explanations
- community involvement
- research relationship negotiated
- respect for privacy
- capacity development
- access to data
- community interests supported and benefits maximized, harms reduced or avoided
- focus on group rights

First Nations governance and self-government implies jurisdiction and control over a full range of institutions, processes, and research
Three minimum requirements for effective government: power, resources, and legitimacy
OCAP supports these minimum requirements
Defining the researcher
- new models that have the First Nations communities as researchers
- Change in funding structure
Capacity and quality
- need strategies to provide individual opportunities that also produce benefits for the collective
- put research dollars into First Nations communities and organizations
- need for culture change away from paternalistic view of research in First Nations
- support community research initiatives
OCAP in practice
- Resistance to OCAP
- Judgment of how to respect OCAP, get research done, what compromises are acceptable, whether to proceed with a project and under what terms

First Nations Research Policy
- research should provide clear benefits to First Nations
- help develop capacity
- increase First Nations control of information and research processes
- support self-determination
- support cultural preservation and development
Data ownership and data sharing
- control of data can help counterbalance the lack of capacity and lack of voice of First Nations
- release or sharing data only after First Nations can disseminate their own interpretation of the research
- releasing data for specific purposed only
- releasing statistical data only for
- reviewing and approving prior to publication
- First Nations ethical review can ensure the above aspects are met
Benefits of OCAP
- rebuild trust with communities
- improves quality and accuracy
- results are more democratic
- participatory
- holistic approach
- minimizes biases and misinterpretations
- community empowerment and self-determination
- more relevant and useful research results
- meaningful capacity development

The ego vs. eco diagram posted by Cynthia on twitter really demonstrated not only the cultural beliefs of First Nations but also the #culturechange required to move towards #onehealth research and practice. We need to move towards #eco and away from #ego - this will be a pinnacle aspect of #culturechange required to fully embrace the concept of #onehealth.
This has sparked a curiosity in me to explore food production and regain a connection with my food source. I am thinking of traveling with WWOOF (Work exchange on organic and sustainable properties) #R37. http://wwoofinternational.org/
Gyles, C. (2010) "Agroterrorism" CVJ, 51:347-348.

Agroterrorism → deliberate infection of animals with pathogenic microorganisms or contamination of foods of animal origin with toxic chemicals that could be introduced to feed
- animal suffering
- loss of valuable animals
- cost of containment of outbreaks and disposal of carcasses
- lost trade
- other economic effects involving suppliers, transporters, distributors, and restaurants
Attractiveness of agroterrorism
- quite easy to obtain
- little expertise required
- farming methods may facilitate the rapid spread of contagious agents
- low-tech inexpensive method to create havoc
- insects can spread pathogens to infest corps
- infectious agents to attack animals also
- be prepared for the possibility of an attack
- Defence Research and Development Canada and CFIA preparing emergency preparedness and response to ensure Canada is in a good position to respond
- screening and rapid testing
- coordination among federal and provincial labs and US colleagues
- surveillance
- vaccines available in the event of an outbreak
- reporting system with producers
- prevention best approach to being prepared
- biosecurity major part of a good prevention strategy
- veterinarians play a crucial role in education of producers and monitoring disease and biosecurity

U.S. Food and Drug Administration. Food Defense Awareness for Food Professionals. Retrieved from U.S. Food and Drug Administration website: http://www.accessdata.fda.gov/scripts/FDTraining/course_01/FD01_000.cfm

Food defense → prevent intentional contamination of food products by biological, chemical, physical, or radiological agents
Food safety → prevention of unintentional of food products by agents likely to occur in the food supply
Food security → all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life
- physical and economic access to food that meets people’s dietary needs as well as their food preferences
Food protection → robust strategy to protect the nation’s food supply from both unintentional and intentional contamination
Biosecurity → preventive measures to reduce the risk of transmission of infectious diseases, quarantined pests, invasive alien species, and living modified organisms
Food terrorism → act or threat of deliberate contamination of food for human consumption with chemical, biological, or radionuclear agents for the purpose of causing injury or death to civilian populations or disruption of social, economic, or political stability
Agroterrorism → malicious attempt by a person or group to disrupt or destroy the agricultural industry or food supply systems
Bioterrorism → unlawful use of biological agents or toxins targeted at civilian populations to coerce political or social objectives

