Associate Professor John Hall

AIM: To describe the characteristics of people in Central and Eastern Sydney (CES), NSW, who had a General Practice Management Plan (GPMP) and claimed for at least one private allied health service item; and to examine if allied health service use results in less hospitalisations over a five-year period. BACKGROUND: The number of people living with chronic health conditions is increasing in Australia. The Chronic Disease Management programme was introduced to the Medicare Benefits Schedule (MBS) to provide a more structured approach to managing patients with chronic conditions and complex care needs. The programme supports general practitioners claiming up to one GPMP and one Team Care Arrangement every year, and the patient additionally claiming for up to five private allied health services visits. METHODS: A prospective longitudinal study was conducted. The sample consisted of 5771 participants in CES who had a GPMP within a two-year health service utilisation baseline period (2007-2009). The analysis used the 45 and Up Study questionnaire data linked to the MBS, hospitalisation, death and emergency department data for the period 2006-2014. FINDINGS: Of the eligible participants, 43% (2460) had at least one allied health service item claim in the subsequent 12 months. Allied health services were reported as physiotherapy, podiatry and other allied health services. The highest rates of allied health service use were among participants aged 85 years and over (49%). After controlling for confounding factors, a significant difference was found between having claimed for five or more physiotherapy services and emergency admissions (HR: 0.83; 95% CI: 0.72-0.95) and potentially preventable hospitalisations (HR: 0.79; 95% CI: 0.64-0.96) in the subsequent five years. Use of allied health service items was well targeted towards those with chronic and complex care needs, and use of physiotherapy services was associated with less avoidable hospitalisations.

Objective The aim of this study was to examine the trend in socioeconomic inequalities in child undernutrition in Nigeria. Methods The study analysed cross-sectional data from the Nigeria Demographic and Health Survey (NDHS) 2003 to 2013. The outcome variables were stunting, wasting and underweight among children under-five years. The magnitude of child undernutrition in Nigeria was estimated via a concentration index, and the socioeconomic factors contributing to child undernutrition over time were determined using the decomposition method. Results The concentration index showed an increase in childhood wasting and underweight in Nigeria over time. The socioeconomic factors contributing to the increase in child undernutrition were: child¿s age (0¿23 months), maternal education (no education), household wealth index (poorest household), type of residence (rural) and geopolitical zone (North East, North West). Conclusions To address child undernutrition, there is a need to improve maternal education and adopt effective social protection policies especially in rural communities in Nigeria.

Background: Pregnancy stress could lead to adverse health outcomes for both mother and child. Few studies have explored the effectiveness of stress management strategy among pregnant women. Objectives/Aims/Hypotheses: To examine the effectiveness of cognitive-behavioral stress management for pregnant women. Design: Randomized Controlled Trial. Methods: 100 pregnant women (at 6¿8 week of pregnancy) were selected by convenience sampling. Participants in the control group (N = 50) received routine prenatal examination and health education, while those in the intervention group (N = 50) received cognitive-behavioral stress management. Pregnancy Pressure Scale was measured at baseline and 39th weeks of pregnancy. Results: Pregnancy Pressure Scale score increased in both intervention and control groups. However, the score in the intervention group was significantly lower than those in the control group (p < 0.01). Conclusions: Cognitive-behavioral stress managment can effectively reduce pregnant women's stress levels. Impact statement: Nurses and midwives should conduct cognitive-behavioral stress management to help pregnant women reduce their stress.

Background: Sub-Saharan Africa has one of the highest levels of child malnutrition globally. Therefore, a critical look at the distribution of malnutrition within its sub-regions is required to identify the worst affected areas. This study provides a meta-analysis of the prevalence of malnutrition indicators (stunting, wasting and underweight) within four sub-regions of sub-Saharan Africa. Methods: Cross-sectional data from the most recent Demographic and Health Surveys (2006-2016) of 32 countries in sub-Saharan Africa were used. The countries were grouped into four subregions (East Africa, West Africa, Southern Africa and Central Africa), and a meta-analysis was conducted to estimate the prevalence of each malnutrition indicator within each of the sub-regions. Significant heterogeneity was detected among the various surveys (I2 >50%), hence a random effect model was used, and sensitivity analysis was performed, to examine the effects of outliers. Stunting was defined as HAZ<-2; wasting as WHZ<-2 and underweight as WAZ<-2. Results: Stunting was highest in Burundi (57.7%) and Malawi (47.1%) in East Africa; Niger (43.9%), Mali (38.3%), Sierra Leone (37.9%) and Nigeria (36.8%) in West Africa; Democratic Republic of Congo (42.7%) and Chad (39.9%) in Central Africa. Wasting was highest in Niger (18.0%), Burkina Faso (15.50%) and Mali (12.7%) in West Africa; Comoros (11.1%) and Ethiopia (8.70%) in East Africa; Namibia (6.2%) in Southern Africa; Chad (13.0%) and Sao Tome & Principle (10.5%) in Central Africa. Underweight was highest in Burundi (28.8%) and Ethiopia (25.2%) in East Africa; Niger (36.4%), Nigeria (28.7%), Burkina Faso (25.7%), Mali (25.0%) in West Africa; and Chad (28.8%) in Central Africa. Conclusion: The prevalence of malnutrition was highest within countries in East Africa and West Africa compared to the WHO Millennium development goals target for 2015. Appropriate nutrition interventions need to be prioritised in East Africa and West Africa if sub-Saharan Africa is to meet the WHO global nutrition target of improving maternal, infant and young child nutrition by 2025.

