Moving forward health equity: implementation research on governance for health equity at local level.

286 p.BACKGROUND: Urbanization is one of the leading sociodemographic trends of the 21st century, which makes urban areas one the most important settings for tackling current and new global challenges. In fact, the importance urban health has been increasingly recognised for its central role shaping public health globally. In this context, an equity-promoting urban governance offers a window of opportunity not only to face these challenges, but also to be part of the solution. Policy coherence, accountability and social participation have been identified both as drivers of health equity and key dimensions of governance for health equity.OBJECTIVE: The fundamental question that underlies this research is how local health strategies can drive forward an equity-promoting urban governance for health. This thesis aims to describe the urban governance for health context in three urban case studies, and to appraise and comparatively analyse how the key dimensions of governance for health equity have been incorporated within local health strategies. Moreover, the thesis assesses the main barriers and facilitators of the implementation of equity-promoting local health strategies. ,METHODS: This is a qualitative-based implementation research, which employs a multiple case study method to in-depth examine the local health strategies of Bilbao, Barcelona and Liverpool. Participant observation, document analysis and 27 in-depth semi-structured interviews among technicians, managers, decision-makers and other local actors were conducted. The key dimensions of governance for health equity were assessed: 1. Policy coherence was analysed using an adaptation of the Storm's Maturity Model for HiAP; 2. Accountability was assessed using the Ebrahim and Weisband¿s proposal and the corresponding domain of the PAHO Equity Commission's rubric for accountability; 3. Social participation was analysed using the Health Canada¿s Public Involvement Continuum model. To assess the barriers and facilitators of the implementation processes the Consolidated Framework for Implementation Research was used. In addition, to contrast and validate the comparative analysis results, 16 experts in the field of governance for health, health equity and implementation science were interviewed.RESULTS: There were significant variations in the levels of maturity of policy coherence, accountability and participation across the local health strategies explored, being more developed in the cases of Barcelona and Liverpool, and somewhat more incipient in Bilbao. The heterogeneity of the governance for health strategies revealed that there is no one-size-fits-all type of strategy that fosters health equity. However, there are elements in common that can act as enablers of an equity approach.Regarding policy coherence, the results suggest that a democratic and socially progressive political environment supports the integration of health and equity as a shared value. Likewise, the establishment of legal and regulatory frameworks such as public health laws or strategic government plans can provide an umbrella for the institutionalization of a social model of health. Specifically with regard to local health strategies, these seem to be more operative when they involve multi-level policies, as they enable more easily the establishment of structures and resources for intersectoral action for health, the use of decision-support tools, and the development of individual and institutional capacities, which are key elements for its implementation. Building synergies with other programs and networks can also foster the implementation of policy coherence at the local level.With regard to accountability, a human rights-based approach to health combined with structures, mechanisms and processes for accountable governance can foster transparency and answerability, but also compliance and enforcement. Accountability in local health strategies can be operationalized through Public Health Observatories with a technical profile and a sufficient degree of autonomy from the political level. Ensuring continuous and inclusive monitoring and evaluation, an availability of openly available disaggregated local data as well as the generation and transfer of applied knowledge are also key enablers of accountability at the local level.Regarding social participation, a more horizontal model of governance involves promoting deliberative capacity and the decentralisation of power through the establishment of a variety of processes, mechanisms and instruments that encourage the participation of all social groups. It is key ensuring an inclusive and representative participation and incorporate social participation as an essential part of the whole policy circle. Local health strategies should strive for leadership by and for the community, including specific actions for the development of participatory skills and capacities for both the population and local government.CONCLUSION: The results highlight that progress in the implementation of equity-promoting local health strategies requires the inclusion of equity as a general value and as a specific policy objective through goals to reduce inequalities, but also through goals to strengthen and operationalise policy coherence, accountability and social participation. This implies moving from short-term, fragmented or isolated policies to a comprehensive set of policies that place equity at the centre. Effective policy action to respond to the global challenges cannot fit into low-cost policy options that fits within electoral cycles. Health inequalities will only be reduced as a result of substantial political change; moving forward policy coherence, accountability and social participation into local health strategies can foster the creation of arenas to challenge the distribution of power