Importance of food defense
- food and agricultural sector is critical infrastructure and destruction would result in negative impacts on national economic security, security, national public health and safety
- food supply is more global and highly complex involving multiple stages across the food chain, increasing accessibility making regulation difficult
- potential to cause large number of illnesses or deaths (especially in vulnerable populations)
- potential to cause economic damage (economic losses)
- potential to cause psychological damage (fear)
- accessibility and vulnerability important in intentional contamination
- contamination can occur at several points of the food process from farm-to-fork
- global food network means that contamination will have a far reaching affect

Intentional contamination
Economically motivated adulteration → fraudulent, intentional substitution or addition of a substance in a product for the purpose of increasing the apparent value of the product or reducing the cost of production
Tampering → intentional modification of a product in a way that would be harmful to the consumer
Terrorism → domestic and foreign aggressors, politically or ideologically oriented, well funded, sophisticated, capable of efficient planning, death, destruction, publicity, and economic damage
Disgruntled employees → personal vendetta, bribed or manipulated by an outside source, often have legitimate access to the food product
Counterfeiting/ diversions → misrepresentation of a product or masquerading foods as something they are not
Exterior attack → raw material used in production of the targeted food may contaminated at a point where it is grown, transported, or processed
Forced entry → person attempting to contaminate the food enters by breaking into the facility
Covert entry → deception, stealth, posing as a member of a visiting group of people
Insider compromise → person(s) contaminating the food has legitimate access to the food, i.e. employee
Biological → bacteria, toxins, viruses, parasite-type organisms
Chemical → cleaning compounds, maintenance chemical, pesticides, herbicides, laboratory chemicals
Radiological → radioactive elements that can be delivered in liquid or solid form
Physical → glass, metal, wood, etc.

How to defend firm
- food defense plan
Prevention, Response, Recovery
Managerial → preparation of the possibility of a malicious act, supervision, recall procedures, investigation of suspicious activities, evaluation of associated programs
Procedural → procedures for personnel, the public, access areas, and operations that may prevent malicious act
Physical → security measures, facility, laboratories, water and utilities, computer systems, and storage and incoming materials and finished product
Front line employees must be part of your food defense program
Broad mitigation strategies → vulnerability assessments → focused mitigation strategies → food defense plan
Impact to firm → financial, indirect multipliers, global (trade embargos), psychological, health
having a food defense plan: supports safety and quality initiatives, reduces the cost of more mundane security lapses, reduces risk of devastating event, reduces impact of a minor event, can provide a competitive advantage

FDA is responsible for food security directed by the Public Health Security and Bioterrorism Preparedness and Response Act
FDA Resources: A(Assure) L(Look) E(Employees) R(reports) T(threats), CARVER + Shock
Common misconceptions and responses
- any firm is vulnerable
- it is everyone’s job and responsibility to ensure contamination does not occur
- domestic acts instead of foreign acts are more common
- intentional contamination within a firm is possible
- cost-effective solutions are available to smaller firms
- consultant not necessary, free resources available through FDA

Food Defense Plan:
- assessment of broad mitigation strategies → outside security, inside security, logistics, production, and storage security, management and personnel security
- development of action items from broad mitigation assessment
- vulnerability assessment → assessing accessibility and vulnerability, identifying all food products, create a flowchart for each food product, identify the process steps of each food product, evaluate the risk of each process step, rank process steps by overall vulnerabilities
- selection of focused mitigation strategies → focused mitigation strategies additional level of security to vulnerable areas within food processing or production steps, visibility, equipment,
o focused mitigation strategies: managerial strategies, procedural strategies, physical strategies
- Food defense plan content: firm and facility information, general food product information, employee information, property description, response plan, and action plan
Food defense team – food defense coordinator, facility management, human resources manager, inspection, access, monitoring, production manager, quality control/ quality assurance manager, employee representatives, occupational health & safety, corporate headquarters, legal adviser/ counsel, chief executive officer (CEO)/president, head of security
FDA Food Defense Plan Builder – guide

U.S. Food and Drug Administration. (2007). An overview of the CARVER plus shock method for food sector vulnerability assessments. FDA, 1-14.