Background: The physical and psychological impact of female genital mutilation / cutting (FGM/C) can be substantial, long term, and irreversible. Parts of the health sector in Australia have developed guidelines in the management of FGM/C, but large gaps exist in community and professional knowledge of the consequences and treatment of FGM/C. The prevalence of FGM/C amongst Australian women is unknown. Our article reviews the literature on research on FGM/C in Australia, which focuses on health system response to women and girls with FGM/C. Recommendations are made for policy reform in health, legislation, and community programs to provide the best healthcare, protect children, and help communities abandon this harmful practice. Main body: Midwives and doctors in Australia acknowledged a lack of knowledge on FGM/C, clinical guidelines and consequences for maternity care. In a metropolitan Australian hospital with specialised FGM/C care, women with FGM/C had similar obstetric outcomes as women without FGM/C, underlining the importance of holistic FGM/C clinics. Greater focus on integration of refugee and migrant populations into their new cultures may be an important way of facilitating the abandonment of this practice, as is education of communities that practise FGM/C, and experts involved in the care and protection of children. Men could be important advocates for protecting women and girls from violence and FGM/C through a man-to-man strategy with programs focussing on men¿s health and other personal issues, education, and communication. The Australian Government has identified gender-based violence as an area of priority and has been implementing a National plan to reduce violence against women and their children 2010-2022. A multidisciplinary network of experts on FGM/C could be established within this taskforce to develop well-defined and rapid referral pathways to care for and protect these children, as well as coordinate education and prevention programs to help communities abandon this harmful practice. Conclusion: Countries of migration can be part of the solution for abandonment of FGM/C through community interventions and implementation of national and coordinated training in FGM/C of experts involved in the care and protection of children and women. The global focus on collaboration on research, training and prevention programs should be fostered between countries of FGM/C prevalence and migration.

Introduction: Child undernutrition is a major public health problem. One third of all undernourished children globally reside in Sub-Saharan Africa (SSA). The aim of this study was to systematically review studies to determine the factors associated with stunting, wasting and underweight in SSA and contribute to the existing body of evidence needed for the formulation of effective interventions. Methods: This systematic review was conducted using the 2015 Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Five computerized bibliographic databases were searched: Scopus, PubMed, PsycINFO, CINAHL and Embase. The included studies were rated using eight quality-appraisal criteria derived from the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist: sample size, sampling methodology, response rate, outcome measures, statistical analyses, control for confounding, study limitation, and ethical consideration. Results: Of a total of 2810 articles retrieved from the five databases, 49 studies met our inclusion criteria. The most consistent factors associated with childhood stunting, wasting and underweight in SSA were: low mother¿s education, increasing child¿s age, sex of child (male), wealth index/SES (poor household), prolonged duration of breastfeeding (>12 months), low birth weight, mother¿s age (<20 years), source of drinking water (unimproved), low mother¿s BMI (<18.5), birth size (small), diarrhoeal episode, low father¿s education and place of residence (rural). Conclusions: The factors that predispose a child to undernutrition are multisectoral. To yield a sustainable improvement in child nutrition in SSA, a holistic multi-strategy community-based approach is needed that targets the factors associated with undernutrition, thereby setting the region on the path to achieving the WHO global nutrition target by 2025.