Einflussfaktoren auf die Lebensqualität bei Patienten mit Systemischer Sklerose am Beispiel von Mangelernährung, Sarkopenie und digitalen Ulzerationen

Objectives: The present thesis investigates the impact of malnutrition and sarcopenia on the quality of life in patients with systemic sclerosis (SSc) in two cross-sectional studies. In another cross-sectional and longitudinal study on digital ulcers (DU) we developed a scoring system (DUS) for the quantification of the severity of DU. Since DU affect the quality of life and disease-associated disability the objectification of their severity is very important for monitoring therapy outcome. Methods: We used the Malnutrition Universal Screening Tool (MUST) to evaluate the risk of malnutrition. Sarcopenia was defined using the criteria of the EWGSOP (European Working Group on Sarcopenia in Older People) and measured by bioelectrical impedance analysis and hand grip strength. Quality of life and disease-associated disability were evaluated using the Short-Form 36 Health Survey (SF-36) and Scleroderma Health Assessment Questionnaire (SHAQ). The severity of digital ulcers was quantified by a newly developed score, which takes into account the size and type of the digital ulcer. Statistical analysis was performed using SPSS und STATA. Results: We included 129 patients each into the malnutrition and into the sarcopenia study. In 10.9% of all patients we found a high risk for malnutrition. These patients were more likely to suffer from anemia (p = 0.004) and cardiac involvement (p = 0.027). The prevalence of sarcopenia was 22.5%. Patients with a high risk for malnutrition as well as patients with sarcopenia showed a significantly higher disease-related disability and a lower quality of life. We included 65 patients in the study on DU. The longitudinal analysis showed a significant correlation between hand function and the Digital Ulcer Score (DUS). Take home points: Patients with sarcopenia and patients at high risk for malnutrition showed a reduced quality of life. The Digital Ulcer Score can contribute to a simplification of the diagnostic evaluation and follow-up of DU. By monitoring disease burden over time in the long term it could contribute to an improved quality of life for SSc patients.Einleitung: Die vorliegende Publikationspromotion untersucht in zwei Querschnittsstudien den Einfluss von Mangelernährung und Sarkopenie auf die Lebensqualität bei Patienten mit Systemischer Sklerose (SSc). In einer weiteren Querschnitts- und Longitudinalstudie zu digitalen Ulzerationen (DU) entwickelten wir einen Score (DUS) zur Quantifizierung des Schweregrades von DU. Da diese die Lebensqualität und krankheitsassoziierte Behinderung beeinflussen, ist eine Objektivierung des Schweregrades zur Therapieüberwachung besonders wichtig. Methoden: Wir verwendeten das Malnutrition Universal Screening Tool (MUST) um das Risiko für Mangelernährung zu ermitteln. Sarkopenie wurde mit Hilfe der Kriterien der EWGSOP (European Working Group on Sarcopenia in Older People) definiert und mittels Bioimpedanzanalyse und Handkraftmessung bestimmt. Die Lebensqualität und krankheitsassoziierte Behinderung wurden mittels Short-Form 36 Health Survey (SF-36) und Scleroderma Health Assessment Questionnaire (SHAQ) bestimmt. Das Ausmaß der DU wurde mit Hilfe eines neu entwickelten Scores ermittelt, der sich aus Größe und Art der digitalen Läsionen zusammensetzt. Die statistische Auswertung erfolgte in SPSS und STATA. Ergebnisse: In die Studien zu Mangelernährung und Sarkopenie wurden jeweils 129 Patienten eingeschlossen. Bei 10,9% der Patienten stellten wir ein hohes Risiko für Mangelernährung fest. Diese Patienten litten vermehrt unter Anämie (p = 0,004) und kardialer Beteiligung (p = 0,027). In der zweiten Studie betrug die Prävalenz der Sarkopenie 22,5%. Sowohl Patienten mit einem hohen Risiko für Mangelernährung als auch Patienten mit Sarkopenie litten an einer stärkeren krankheitsassoziierten Behinderung und zeigten eine reduzierte Lebensqualität. In die Studie zu DU schlossen wir weitere 65 Patienten ein. Die longitudinale Analyse zeigte eine signifikante Korrelation zwischen der Handfunktion und dem Digitale Ulzerationen Score (DUS). Schlussfolgerung: Patienten mit Sarkopenie und Patienten, die unter einem hohen Risiko für Mangelernährung litten, waren in ihrer Lebensqualität eingeschränkt. Der Digitale Ulzerationen Score kann die Objektivierbarkeit und Verlaufskontrolle der DU erleichtern und durch eine verbesserte Kontrolle des Therapieerfolgs langfristig womöglich auch zur Verbesserung der Lebensqualität beitragen