CARVER shock method is an offensive targeting prioritization tool, adapted for the food sector.
- think like an attacker to identify the most attractive targets for attack
- protect most vulnerable points
Criticality – measure of public health and economic impacts of an attack
Accessibility – ability to physically access and egress from target
Recuperability – ability of system to recover from an attack
Vulnerability – ease of accomplishing attack
Effect – amount of direct loss from an attack as measured by loss in production
Recognizability – ease of identifying target

SHOCK – health, economic, and psychological impacts of an attack

Steps for conducting a CARVER + Shock analysis
Step 1 – Establish parameters – what food supply chain is going to be assessed? what type of attacker and attack are you trying to protect? what agent(s) might be used?
Step 2 – Assemble experts – experts in food production, food science, toxicology, epidemiology, microbiology, medicine, radiology, risk assessment
Step 3 – Detailing food supply chain – flow chart of the system and its subsystems
Step 4 – Assigning scores – nodes with higher scores are potentially the most vulnerable nodes (most attractive targets for attacker)
Scores 1-10
Criticality → target is critical when introduction of threat agents into food at this location has significant health or economic impact
Accessibility – openness of target to the threat
Recuperability → time for the specific system to recover productivity
Vulnerability → ease with which threat agents can be introduced in quantities sufficient to achieve the attacker’s purpose once the target has been reached
Effect → measure of the % of system productivity damaged by an attack at a single facility
Recognizability → degree to which it can be identified by an attacked without confusion with other targets or components
Shock → combined measure of health, psychological, and collateral national economic impacts of a successful attack on the target system
Total score can then be calculated for each node in a system to determine the most vulnerable node and measures to mitigate vulnerability of nodes can then be planned and implemented
Step 5 – Applying what has been learned – countermeasures that minimize the attractiveness of nodes as targets

The #syndemics block activity in the seminar helped visual the interaction of the different variables in a syndemic. What I found really interesting was that we found poverty to be a central variable in almost all syndemics. This really emphasized that if we can intervene on this #SDOH, we can have a huge impact on #syndemics and health of populations #upstream.
Rock, M., Buntain, B. J., Hatfield, J. M., & Hallgrímsson, B. (2009). Animal–human connections, “one health,” and the syndemic approach to prevention. Social Science & Medicine, 68(6), 991-995.

Syndemic → involves two or more afflictions that, by interacting synergistically, contribute to excess burden of disease
Syndemic orientation towards prevention focused on the connection among health-related problems and considers those connections when developing health policies
Animal-human connections – multiple connections with human health problems
- applies to zoonotic and non-zoonotic diseases

New definition of Syndemic → two or more afflictions that interact synergistically within the context of specific physical and social environments, especially as a result of inequality within and between human populations, to produce excess disease burdens in a human population, an animal population, or multiple such populations
Case study – TB, M.Bovis, and HIV – Syndemic created
Animal-human connections are economic, cultural, and emotional in nature
Health of pets important for controlling disease – vaccinating animals
one health is supporting research examining the entwining of human health with animal health
Social inequality has a strong influence on health of populations
Prevention-oriented research that takes into consideration connections between physical environments, social environments, human populations, and animal populations

Education → teaching syndemics in seminars
Funding → funding agencies need to create special competitions for research on animal-human syndemics, change within research cultures and educational institutions
Bring together expertise in social, animal, and human health sciences – maximize capacity to understand key health risks and to promote health

Singer, M., & Clair, S. (2003). Syndemics and Public Health: Reconceptualizing Disease in Bio‐Social Context. Medical anthropology quarterly, 17(4), 423-441.

Syndemic → two or more epidemics interacting synergistically and contributing, as a result of their interaction, to excess burden of disease in a population
- health problems cluster by person, place, or time
- enhanced infection due to disease interaction, e.g. TB, HIV, M.bovis

Biological Synergism
- Syndemic – actual biological interaction occurring
- E.g. lethal synergism of influenza virus and pneumococcus
- Accelerated replication of secondary infectious agent

Social context
- social conditions are important determinant in the health of individuals and populations
- poverty, social conditions, violence, discrimination, etc. all important in synergism of disease and ill health
- interactions between diseases and adverse health conditions
- intertwined and mutually enhancing epidemics involving disease interactions at the biological level that develop and are sustained in a community/ population because of harmful social conditions and injurious social connections
- All of the social determinants of health interact synergistically
- Diseases interact with each other and with social conditions to produce excess morbidity and morality in a population
- E.g. case study of HIV and IDU

Biosocial reconception of disease
- disease are not discrete, boundable entities , a more holistic approach that emphasizes interrelationships and the influence of contexts is needed
- multiple, interacting deleterious conditions among populations produced by the structural violence of social inequality
- unidirectional, bidirectional, and dialectical disease interplay
- assessment of how public health system and communities can better respond to syndemics

World Summit on the Information Society. (2005). Connecting for health: Global vision, local insight. World Health Organization.