ACCESS AND UTILISATION OF HEALTH CARE: The armed conflict that engulfed the Solomon Islands between 1998 and 2003 significantly disrupted the provision of health care especially in rural and remote areas. There is one doctor for 3,300 people and approximately 13 nurses and midwives for 10,000 people. Despite limitations 87% of people seek health care when sick. FINANCING THE HEALTH SYSTEM: The SIG placed a series of reservations on ministerial goods and services budgets that effectively the budget by 33%, severely impacting provincial budgets and resulting in acquired debts. Shortfalls have been addressed by allocating Health Sector Support Program funds to the provinces to allow services to continue, a strategy that will likely recur, but by which donor support replaces government provision Provincial health accountants have received training in MYOB in 2009 but acquittal systems require higher level accounting skills for reports to be submitted on time to permit the release of subsequent funding tranches. HUMAN RESOURCES FOR HEALTH: The shortage of doctors and specialists is a key challenge. As at December 2010, there were a total of 2,728 health workers in the public sector in Solomon Islands. Staff costs consume on average 55% of provincial health grants Filled Public Service Division staff establishments and budgetary reservations have reduced the ability to meet the salary and wage costs of new graduates. Solomon Islands is currently negotiating to assist Vanuatu in filling its nursing staff vacancies with its surplus The return of 75 Cuban trained medical officers from 2013 presents the management challenge of accessing budget provisions for so many new positions and in funding the infrastructure needed to house, equip and maintain them in service. HEALTH MANAGEMENT STRUCTURE: Provincial health managers are operationally responsive to local needs, managerially responsible to provincial governments, while being concerned with adherence to central MHMS policy and to Ministry of Finance and Public Service Division regulations. The delineation of central and provincial health authorities' responsibilities requires guidelines in a changing system, where both population-based and targeted vertical programs are implemented at local levels. NUMBER AND DISTRIBUTION OF MANAGERS: Nine of the 10 positions of Provincial Health Director have experienced high turnover, which reportedly occurs without adequate handover to incoming appointees, most of whom are recent clinical graduates. Health services in the Honiara urban area are provided through the Honiara City Council. Church health services are staffed by government employees. COMPETENCE OF DISTRICT HEALTH MANAGERS: Management skills are reportedly weak at the provincial level. The Regional Assistance Mission to Solomon Islands provides governance training inputs to provincial government staff. Provincial health departments have limited financial and human resource management capacity. They also have clinical backgrounds and no training in public health planning or health services management, other than that provided by donors, the Regional Assistance Mission itself and the MHMS. MANAGEMENT WORKING ENVIRONMENT: Provincial health directors have limited control over health staff. Little supportive supervision in management is provided to new provincial health directors. No performance management systems are in place to ensure that staff are properly assessed and supported to do their best Large numbers of non-government organisations working at the provincial level in youth and women's programs require coordination by Provincial health directors to avoid duplication or implementation of programs that will require ongoing funding, but this is not done. FUNCTIONING OF MANAGEMENT SUPPORT SYSTEMS: Management support systems for budgeting and finance, management information and procurement and supply do not function adequately to support provincial health directors to manage...

Malaria, a completely preventable and treatable disease, remains one of the biggest killers in Sub-Saharan Africa today. The objectives of this study were to describe the impact of malaria on a small rural community in Uganda (Bufuula) and to implement and evaluate a malaria prevention program (subsidised insecticide treated nets with an accompanying education session). In January 2006, a survey of 202 households (100% response rate) was conducted, and meetings held with the Village Council, which revealed that malaria was the community's major cause of morbidity and mortality, and showed there was a lack of access to preventative measures. Furthermore, 34% of each household's income was allocated to the burden of malaria. A malaria education and mosquito net distribution session was held in January 2006, which was attended by over 500 villagers who purchased 480 heavily-subsidised long lasting insecticide treated nets (LLINs). Home visits were conducted 1 week later to ensure the LLINs were hung correctly. A follow-up survey was conducted in January 2007. There was a rise in net ownership following the program (18% to 51%, P < 0.0001) and lower rates of childhood malaria prevalence (14%) than reported in Ugandan national statistics (40%). However, only half the nets owned were being used correctly by those most vulnerable to the illness. The findings suggest that mosquito nets must be provided with an effective education program and may be more successful if conducted in whole districts simultaneously rather than on a per-community basis. The evidence for super-targeting strategies for those most vulnerable is also considered. These findings provide important lessons and considerations for other wide-scale malaria prevention programs. © 2009 Springer Science+Business Media, LLC.

