Organizing integrated health-care services to meet older people's needs.

In most countries, a fundamental shift in the focus of clinical care for older people is needed. Instead of trying to manage numerous diseases and symptoms in a disjointed fashion, the emphasis should be on interventions that optimize older people's physical and mental capacities over their life course and that enable them to do the things they value. This, in turn, requires a change in the way services are organized: there should be more integration within the health system and between health and social services. Existing organizational structures do not have to merge; rather, a wide array of service providers must work together in a more coordinated fashion. The evidence suggests that integrated health and social care for older people contributes to better health outcomes at a cost equivalent to usual care, thereby giving a better return on investment than more familiar ways of working. Moreover, older people can participate in, and contribute to, society for longer. Integration at the level of clinical care is especially important: older people should undergo comprehensive assessments with the goal of optimizing functional ability and care plans should be shared among all providers. At the health system level, integrated care requires: (i) supportive policy, plans and regulatory frameworks; (ii) workforce development; (iii) investment in information and communication technologies; and (iv) the use of pooled budgets, bundled payments and contractual incentives. However, action can be taken at all levels of health care from front-line providers through to senior leaders - everyone has a role to play.

Dans la plupart des pays, un changement fondamental de priorité dans l'organisation des soins cliniques destinés aux personnes âgées est nécessaire. Plutôt que d'essayer de gérer la variété des maladies et symptômes de manière individuelle, l'accent devrait être mis sur les interventions qui optimisent les capacités physiques et mentales des personnes âgées sur tout leur parcours de vie et qui leur permettent de continuer de réaliser les activités qui comptent pour elles. Mais cela suppose de modifier le mode d'organisation des prestations, avec une meilleure intégration à l'intérieur du système de santé et entre les services de santé et d'aide sociale. Cela ne signifie pas que les structures existantes doivent fusionner, mais plutôt qu'une grande diversité de prestataires doit travailler ensemble de manière plus coordonnée. Des données factuelles montrent que des prestations de santé et d'aide sociale intégrées entraînent de meilleurs résultats sur la santé des personnes âgées que les prestations de soins habituelles, pour un coût équivalent; d'où l'obtention d'une meilleure rentabilité des investissements comparativement aux modes de travail classiques. Elles permettent aussi aux personnes âgées de s'impliquer socialement et d'apporter leurs contributions à la société pendant plus longtemps. Une telle intégration est particulièrement importante au niveau des soins cliniques: des évaluations exhaustives devraient être réalisées chez les personnes âgées dans une optique d'optimisation de leurs capacités fonctionnelles, et les plans de soins devraient être communs à tous les prestataires. Au niveau du système de santé, l'intégration des prestations nécessite: (i) l'adoption de politiques, programmes et cadres réglementaires favorables; (ii) le développement du personnel de santé; (iii) un investissement dans les technologies de l'information et de la communication; et (iv) la mise en place de budgets communs, de paiements regroupés et de mesures contractuelles incitatives. Toutefois, des actions peuvent être entreprises à tous les niveaux d'organisation des soins de santé, depuis les prestataires de première ligne jusqu'aux hauts responsables ­ tout le monde a un rôle à jouer.