New expectations for governments – public sector has neither the financial nor the institutional resources to meet their challenges and a mix of public and private resources is required
- shift to a more people-centered approach to development
Health and ICT closely linked – information and communication technologies (ICT) meet health targets
ICT coordinates complex activities, changing how health care is delivered
Shared information, brings people together, partnerships, enables informed decision making, and cost-effective use of resources
Examples of ICT in health
Identify disease and risk factor trends, model diseases in population, analyze demographic and social data, access research, publications, and databases, monitor and communicate potential threats to health, track and provide patient information, enable communication between patients and professionals, deliver services, standardize ordering and delivery of drug supplies, monitor quality and safety in patient care settings
Manages data and training and education of health care professionals
Globalization of world – utilization of ICT very beneficial
ICT is primarily from private sector – need to develop evidence base around success factors and implementation of ICT in health
Issues of security in online environment, spam, borderless health – consumer protection
Burden of non-communicable diseases in HICs and double burden of non-communicable diseases and communicable diseases in LMICs
Barriers to ICT in LMICs – language and literacy barriers and logistic barriers of how to implement
Investment in health, ICT, and education – competing sectors
Responsibilities in a global information society → security, legal, and ethical issues
Issues with access to ICT – priority to improve access to ICT in LMICs
ICT crucial in mitigation and response for disaster preparedness – connecting public with information and health ministries and national emergency commissions
ICT is used to track threats to health
Networked, citizen-centred health
Centres in eHealth have been established in regions to continue ICT diffusion but main barriers are low adult literacy rates, low per-capita incomes, high percentage of people living in rural areas in the poorest countries of the region
Increase ICT training and literacy

Advancing ICT in health
Affordable, reliable, and durable infrastructure, technology and tools designed and developed for health, education and training, policies and standards, evaluation, leadership and commitment
ICT statistics to assess development and diffusion of ICT
Index of ICT diffusion
Connectivity → physical infrastructure available to a country
Access → number of internet users, adult literacy rate, GDP per capita
Policy → internet exchanges, competition in Internet service provider market

WHO is collecting country fact sheet on health and ICT diffusion to measure progress and implementation of ICT and barriers remaining.

van Gemert-Pijnen, J. E., Nijland, N., van Limburg, M., Ossebaard, H. C., Kelders, S. M., Eysenbach, G., & Seydel, E. R. (2011). A holistic framework to improve the uptake and impact of eHealth technologies. Journal of medical Internet research, 13(4).

Mismatch between users and technology
Holistic approach to boosting the uptake and impact of eHealth technologies
Review of eHealth technologies → Holistic framework for the development of eHealth technologies
1) eHealth technology development is a participatory process – stakeholder involvement must span the entire development process
2) eHealth technology development involves continous evaluation cycles - Evaluation as such is a cyclic, longitudinal research activity interwoven with all stages in the development process and as such without a fixed end
3) eHealth technologies intertwined with implementation – conditions for implementation must be taken into consideration from the get-go
4) eHealth technology development changes the organization of health care – creation of new processes and infrastructure for health care delivery
5) eHealth technology development should involve persuasive design techniques – a way for communicating and sharing personal information, self-care, behaviour change, rewards
6) eHealth technology development needs advanced methods to assess impact – broader view needed to assess the overall impact on health care

eHealth → all kinds of information and communication technology used for supporting health care and promoting a sense of well-being
Research and development activities
Multidisciplinary project management → cooperation between those responsible for producing the technology and those that participate to ensure that eHealth technologies fit in with the needs and values
Contextual inquiry → information gathering from the intended users and the environment in which the technology will be implemented
Value specification → recognition and quantification of the economic, medical, social, or behavioral values of the key stakeholders
- Value specification refers to goal setting and to defining the functional and organizational requirements to realize the values
Design → building prototypes that fit with the values and user requirements
Operationalization → the actual introduction, adoption, and employment of the technology in practice, training, education, and deployment of the eHealth technology in daily practice
Summative evaluation → the actual uptake of a technology (its usage) and the assessment of the impact of eHealth technologies in terms of clinical, organizational, and behavioral terms
Framework is a holistic approach and comprehensive development strategy
Stakeholder engagement resulted in commitment, trust, and a positive attitude toward investments in eHealth technologies

