Development of Somaliland national harmonised medical curriculum.

BACKGROUND AND OBJECTIVES: The rational for the Somaliland national harmonised curriculum (NHC) was driven by shared concern about the quality of medical education. PROCESS: The Ministry of Education and Science and the Ministry of Health Development produced a Medical Education Policy 2018. Policy objectives included the development of the NHC and accreditation for medical schools that met the standards of the World Federation for Medical Education (WFME). Two bodies were asked to oversee these aims: the National Health Professions' Commission (NHPC) and the National Commission of Higher Education (NCHE). Between 2018 and 2020, a collaborative approach between the Somaliland government, medical school stakeholders, King's Global Health Partnership's (KGHP) volunteers and the Tropical Health Education Trust (THET) team was used to design the 6-years NHC. The NHC structure, content and delivery were grounded by WFME standards, health needs of the local population, student focused and active learning methods, and feasibility of implementation in medical schools. OUTCOMES: The NHC comprises details about the educational outcomes, curriculum model and framework, educational principles, instructional and learning methods, core as well as optional content, and assessment strategy. CONCLUSIONS: The approach used to develop the NHC ensured it is bespoken for Somaliland. Ongoing evaluation of patient and population needs, each medical school's review of programme implementation and outcomes will inform continuous revision and renewal.

Avoidance of healthcare service use and correlates among HIV-positive patients in Vietnam: a cross-sectional study.

OBJECTIVE: The prevention of HIV/AIDS is not making sufficient progress. The slow reduction of HIV/AIDS infections needs to prioritise hesitancy towards service utilisation, including treatment duration, social support and social stigma. This study investigates HIV-positive patients' avoidance of healthcare services and its correlates. DESIGN: A cross-sectional study. SETTING: The secondary data analysis used cross-sectional data from a randomised controlled intervention, examining the effectiveness of HIV-assisted smartphone applications in the treatment of HIV/AIDS patients in the Bach Mai and Ha Dong clinics in Hanoi. METHODS: Simple random sampling was used to identify 495 eligible patients. Two-tailed χ2, Mann-Whitney, multivariate logistic and ordered logistic regression models were performed. PRIMARY AND SECONDARY OUTCOME MEASURES: The main study outcome was the patients' healthcare avoidance and frequency of healthcare avoidance. The association of individual characteristics, social and behavioural determinants of HIV patients' usage of health services was also determined based on the collected data using structured questionnaires. RESULTS: Nearly half of the participants avoid health service use (47.3%), while 30.7% rarely avoid health service use. Duration of antiretroviral therapy and initial CD4 cell count were negatively associated with avoidance of health services and frequency of health service avoidance. Similarly, those with the middle and highest income were more likely to avoid health services compared with those with the lowest income. People having health problems avoided health service use more frequently (OR 1.47, 95% CI 1.35 to 1.61). CONCLUSIONS: Our study's findings identify characteristics of significance in relation to health service avoidance and utilisation among HIV-positive patients. The results highlighted the need to improve satisfaction, adherence and utilisation of treatment. Moreover, identifying ways to address or incorporate those social determinants in new policy may also help the treatment of HIV/AIDS and strategically allocate funding in the changing financial and political climate of Vietnam. TRIAL REGISTRATION NUMBER: Thai Clinical Trials Registry TCTR20220928003.

Using Systems Science for Strategic Planning of Obesity Prevention and Treatment: The Roundtable on Obesity Solutions Experience.

The sustained multi-decade increase in the prevalence of obesity calls for a new approach on addressing this public health concern. The Roundtable on Obesity Solutions (ROOS) (of the National Academies of Sciences, Engineering, and Medicine NASEM), a multisector group comprised of members from a variety of organizations and institutions, initiated a year-long effort to build a strategic plan and roadmap for action that would drive a paradigm shift for the ROOS in pursuing obesity solutions. Following a review of obesity prevention and treatment recommendations with sufficient actionable-evidence by authoritative organizations, the ROOS deployed systems science methods. Members engaged in group model building (GMB) exercises to develop an obesity systems map based on determinants and drivers from a multi-sector perspective and overlaid with aligned solutions. To expand the understanding of systems science approaches and methods, 3 public workshops were held in tandem with the development of the map. The causal map was refined, and solutions were ranked using a leverage-point framework to inform a strategic plan and narrative roadmap for action. For the ROOS, structural racism and social justice, biased mental models and social norms, and effective health communications were prioritized as the leverage points most likely to have a significant impact in addressing obesity. Complementary to the mission, vision, and guiding principles of the ROOS, the obesity systems map, and narrative roadmap will drive the ROOS activities over the next 3-6 years and serve as a resource for researchers, organizations, and institutions involved with policy, prevention, and treatment of obesity.