En la mayoría de países se necesita un cambio fundamental en el enfoque de la atención clínica que reciben las personas mayores. En lugar de intentar gestionar numerosas enfermedades y síntomas por separado, debería ponerse énfasis en las intervenciones que optimizan las capacidades físicas y mentales de las personas mayores durante su vida y que les permitan hacer lo que ellos valoran. Esto, a su vez, requiere un cambio en la forma en la que se organizan los servicios: debería haber más integración dentro del sistema sanitario y entre los servicios sanitarios y sociales. Las estructuras organizativas existentes no deben fusionarse, sino que el amplio conjunto de proveedores de servicios debe trabajar conjuntamente de una forma más coordinada. Las pruebas indican que la atención sanitaria y social integrada para las personas mayores contribuye a unos mejores resultados sanitarios a un coste equivalente a la atención habitual. De esta forma, se obtiene una mayor rentabilidad de la inversión que la obtenida con formas de trabajar más familiares. Además, las personas mayores pueden participar y contribuir en la sociedad durante más tiempo. La integración a nivel de la atención clínica es especialmente importante: las personas mayores deberían someterse a asesoramiento integral con el objetivo de optimizar la capacidad funcional, y deberían compartirse los planes de atención entre todos los proveedores. A nivel del sistema sanitario, la atención integrada requiere: (i) política, planes y marcos normativos de apoyo; (ii) desarrollo del personal sanitario; (iii) inversión en tecnologías de la información y comunicación; y (iv) el uso de presupuestos y pagos combinados e incentivos contractuales. No obstante, esto puede realizarse en todos los niveles de la atención sanitaria, desde los proveedores de primera línea hasta el personal directivo; todos juegan un papel.

The World report on ageing and health: a policy framework for healthy ageing.

Although populations around the world are rapidly ageing, evidence that increasing longevity is being accompanied by an extended period of good health is scarce. A coherent and focused public health response that spans multiple sectors and stakeholders is urgently needed. To guide this global response, WHO has released the first World report on ageing and health, reviewing current knowledge and gaps and providing a public health framework for action. The report is built around a redefinition of healthy ageing that centres on the notion of functional ability: the combination of the intrinsic capacity of the individual, relevant environmental characteristics, and the interactions between the individual and these characteristics. This Health Policy highlights key findings and recommendations from the report.

Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective.

BACKGROUND: Major gaps remain - especially in low- and middle-income countries - in the realization of comprehensive, community-based mental health care. One potentially important yet overlooked opportunity for accelerating mental health reform lies within emergency situations, such as armed conflicts or natural disasters. Despite their adverse impacts on affected populations' mental health and well being, emergencies also draw attention and resources to these issues and provide openings for mental health service development. CASE DESCRIPTION: Cases were considered if they represented a low- or middle-income country or territory affected by an emergency, were initiated between 2000 and 2010, succeeded in making changes to the mental health system, and were able to be documented by an expert involved directly with the case. Based on these criteria, 10 case examples from diverse emergency-affected settings were included: Afghanistan, Burundi, Indonesia (Aceh Province), Iraq, Jordan, Kosovo, occupied Palestinian territory, Somalia, Sri Lanka, and Timor-Leste. DISCUSSION AND EVALUATION: These cases demonstrate generally that emergency contexts can be tapped to make substantial and sustainable improvements in mental health systems. From these experiences, 10 common lessons learnt were identified on how to make this happen. These lessons include the importance of adopting a longer-term perspective for mental health reform from the outset, and focusing on system-wide reform that addresses both new-onset and pre-existing mental disorders. CONCLUSIONS: Global progress in mental health care would happen more quickly if, in every crisis, strategic efforts were made to convert short-term interest in mental health problems into momentum for mental health reform.

Developing the World Health Organization Disability Assessment Schedule 2.0.

OBJECTIVE: To describe the development of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) for measuring functioning and disability in accordance with the International Classification of Functioning, Disability and Health. WHODAS 2.0 is a standard metric for ensuring scientific comparability across different populations. METHODS: A series of studies was carried out globally. Over 65,000 respondents drawn from the general population and from specific patient populations were interviewed by trained interviewers who applied the WHODAS 2.0 (with 36 items in its full version and 12 items in a shortened version). FINDINGS: The WHODAS 2.0 was found to have high internal consistency (Cronbach's alpha, α: 0.86), a stable factor structure; high test-retest reliability (intraclass correlation coefficient: 0.98); good concurrent validity in patient classification when compared with other recognized disability measurement instruments; conformity to Rasch scaling properties across populations, and good responsiveness (i.e. sensitivity to change). Effect sizes ranged from 0.44 to 1.38 for different health interventions targeting various health conditions. CONCLUSION: The WHODAS 2.0 meets the need for a robust instrument that can be easily administered to measure the impact of health conditions, monitor the effectiveness of interventions and estimate the burden of both mental and physical disorders across different populations.

Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care.

The burden of chronic diseases, such as heart disease, cancer, diabetes, and mental disorders is high in low-income and middle-income countries and is predicted to increase with the ageing of populations, urbanisation, and globalisation of risk factors. Furthermore, HIV/AIDS is increasingly becoming a chronic disorder. An integrated approach to the management of chronic diseases, irrespective of cause, is needed in primary health care. Management of chronic diseases is fundamentally different from acute care, relying on several features: opportunistic case finding for assessment of risk factors, detection of early disease, and identification of high risk status; a combination of pharmacological and psychosocial interventions, often in a stepped-care fashion; and long-term follow-up with regular monitoring and promotion of adherence to treatment. To meet the challenge of chronic diseases, primary health care will have to be strengthened substantially. In the many countries with shortages of primary-care doctors, non-physician clinicians will have a leading role in preventing and managing chronic diseases, and these personnel need appropriate training and continuous quality assurance mechanisms. More evidence is needed about the cost-effectiveness of prevention and treatment strategies in primary health care. Research on scaling-up should be embedded in large-scale delivery programmes for chronic diseases with a strong emphasis on assessment.

Preventing cancer through tobacco and infection control: how many lives can we save in the next 10 years?

This paper presents projections for cancer mortality, incidence and burden of disease (as disability adjusted life years) for 2005, 2015 and 2030. The projections are based on the latest available WHO mortality estimates from 2002, updated with mortality data from 107 countries and augmented by region and site-specific cancer survival models. Cancer accounted for an estimated 7.6 million deaths in 2005, and 72% of these deaths were in low-income and middle-income countries. For cancer deaths under age 70, 79% are estimated to occur in low-income and middle-income countries. Without intervention, the number of global deaths is projected to rise to 9 million in 2015 and a further 11.5 million in 2030. The rising burden of this disease, especially in low-income and middle-income countries, leads us to propose a global goal for cancer: a 2% reduction per annum over and above that which may happen as a result of current trends in prevention, case management and treatment. Achieving this goal would result in 7.7 million fewer deaths from cancer over the period from 2005 to 2015. More of these deaths will be averted in low-income and middle-income countries than in high-income countries. The scientific knowledge to achieve this goal already exists, and the target could be reached through effective cancer prevention strategies, including tobacco control, hepatitis B vaccination and prevention of cervical cancer.

Preventing chronic diseases: taking stepwise action.

The scientific knowledge to achieve a new global goal for the prevention of chronic diseases--a 2% yearly reduction in rates of death from chronic disease over and above projected declines during the next 10 years--already exists. However, many low-income and middle-income countries must deal with the practical realities of limited resources and a double burden of infectious and chronic diseases. This paper presents a novel planning framework that can be used in these contexts: the stepwise framework for preventing chronic diseases. The framework offers a flexible and practical public health approach to assist ministries of health in balancing diverse needs and priorities while implementing evidence-based interventions such as those recommended by the WHO Framework Convention on Tobacco Control and the WHO Global Strategy on Diet, Physical Activity and Health. Countries such as Indonesia, the Philippines, Tonga, and Vietnam have applied the stepwise planning framework: their experiences illustrate how the stepwise approach has general applicability to solving chronic disease problems without sacrificing specificity for any particular country.

Integrated approaches to prevention and control of chronic conditions.