Nivel de salud y autonomía en los Centros de Día para mayores

Fundamento: Nuestro interés se centra en conocer el estado de salud en general y el nivel de autonomía en las actividades de vida diaria de los usuarios de los Centros de Día. Método: El estudio consistió en la administración de un cuestionario diseñado por los propios investigadores y validado mediante una prueba de jueces. El cuestionario contenía 50 preguntas referentes a los diversos aspectos analizados. La muestra incluyó todos los centros de día situados en la provincia de Lleida. Resultados: El estudio de las variables sobre nivel de autonomía en las actividades de vida diaria y salud muestran que el 65% de los usuarios de los Centros de Día padecen alguna enfermedad. Por otro lado, el estado de salud se relaciona con la edad y con el tipo de centro. En cuanto a la percepción subjetiva, el reultado principal fue que un 44% de las personas mayores destacan las limitaciones provocadas por su estado de salud. Conclusiones: Los resultados de la encuesta ponen de manifiesto la necesidad de aplicar programas de educación para la salud, debido al gran número de usuarios que en estos Centros de Día presentan problemas de salud. Además, también se ha puesto de manifiesto una necesidad de mejora del grado de aceptación de las limitaciones impuestas por el propio estado de salud. Estas adaptaciones servirían, sin duda, para prevenir y promocionar la salud y así aumentar la calidad de vida de las personas mayores

Sustaining mental health and wellbeing programmes in schools: recommendations from an online roundtable

Despite recent investments in school-based mental health and wellbeing promotion in England, the sustainability of mental health interventions remains a substantial challenge. This article brings together potential solutions to sustaining interventions in schools, drawing on insights from an online roundtable discussion held in July 2022. Facilitated by researchers and informed by recent research on barriers and facilitators to sustaining school-based mental health interventions, 16 participants came together to discuss challenges and solutions. Participants included school staff, policy makers, educational psychologists, researchers and mental health intervention developers. The discussion explored the need for accountability at all levels (e.g., from school leaders to policy makers and Ofsted) and the potential value of engaging schools more consistently with academic evidence. Participants also discussed the importance of creating a healthy and sustainable ecosystem for interventions (underscoring the significance of staff wellbeing, adequate resourcing, and longer-term funding commitments), and moving beyond separate, isolated interventions. The findings offer a range of recommendations for school decision makers, mental health researchers, intervention developers, and those working in the wider system around schools

Sustaining mental health and wellbeing programmes in schools: recommendations from an online roundtable

Despite recent investments in school-based mental health and wellbeing promotion in England, the sustainability of mental health interventions remains a substantial challenge. This article brings together potential solutions to sustaining interventions in schools, drawing on insights from an online roundtable discussion held in July 2022. Facilitated by researchers and informed by recent research on barriers and facilitators to sustaining school-based mental health interventions, 16 participants came together to discuss challenges and solutions. Participants included school staff, policy makers, educational psychologists, researchers and mental health intervention developers. The discussion explored the need for accountability at all levels (e.g., from school leaders to policy makers and Ofsted) and the potential value of engaging schools more consistently with academic evidence. Participants also discussed the importance of creating a healthy and sustainable ecosystem for interventions (underscoring the significance of staff wellbeing, adequate resourcing, and longer-term funding commitments), and moving beyond separate, isolated interventions. The findings offer a range of recommendations for school decision makers, mental health researchers, intervention developers, and those working in the wider system around schools

Changes in gait during constant pace treadmill running.