Primary Care and Public Health Collaboration Reports: A Qualitative Review of Integration Aims, Participants, and Success Determinants.

This qualitative review of 57 published case reports aimed to analyze primary care and public health integration efforts in 45 states to summarize collaboration aims, participants, and systemic, organizational, and interactional success determinants. Chronic disease management, maternal and child health, and wellness and health promotion were the most commonly reported aims of collaboration between primary care and public health entities in the United States. Typical participants were government public health structures, health delivery systems, communities, academia, state professional medical associations, and employers and businesses. Systemic, organizational, and interactional determinants included adequate funding, multiple stakeholder engagement, leadership, data and information sharing, capitalization on collaborator resources, community engagement, steering committees, effective communication, regular meetings, shared mission, vision, and goals, previous positive relationships, collaborations, and partnerships. The present study contributes to the body of knowledge of when, where, and under what contextual circumstances collaboration and integration have been perceived as effective. Future research could extrapolate which determinants are more essential than others and focus on how systemic, organizational, and interactional factors are interrelated. To advance the practice of successful integration between primary care and public health entities, longitudinal research is needed to examine the degree of integration and sustainability.

Weight management and physical activity throughout the cancer care continuum.

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

An Integrated Framework For The Prevention And Treatment Of Obesity And Its Related Chronic Diseases.

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

The value of diagnostic medical imaging.

Diagnostic medical imaging has clear clinical utility, but it also imposes significant costs on the health care system. This commentary reviews the factors that drive the cost of medical imaging, discusses current interventions, and suggests possible future courses of action.

Self-reported health parameters compared with clinician measurements: methods in practice-based research.

CONTEXT: Self-reported health data are used by health insurance companies to assess risk. Most studies show underreporting compared with clinical measurements. OBJECTIVE: To compare self-reported height, weight, blood pressure, waist circumference, and dietary intake with registered dietitian's (RD's) measures of the same parameters. DESIGN: This is a secondary analysis of data collected in a larger study on the benefits of Medical Nutrition Therapy from an RD for overweight and obese patients when provided free of charge through an insurance benefit. SETTING: Participants completed a health risk assessment survey at home, from which the self-reported measures were extracted. The clinical measurements were taken by an RD in the office during a visit for Medical Nutrition Therapy. PARTICIPANTS: Participants were 81.4% female, with a mean body mass index of 35.0. All were insured and had a least 1 visit with an RD. MAIN OUTCOME MEASURE(S): Main outcomes were correlation between self-reported and RD-measured height, weight, body mass index, blood pressure, and waist circumference. Blood pressure was categorized as normal or high and the κ statistic was used to examine category agreement between the 2 measures. Servings of food groups were compared between the 2 measures by examining cumulative percent within 0, 1, or 2 servings of the RD-measured value. RESULTS: The 2 measures of height and weight were highly correlated (0.974 and 0.986, respectively). Blood pressure was more weakly correlated and when categorized had low κ scores, as did servings of food groups. CONCLUSIONS: Height and weight were more closely correlated than in previous studies. In an insured population enrolled in a weight management program, self-reported measures may be accurate for determining program impact. Blood pressure may be better collected categorically than continuously. The necessity of food intake assessment on a risk assessment should be reconsidered.

Twelve tips to improve medical teaching rounds.

The ward round is the bread and butter of internal medicine. It forms the basis of clinical decision making and reviewing patients' progress. It is fundamental to the role of the internal medical physician. It allows for the review of the patients' notes, signs and symptoms, physiological parameters and investigation results. Most importantly, it allows for an interaction with the patient and their relatives and is a means of relating medical information back, answer queries and plan future medical management strategies. These should be integrated into the teaching round by a senior clinician so that time away from the bedside is also used to enhance the teaching and learning experience. Here, I would like to draw on my experience as a learner as well as an educator, together with the available literature, to draw up a simple 12-step teaching strategy that should help the ward round serve the dual purpose of teaching medical students and junior doctors.

Transforming quality of care in North Carolina.