Integrated approaches to prevention and control of chronic conditions. Chronic conditions currently account for more than 50% of the global disease burden, and this figure is projected to continue to rise. Yet, around the world, health care systems are not organized to provide effective and efficient care for chronic health problems. Health care systems have evolved around the concept of acute, infectious disease, and they perform best when addressing patients' acute and urgent symptoms. Without change, health care systems will grow increasingly inefficient and ineffective. Effective prevention, management, and rehabilitation of chronic conditions require an evolution of health care, away from a model that is focused on acute symptoms toward a coordinated, comprehensive system of care. The results of this shift include less waste and improved efficiency. Integrated health care models that transcend specific illnesses provide a feasible solution. The World Health Organization's Innovative Care for Chronic Conditions Framework provides a flexible but comprehensive model to build or redesign health systems in accord with local resources and demands.

Research to practice: international dissemination of evidence-based behavioral medicine.

BACKGROUND: In recent years, there has been a dramatic rise in the global prevalence of chronic conditions. Cancer, diabetes, cardiovascular diseases chronic lung disorders, and their common behavioral risk factors are escalating rapidly in developing countries, many of which are still struggling with infectious diseases and poor health system infrastructures. PURPOSE: This article examines the role that behavioral medicine can play to improve global health. METHODS: The World Health Organization's Innovative Care for Chronic Conditions Framework provides a model for identifying areas for behavioral medicine influence, including patient-provider interactions, organization of health care, community mobilization, and national policy and financing. RESULTS: Behavioral medicine has a large role to play in international health. Examples from around the world are provided. CONCLUSIONS: Because behavior is the product of multilevel, multifactoral determinants, there are many areas of influence for behavioral medicine specialists who want to contribute to global health. By focusing attention internationally, with special attention toward the needs of developing countries, the field of behavioral medicine will be not only responding to its global responsibilities but also repositioning itself to be increasingly relevant for the 21st century.

The World Health Organization's Framework Convention on Tobacco Control: implications for global epidemics of food-related deaths and disease.

This paper reviews the major elements of the WHO Framework Convention on Tobacco Control and considers those that can be applied to diet and nutrition. Tobacco and food policy have important differences: the two commodities have distinctly different health impacts, and food companies may be more responsive to public concerns than the tobacco industry. Nevertheless, both food and tobacco policy address public health issues surrounding legal products. Both require comprehensive and multi-sector approaches at global and national levels. The degree of flexibility possible in interacting and partnering with the private sector and food and related industries and the related implications for regulations and laws are reasons for a more nuanced approach to diet and physical activity policy.

One-year follow-up of first onset low back pain.

Efforts to examine the process and risk of developing chronic back pain have relied generally upon retrospective study of individuals with already established pain. In an alternative approach to understanding the clinical course and evolution of low back disorders, a cohort of 76 men experiencing their first episode of back pain was assessed prospectively at 2, 6 and 12 months following pain onset. Standard measures of pain (Descriptor Differential Scale: DDS), disability (Sickness Impact Profile: SIP), and distress (Beck Depression Inventory: BDI) were employed to classify the sample into five groups: Resolved, Pain Only, Disability/Distress Only, Pain and Mild Disability/Distress, and Clinical Range. At both 6 and 12 months post pain onset, most (78%, 72% respectively) of the sample continued to experience pain. Many also experienced marked disability at 6 months (26%) and 12 months (14%). At 12 months, no participants had worsened relative to the 2-month baseline. Doubly multivariate analyses of variance (MANOVAs) were employed to compare baseline groups (Pain Only, Pain and Mild Disability/Distress, Clinical Range) on the DDS, SIP, and BDI across time. The group by time interaction from 2 through 12 months was reliable, with greatest change occurring in the Clinical Range group in disability and distress; interestingly, the decrease in pain was comparable among all groups. Follow-up tests across measures demonstrated greater change in the early (2-6-month) interval and relative stability in the later (6-12-month) interval. Comparison of those classified as 'improvers' with those who did not improve from 2 to 12 months showed similar findings. The clinical course of first onset back pain may be prolonged for many patients, and involves a continuum of related disability and distress. Individuals at risk for marked symptoms 1 year after an initial episode of back pain can be identified early, and prompt treatment might reduce the risk of pain chronicity.