Scott, R. (2004) Investigating e-health policy — tools for the trade. J Telemed Telecare. 10: 246-248

Policy commitment within a jurisdiction
1) Regulations and laws governing e-health activity
2) statements, directives, and guidelines defining and delimiting e-health activity
3) Evidence of proactive consideration of e-health activity
4) Broad suggestions of intended direction encompassing e-health activity

Reactive policies → jurisdiction has e-health policy, but it has generated in response to some outside pressure
Proactive policies → jurisdiction has e-health policy, developed somewhat in advance of immediate need, and planned within an overall e-health-related strategy
‘Glocal’ – what happens locally has global impact, and what happens globally has local impact

Goal of seamless inter-jurisdictional e-health

Partnership Assessment Tool (PAT) is a toolkit for developing ethical research partnerships. Partnerships are a strategy for ensuring ethical research is conducted, particularly in #LMICs.
In my work experience, I interviewed an employee at Shell in the occupational health & safety department who informed me of the highly innovative and well-managed global medical database utilized by Shell. The medical database tracked health information from all around the globe and could be accessed by occupational health nurses from around the globe. Shell effectively conducted health surveillance for the company through the medical database, which can be seen as an #eHealth tool. #WPW is effectively utilizing #eHealth strategies and could share learnings if embedded in a larger community-based intervention.
I liked in the seminar that we discussed multiple #eHealth strategies like email, text messages, and databases. Also, the skype/ video conferencing medical appointments and meetings being explored in #LMICs. There is so much potential for reaping the benefits of #eHealth but there are also logistical concerns when using #eHealth in #LMICs, mostly around accessibility. If accessibility is improved, #eHealth provides an innovative way to deliver health care and conduct health surveillance.
#technologicalrevolution #futureofhealthcare
I liked this YouTube video because it described the benefits of #eHealth in health care service delivery. Hopefully Canada can catch up to Australia.#R38
Samantha's tweet provided a visual description of how syndemics are the overlay of complicated variables. Intervening on syndemics requires acknowledging all of the overlapping variables and #SDOH.
Prior to the seminar, I understood that capacity building is important but I didn't realize how one would create capacity in #LMICs.
The exploration of AIMS in Neil Turok's Ted Talk "Finding the next Einstein in Africa" put theory into practice and demonstrated capacity building in action. It outlined how creating a world class institution will develop individuals into world class researchers who are inspired to tackle the #wickedproblems facing our globalizing world. Ideally, inspiring them to stay within their own nation to build research capacity. #R40
In the #capacitybuilding seminar, we spoke to different levels of analysis: individual, institutions, and environment. I believe that #WPW can be analyzed from all these different levels and can more importantly have an impact at all of these different levels, particularly if embedded in a community-based intervention program.
Dr.Titanji's Ted Talk "Ethical Riddles in HIV Research" identified 4 important considerations when conducting research in #LMICs:
1. Informed consent – communicate relevant information in a way that is actually understood by participants
2. Community participation – local communities and local REBs involved in developing criteria for participation
3. Ethical review of research – set up local REBs that are independent of government
4. What happens to participants in the clinical trial after the research? – need a clear plan what happens when the trial ends, can care be maintained (e.g. Free HIV treatment program)
Similarly, Erin tweeted an article reflecting on the importance of the 4 points outlined by Dr.Titanji.
#WPW embedded in community-based interventions is effectively utilizing #PPP but in exploring an example of #PPP, #CIH, there was no indication of how the #PPP was developed.
Utilization of the #PAT in the development of #PPP for #WPW and community-based interventions will help ensure that the #PPP is sustainable, well-managed, and conducting ethical health research and interventions.
I really connected with the idea of holding video conference calls to conduct meetings with health professionals, for example, as we have explored the use of an online meditation class in the lab I conducted my thesis work in. The online meditation class enhanced accessibility of the program for rural cancer patients much like the video conferencing is making specialized medical care accessibile to individuals in remote locations. #wayofthefutureofhealth #enhancingservicedelivery #innovation
In researching #WPW, I recognized the inherent ethical responsibility of the employer to protect and promote the health, safety, and well being of the employee. This story has been shared around social media and I really like this story as it highlights the need to not be passive and that we, as a global community, need to demand higher standards from employers. Who pays the cost? Chinese employees in factories should not pay the cost but they currently are - there health is suffering. Shift in mindset and #culturechange to #ecohealth also requires an acknowledgment that individuals in #LMICs deserve equitable access to health and wellbeing just the same as we do in #HICs. The cost of improving conditions in factories costs the consumer only a few dollars - not even comparable to the devastating cost of lost life and ill health in employees in these factories. #R39
Call to action!
Bhutto, Z. A. (2002). Ethics in international health research: a perspective from the developing world. Bulletin of the World Health Organization, 80(2), 114-120.