North Carolina is entering a period of transformative change in health care, as health system consolidation, health care reform, and payment reform combine to dramatically reshape health care. In this turbulent time, maintaining focus on quality of care will be critical. North Carolina has been a national leader in efforts to improve quality of care, starting from classic research in the 1950s on the measurement of quality and culminating in major statewide efforts to improve care through the North Carolina Area Health Education Centers Program, Community Care of North Carolina, the North Carolina Hospital Association, Medicaid, Blue Cross and Blue Shield of North Carolina, academic centers, and many other partners. The purpose of this issue of the NCMJ is to highlight initiatives to improve quality across the continuum of care and across the state. This overview puts these initiatives in context and addresses 3 fundamental questions: Can quality of care be measured and improved? What does the landscape of quality in North Carolina look like now? What should North Carolina's priorities be for improving quality of care moving forward?

UNC Health Systems and Blue Cross and Blue Shield of North Carolina patient-centered medical home collaborative.

UNC Health Systems and Blue Cross and Blue Shield of North Carolina have entered into a joint venture that is designed to improve patient outcomes and experience and to control medical costs for patients with chronic conditions. This commentary reviews the impetus for, and the anticipated outcomes of, the model practice.

Migration and psychological well-being among older adults: a growth curve analysis based on panel data from the Health and Retirement Study, 1996-2006.

PURPOSE: A vibrant body of research examines migration among older adults. Existing research, however, grants scarce attention to the implications of later-life migration for the migrants themselves. Our research focuses on the impacts of migration on depressive symptomatology among older U.S. adults. METHODS: Our analysis employs six waves of panel data from the Health and Retirement Study, 1996-2006. Growth curve modeling techniques are employed. RESULTS: Net of other stressful life events, migration effects appear to vary significantly across persons. Findings highlight the particularly depressive impact of moves motivated by negative life events or circumstances. Results further suggest that later life moves may be especially stressful for women and as individuals age. DISCUSSION: The stress of moving late in life may depend on social integration at destination. Further research should pursue this issue. Study limitations and additional directions for further research are delineated.

The aging farm population and rural aging research.

This article explores the potential and the promise of convergence between gerontological and occupational health researchers to better understand challenges faced by aging farmers including declining economic viability of family farms, the aging of the population of working farmers, and probability of work-related injury or disability among older farmers. Although the need for research seems obvious, the economic, demographic, and psychosocial dynamics of continued work among aging farmers is under-studied in the occupational health literature and absent in the gerontological literature. Following examination of studies of aging farmers drawn from the occupational health literature, we review studies of rural aging in the gerontological literature. First, we compare varying definitions of rural across federal agencies that impact the ability of researchers using these data to examine variability across rural places. Next, we review studies based upon primary data that include rural residence among their independent variables. We describe different definitions of rural residence across federal agencies with an eye toward their methodological and conceptual impact on the rural aging literature. Then we describe inadequate and incomplete definition and measurement of rural residence across published studies of primary data. Following discussion of the implications of these shortcomings for rural aging research including farmers and others engaged in extractive activities, we discuss the potential for joint work among gerontologists and occupational health researchers to better understand the significance of aging for transition in the agricultural economy and the viability of family farms. We recommend attention to the definition and measurement of rural residence to include variability in rural farm and non-farm populations and refocusing the occupational health literature on aging farmers to include a life course perspective from gerontological theory applied through longitudinal research designs.

Actuation of mobility intentions among the young-old: an event-history analysis.

PURPOSE: Although migration decision making is central to understanding later-life migration, the critical step between migration intentions and mobility outcomes has received only limited empirical attention. We address two questions: How often are intended moves actuated? What factors condition the likelihood that mobility intentions will be actuated? DESIGN AND METHODS: We employ data from the 1994-2002 Health and Retirement Study, which is a nationally representative panel targeting households containing persons aged 53 to 63 years at baseline. Event-history techniques are used to examine the link between reported mobility intentions at baseline and mobility outcomes across the study period, net of relevant controls. We conduct separate household-level analyses for couple and noncouple households and recognize three types of moves: local, family oriented, and nonlocal. RESULTS: Findings confirm the utility of mobility expectations as a predictor of future mobility. More importantly, results highlight the complex nature of later-life mobility. The actuation of mobility intentions appears to operate differently in couple than in noncouple households. Moreover, our findings suggest that the role of several key variables depends on the type of move under consideration. IMPLICATIONS: The ability to identify potential "retirement migrants" may be of practical importance for state and local government officials as well as developers interested in recruiting or retaining young-old residents. Our study offers insight on the interpretation of stated mobility intentions. Moreover, consistent with early theoretical work in the field, our analysis suggests that empirical studies must account for heterogeneity among older movers in order to avoid misleading results.