Background. Neonatal mortality accounts for almost 40 per cent of under-five child mortality, globally. An understanding of the factors related to neonatal mortality is important to guide the development of focused and evidence-based health interventions to prevent neonatal deaths. This study aimed to identify the determinants of neonatal mortality in Indonesia, for a nationally representative sample of births from 1997 to 2002. Methods. The data source for the analysis was the 2002-2003 Indonesia Demographic and Health Survey from which survival information of 15,952 singleton live-born infants born between 1997 and 2002 was examined. Multilevel logistic regression using a hierarchical approach was performed to analyze the factors associated with neonatal deaths, using community, socio-economic status and proximate determinants. Results. At the community level, the odds of neonatal death was significantly higher for infants from East Java (OR = 5.01, p = 0.00), and for North, Central and Southeast Sulawesi and Gorontalo combined (OR = 3.17, p = 0.03) compared to the lowest neonatal mortality regions of Bali, South Sulawesi and Jambi provinces. A progressive reduction in the odds was found as the percentage of deliveries assisted by trained delivery attendants in the cluster increased. The odds of neonatal death were higher for infants born to both mother and father who were employed (OR = 1.84, p = 0.00) and for infants born to father who were unemployed (OR = 2.99, p = 0.02). The odds were also higher for higher rank infants with a short birth interval (OR = 2.82, p = 0.00), male infants (OR = 1.49, p = 0.01), smaller than average-sized infants (OR = 2.80, p = 0.00), and infant's whose mother had a history of delivery complications (OR = 1.81, p = 0.00). Infants receiving any postnatal care were significantly protected from neonatal death (OR = 0.63, p = 0.03). Conclusion. Public health interventions directed at reducing neonatal death should address community, household and individual level factors which significantly influence neonatal mortality in Indonesia. Low birth weight and short birth interval infants as well as perinatal health services factors, such as the availability of skilled birth attendance and postnatal care utilization should be taken into account when planning the interventions to reduce neonatal mortality in Indonesia. © 2008 Titaley et al; licensee BioMed Central Ltd.

Objective: To understand the profile and impact of aeromedical evacuations in remote Indigenous communities. Design: Descriptive study. Setting: A primary health care centre in east Arnhem Land, Northern Territory, Australia. Participants: Four hundred and ten evacuations from a total population of more than 2200 were analysed from February 2003 to August 2005. Mainoutcome measures: Patient demographics, seasonal variations, diagnostic categories, utilisation of staff resources. Results: On average 6.5% of the community were evacuated to hospital every year with an evacuation occurring every 2.2 days. Children aged under five years were 3.3-fold overrepresented in evacuations (comprising 37.7% of those evacuated versus 11.3% of the community, P < 0.001). Four diagnostic categories accounted for 61% of evacuations: respiratory disease (21%), obstetric conditions (15%), gastroenteritis (14%) and injury/poisoning (11%). Over the study period four patients required intubation at the clinic. Evacuation rates were higher in the monsoon season. Forty-seven per cent of evacuations occurred after hours. The waiting time for plane arrival ranged from one hour to 21 hours with a median wait-time of three hours. Conclusion: Aeromedical evacuations place a heavy burden on primary health centres. Clinic staff are regularly required to provide hospital-level acute care, often for several hours at a time. Meeting this burden competes with primary prevention programs and regular clinic duties. The age and diagnostic profiles encountered in this study have significant implications for the range of skills required to provide an adequate acute care service. This study highlights the need for remote area health centres to be well resourced to meet these needs. © 2006 The Authors Journal Compilation © 2006 National Rural Health Alliance Inc.

The objective of the study was to investigate trends in blood lead concentrations in preschool children between 1991 and 2003, as part of the evaluation strategy of a public health lead management program in Broken Hill, Australia. Since 1991, all Broken Hill children aged 1-4 years have been offered at least annual blood lead screening as part of a community-wide lead management program. Recruitment of children was promoted throughout the period using local media and distribution of promotional material from health care centres and preschool, childcare, and educational facilities around the city. Venous blood samples were collected using standard procedures and analyses were subjected to internal and external quality control programs. Because the frequency distribution of blood lead levels are skewed, geometric rather than arithmetic means were used for comparative purposes. Trend analysis was based on age and sex standardised mean blood lead levels. The number of 1- to 4-year-old children screened ranged between 496 and 948 in any one year and response rates varied between 39% and 73%. The age-sex standardised mean blood lead level decreased from 16.3 µg/dL to 7.1 µg/dL between 1991 and 2003. Overall, blood lead levels declined by 56% over 13 years. These reductions were consistently observed irrespective of age or where a child lived in the town. The rate of decline has slowed since 1997. We conclude that substantial progress has been made in dealing with the lead problem in Broken Hill children, although the rate of decline of blood lead levels has slowed. Continued public health action is still needed to bring the proportion of young children with significantly elevated blood lead levels (> 15 µg/dL) down from the 2003 figure of 12% to the NHMRC community-based target for lead in young Australians of 5%. © 2005 Elsevier B.V. All rights reserved.

Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was "primary health care" (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own healthcare services. Changes in economic philosophy led to the replacement of PHC by "Health Sector Reform", based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.

Almost all leprosy cases reported in industrialized countries occur amongst immigrants or refugees from developing countries where leprosy continues to be an important health issue. Screening for leprosy is an important question for governments in countries with immigration and refugee programmes. A decision analysis framework is used to evaluate leprosy screening. The analysis uses a set of criteria and parameters regarding leprosy screening, and available data to estimate the number of cases which would be detected by a leprosy screening programme of immigrants from countries with different leprosy prevalences, compared with a policy of waiting for immigrants who develop symptomatic clinical diseases to present for health care. In a cohort of 100,000 immigrants from high leprosy prevalence regions (3.6/10,000), screening would detect 32 of the 42 cases which would arise in the destination country over the 14 years after migration; from medium prevalence areas (0.7/10,000) 6.3 of the total 8.1 cases would be detected, and from low prevalence regions (0.2/10,000) 1.8 of 2.3 cases. Using Australian data, the migrant mix would produce 74 leprosy cases from 10 years intake; screening would detect 54, and 19 would be diagnosed subsequently after migration. Screening would only produce significant case-yield amongst immigrants from regions or social groups with high leprosy prevalence. Since the number of immigrants to Australia from countries of higher endemnicity is not large routine leprosy screening would have a small impact on case incidence.

This paper looks at the success of measures adopted to improve vaccination coverage of infants in the Republic of Vanuatu. In 1982 the Department of Health introduced an Expanded Programme on Immunization (EPI). Since the republic has over 80 inhabited islands, a scattered population, rough terrain and a lack of transport and communications infrastructure, achieving a high vaccination coverage rate proved difficult. Coverage of infants remained low until 1987. From that year onwards various strategies were employed to increase coverage, including 1) adopting the WHO-recommended diphtheria-pertussis-tetanus (DPT) and oral polio vaccine (OPV) vaccination schedule (6, 10 and 14 weeks) instead of the former schedule (3, 6 and 9 months); 2) improving the training, support and supervision of staff delivering maternal and child health (MCH) services; and 3) improving community involvement through social mobilization activities in areas of low coverage. Data on vaccination coverage of infants for the period 1984 to 1990 were compared. Over this period coverage of infants with 3 doses of DPT rose from 29% to 76%, with 3 doses of OPV from 29% to 78%, and with measles vaccine from 19% to 66%. These dramatic improvements have largely occurred since 1987. The results demonstrate the success of the measures adopted, and the experience of Vanuatu offers lessons in improving vaccination coverage for other countries in the region.

Side-effects of leprosy treatment with dapsone are said to be uncommon, with drug allergy occurring in only one of every several hundred patients treated with dapsone. The dapsone or sulphone syndrome (DDS) has been recognized since the earliest days of sulphone therapy but until recently its incidence had been decreasing. In Vanuatu, during the years 1988-1991, nine leprosy patients have developed the dapsone syndrome, four of whom have died. During the last 4 years only 37 patients were started on treatment, which is an incidence of the dapsone syndrome of 24% with a fatality rate of 11%. All the patients were being given multi-drug treatment (MDT) of daily dapsone (100mg) and clofazimine (50mg) and monthly rifampicin (600mg) and clofazimine (300mg). There has been speculation that the increased incidence of what was previously described as a rare reaction is due to the use of MDT, and the reasons for this are discussed. We feel the increase in the number of reactions in Vanuatu since starting MDT is probably due to the high starting dose of 100mg of dapsone, possibly enhanced by the combination with clofazimine and rifampicin and a genetic susceptibility of the Melanesian population.

In 1989 and 1990 several patients were admitted to hospitals in Vanuatu with acute intravascular haemolysis following standard malaria treatment. This included a single 45-mg dose of primaquine given as a malaria control measure for its gametocytocidal effect. Seven of them (all those tested) were subsequently confirmed to have glucose-6-phosphate dehydrogenase (G6PD) deficiency, using a visual colorimetric test kit (Sigma Chemical Co. Ltd). The case reports of four patients admitted to Vila Central Hospital and managed by one of us (PAR) are discussed in detail.