Treadmills are often used by runners when weather conditions are adverse or a specific training effect is desired. Athletes might respond to fatigue differently when running on a treadmill compared with overground conditions, where pace is typically more variable. The purpose of this study was to measure changes in gait parameters over the course of a 10-km treadmill run. Fifteen male competitive runners ran at a constant pace for 10 km at 103% of season's best time on an instrumented treadmill with in-dwelling force plates, and data were analyzed at 5 distances. Kinematic data were derived from high-speed videography and results compared between the early and late stages. Before halfway, step length increased and cadence decreased, whereas during the latter stages, there were significant decreases in impulse and maximum force. Contact time decreased and flight time increased continually, but otherwise most gait variables did not change. The changes in contact and flight times suggested that athletes altered their gait so that more time was spent airborne to allow the treadmill to pass under them. In general, however, the runners maintained their techniques throughout the run. Constant pace treadmill running might therefore be useful with the aim of running for a particular distance and speed with a consistent technique unaffected by factors such as gradient or fatigue. However, the increase in flight time might have aided the runners because of the nature of treadmill running, and athletes and coaches should note that this training effect is impractical during overground running

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One-dimensional non-interacting fermions in harmonic confinement: equilibrium and dynamical properties

We consider a system of one-dimensional non-interacting fermions in external harmonic confinement. Using an efficient Green's function method we evaluate the exact profiles and the pair correlation function, showing a direct signature of the Fermi statistics and of the single quantum-level occupancy. We also study the dynamical properties of the gas, obtaining the spectrum both in the collisionless and in the collisional regime. Our results apply as well to describe a one-dimensional Bose gas with point-like hard-core interactions.Comment: 11 pages, 5 figure

STAT3 mutation impacts biological and clinical features of T-LGL leukemia

STAT3 mutations have been described in 30-40% of T-large granular lymphocyte (T-LGL) leukemia patients, leading to STAT3 pathway activation. Considering the heterogeneity of the disease and the several immunophenotypes that LGL clone may express, the aim of this work was to evaluate whether STAT3 mutations might be associated with a distinctive LGL immunophenotype and/or might be indicative for specific clinical features.Our series of cases included a pilot cohort of 101 T-LGL leukemia patients (68 CD8+/CD4- and 33 CD4+/CD8\ub1) from Padua Hematology Unit (Italy) and a validation cohort of additional 20 patients from Rennes Hematology Unit (France).Our results indicate that i) CD8+ T-LGL leukemia patients with CD16+/CD56- immunophenotype identify a subset of patients characterized by the presence of STAT3 mutations and neutropenia, ii) CD4+/CD8\ub1 T-LGL leukemia are devoid of STAT3 mutations but characterized by STAT5b mutations, and iii) a correlation exists between STAT3 activation and presence of Fas ligand, this molecule resulting highly expressed in CD8+/CD16+/CD56- patients. Experiments with stimulation and inhibition of STAT3 phosphorylation confirmed this relationship. In conclusion, our data show that T-LGL leukemia with specific molecular and phenotypic patterns is associated with discrete clinical features contributing to get insights into molecular bases accounting for the development of Fas ligand-mediated neutropenia

Momentum flux density, kinetic energy density and their fluctuations for one-dimensional confined gases of non-interacting fermions

We present a Green's function method for the evaluation of the particle density profile and of the higher moments of the one-body density matrix in a mesoscopic system of N Fermi particles moving independently in a linear potential. The usefulness of the method is illustrated by applications to a Fermi gas confined in a harmonic potential well, for which we evaluate the momentum flux and kinetic energy densities as well as their quantal mean-square fluctuations. We also study some properties of the kinetic energy functional E_{kin}[n(x)] in the same system. Whereas a local approximation to the kinetic energy density yields a multi-valued function, an exact single-valued relationship between the density derivative of E_{kin}[n(x)] and the particle density n(x) is demonstrated and evaluated for various values of the number of particles in the system.Comment: 10 pages, 5 figure