Predictors of non-local moves among older adults: a prospective study.

OBJECTIVES: The goal of this article was to test a series of established predictors of the hazard of moving for persons primarily in their 50s and 60s. We tested demographic covariates, resources, travel experience, and community and person ties using a prospective design. METHODS: We employed data from the Health and Retirement Study, 1994 to 2002, based on a representative sample of households containing at least one member aged 51 to 61 in 1992. We employed measures available in the Health and Retirement Study to construct a series of Cox proportional hazards models that examined the causes of non-local moves. RESULTS: Community and person ties emerged as important predictors of non-local moves. DISCUSSION: Travel experience, when measured by regular vacationing and second homes, may increase community ties to a destination. The life-course model must be modified in its explanation of the importance of community and person ties, and of life transitions, as motivators of migration.

The effects of alcohol on laboratory-measured impulsivity after L: -Tryptophan depletion or loading.

RATIONALE: Indirect evidence supports a link between serotonergic activity and individual differences in the behavioral response to alcohol, but few studies have experimentally demonstrated that an individual's biological state can influence the sensitivity to alcohol-induced behaviors. OBJECTIVE: Our purpose was to temporarily modify serotonin synthesis in healthy individuals to determine how altered biological states may interact with alcohol administration to affect impulsive behavior. MATERIALS AND METHODS: In a repeated-measures design, 18 normal controls consumed a 50-g L: -tryptophan (Trp) depleting (ATD) or loading (ATL) amino-acid beverage that temporarily decreased or increased (respectively) serotonin synthesis before receiving either a moderate dose of alcohol (0.65 g/kg) or placebo. All participants completed three impulsivity testing sessions on each of the five experimental days. Session one was a baseline session. Session two included testing after ATD-only or ATL-only. Session three included: (1) placebo after ATL (ATL+PBO); (2) placebo after ATD (ATD+PBO); (3) alcohol after ATL (ATL+ALC); (4) alcohol after ATD (ATD+ALC); and (5) Alcohol-only conditions. Impulsivity was assessed using the Immediate Memory Task (Dougherty et al., Behav Res Methods Instrum Comput 34:391-398, 2002), a continuous performance test yielding commission errors that have been previously validated as a component of impulsive behavior. RESULTS: Primary findings were that ATD-only increased impulsive responding compared to ATL-only, and ATD+ALC increased commission errors to levels higher than either the ATL+ALC or Alcohol-only conditions. CONCLUSIONS: These findings demonstrate that reduced serotonin synthesis can produce increased impulsivity even among non-impulsive normal controls, and that the behavioral effects of alcohol are, in part, dependent on this biological state.

Mothers' accounts of screening newborn babies in Wales (UK).

OBJECTIVE: To explore mothers' accounts of screening newborn babies to increase our understanding of how they define screening and talk about the process of consent. DESIGN: A purposive sample of mothers, whose newborn babies had recently been screened, were invited to take part in a semi-structured interview. SETTING: Primary and community-care settings in one region of Wales, UK. PARTICIPANTS: Mothers (n=18) who had recently given birth and been offered screening for their newborn babies. FINDINGS: Information giving about newborn screening was reported to be ad hoc, with most women receiving information in the postnatal period. Mothers talked about newborn screening as a routine procedure that 'had' to be done. There was some recognition that consent for screening should have been given, but this was often compromised because the test was being offered by a trusted health professional and a social expectation that responsible mothers should have their babies tested. CONCLUSIONS: Mothers agreed that information about newborn-baby screening should be given during pregnancy. This is in line with recent recommendations from the UK Newborn Screening Programme Centre. This policy urgently needs to be translated effectively into everyday practice. In addition, the nature of consent required for each test needs to be clarified so that midwifery practice is not compromised and mothers are aware that some tests are advisable whereas others, for less treatable diseases, are a matter of individual choice.

In retirement migration, who counts? A methodological question with economic policy implications.

PURPOSE: We examine the methodological and economic policy implications of three operations of retirement migration. DESIGN AND METHODS: We compared the traditional age-based definition of retirement migration and two retirement-based definitions, based on degree of labor-force participation and retirement income, by using the 2000 U.S. Census Public Use Microdata Sample. RESULTS: The age-based definition overestimated the number of retired migrants, although the ranking of host and donor states remained relatively stable; nevertheless, states revealed different rates of change in inmigration and outmigration and income streams declined. IMPLICATIONS: Retirement-based definitions are more useful and precise for those researchers considering the economic implication of retirement migration.