International biomedical research
ethical guidelines – Nuremburg code, Declaration of Helsinki, CIOMS, Belmont Report – respect for autonomy, respect of beneficence, and justice

Recent controversies in international research and their implications for regulation and guidelines
Controversy about the use of placebo arm in HIV-treatment clinical trials with demonstrated evidence of benefit of standard treatment

National or international guidelines for ethical conduct of research
Lack of capacity in LMICs to develop local guidelines

Specific issues in the ethical conduct in developing countries
Community participation
- community consultation in protocol development, appropriate information disclosure and informed consent, protection of confidentiality and right of dissent, and community involvement in the conduct of research
Prior agreements and benefits of research
- populations that the research is being conducted on must benefit from the research
- avoid undue exploitation of vulnerable populations in LMICs
- reasonable availability – extended community care might not be possible

Standard of care and the use of placebos
Lack of standard care in LMICs
Often use placebos – ethical concerns of using placebos
Using standard care from HICs – sustainable in LMICs?

Linking health and research issues with equity
Reduce the equity gap with more industrialized countries, applying bioethical principles will aid in this process
Inequities in global health and resource allocation are incompatible with the goals of justice

Developing local capacity
Local capacity could be developed by strengthening models for reviewing the ethics of research and undertaking ethical review
partnerships will also help to strengthen ethical review and capacity for ethics

Working towards true global consensus and ownership
Better representation of LMICs in the adoption and ownership of ethical principles in LMICs

Determining the future ethics
LMICs often not included in the debate, new movement toward understanding the religious and cultural context of ethics in many developing countries

Goal going forward is to strengthen bioethics capacity in developing countries; linking health research to community needs in a transparent and participatory process; and increasing communication between scientists and ethicists in industrialized and developing countries.
- reduction in global inequities in health

Afsana, K., Habte, D., Hatfield, J., Murphy, J., & Neufeld, V. (2009). Partnership Assessment Toolkit. Ottawa: Canadian Coalition for Global Health Research.

PAT is a mechanism to create ethical research and partnerships. Research partnership ethics insists that effective health research partnerships - that is research partnerships which not only lead to the completion of research projects but also lead to increased health equity - will only succeed if all parties are truly engaged in a way that is just and beneficial.. The Canadian Coalition for Global Health Research developed the Partnership Assessment Toolkit in 2009. It is an instrument used to challenge and address prevailing North-South inequities in international health research, by giving all parties a voice in the research process. The PAT is used to generate consensus among all partners of a health research project, and seeks to ensure the core competencies of sustainability, knowledge production, knowledge translation, capacity development, and innovation. These competencies are met by the four phases of the PAT, which are inception, implementation, dissemination, and “good endings and new beginnings”.
• Phase 1 (Inception):
o Establishing the vision of the partnership
o Governance and management
o Roles and responsibilities
o Establishing research projects and priorities
o Communication
o Dissemination plan
o Looking towards the end of the partnership
• Phase 2 (Implementation) – takes place over time, living document,
o Evolution of the partnership
o Nurturing the partnership
• Phase 3 (Dissemination) – conclude partnership in positive way and help plan towards future collaborations
• How the partnership plans for, manages, and evaluates knowledge translation activities?
• This section is intended to build upon discussions and structures initiated during Phase 1
o Phase 4 (Good endings and new beginnings):
• Concluding the partnership in a positive way, and being to plant towards future collaborations
• Recommended debriefing and evaluation session with all members of the partnership, with questions such as:
• What have been the three most beneficial aspects of this collaboration?
• What were the three aspects of the collaboration that should be improved for the future?

Whitworth, J. A., Kokwaro, G., Kinyanjui, S., Snewin, V. A., Tanner, M., Walport, M., & Sewankambo, N. (2008). Strengthening capacity for health research in Africa. Lancet, 372(9649), 1590.

Often best African researchers move away to receive better rewards for their work. Need to build research capacity in Africa. Funds allocated to research are beneficial for development.
ISHReCA – institution that supports advocacy, promotes self-sustaining research groups that can initiate and carry out high-quality health research in Africa
Need to promote secondary level science education, train high school science teachers, and create attractive careers in science
Need to advocate for females receiving education and research training in the sciences to promote gender equity
Long-term career funding is needed to create capacity for research in African institutions – promote African researchers staying in country rather than leaving country for better opportunities
North-south and south-south partnerships and funding schemes can provide support for capacity building of research in Africa

Ezeh, A. C., Izugbara, C. O., Kabiru, C. W., Fonn, S., Kahn, K., Manderson, L., ... & Thorogood, M. (2010). Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model. Global Health Action, 3

Need for strong health research capacity in Africa which has created opportunities for innovative interventions
- training programs for masters, doctoral, and postdoctoral training programs offered to scientists in LMICs to enhance research competencies
- north-south, south-south research partnerships to focus on training individual researchers and strengthening research collaborations
- failed to create a critical mass of well-trained and networked researchers across the continent

- framework for developing sustainable health research capacity in Africa
- objectives: strengthen research infrastructure and capacity at African universities, support doctoral training through collaborative doctoral training in population and public health
- context-specific, multidisciplinary research, and strong local research and training institutions are needed to strengthen health systems and ensure their responsiveness to social determinants of health
- development of multidisciplinary research hubs, facilitate high-quality research on policy-relevant priority issues, create networks of locally trained internationally recognized scholars, enhance capacity of African universities to lead globally competitive research and training programs
CARTA partnership
- The Consortium brings together (a) academic and research institutions with extant and longstanding relationships and memoranda of understanding and (b) a variety of related disciplines essential to enhancing health, well-being, and livelihoods in Africa. These allow CARTA to build multidisciplinary research capacity in public and population health.

CARTA partnership
- The Consortium brings together (a) academic and research institutions with extant and longstanding relationships and memoranda of understanding and (b) a variety of related disciplines essential to enhancing health, well-being, and livelihoods in Africa. These allow CARTA to build multidisciplinary research capacity in public and population health.
CARTA’s program of activities
- Strengthening university research capacity, infrastructure, and research agendas
o strengthen human resources and university-wide systems critical to the success and sustainability of program 1) information retrieval 2) higher education management training 3) effective student supervision 4) development of institutional policies and processes 5) strategic financial planning
- Model regional collaborative doctoral training program
o CARTA will recruit a cohort of candidates to initiate collaborative doctoral training program at African universities
o JAS activities to build fundamental research concepts and skills
CARTA makes a difference by offering a well thought through approach for rebuilding and strengthening the capacity of African universities to produce locally trained and skilled researchers and scholars

I successfully achieved my learning objectives by utilizing diverse sources including grey literature, peer-reviewed literature, YouTube videos, and other websites.

I found the exploration of my learning objectives a fruitful reflection of my BHSc degree and the experiences that have helped shape my interests and passions for health promotion.
Another example of partnership in #WPW in Ghana #R27

In 2006, Germany's Ministry for Economic Cooperation and Development (BMZ) teamed up with the Ministry of Health and the Ghana AIDS Commission to help implement HIV mainstreaming activities such as #WPWP within both the public and private sector. #R28
The #WPWP focuses on individuals with a job and a regular income rather than economically disadvantaged or vulnerable populations. BMZ creates partnerships with employers of significant size and level of technological and administrative advancement to create holistic #WPWP in developing countries. The result is a systematic impact by raising health care standards and adding resources to the national health and social protection systems in Ghana. #R28
Witworth et al. (2008)
Full transcript