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ItemA narrative account of implementation lessons learnt from the dissemination of an up-scaled state-wide child obesity management program in Australia: PEACH™ (Parenting, Eating and Activity for Child Health) Queensland(BioMed Central, 2018-03-13) Croyden, Debbie L; Vidgen, Helen A; Esdaile, Emma; Hernandez, Emely; Magarey, Anthea Margaret; Moores, Carly J; Daniels, Lynne AllisonBackground: PEACH QLD translated the PEACH Program, designed to manage overweight/obesity in primary school-aged children, from efficacious RCT and small scale community trial to a larger state-wide program. This paper describes the lessons learnt when upscaling to universal health coverage. Methods: The 6-month, family-focussed program was delivered in Queensland, Australia from 2013 to 2016. Its implementation was planned by researchers who developed the program and conducted the RCT, and experienced project managers and practitioners across the health continuum. The intervention targeted parents as the agents of change and was delivered via parent-only group sessions. Concurrently, children attended fun, non-competitive activity sessions. Sessions were delivered by facilitators who received standardised training and were employed by a range of service providers. Participants were referred by health professionals or self-referred in response to extensive promotion and marketing. A pilot phase and a quality improvement framework were planned to respond to emerging challenges. Results: Implementation challenges included engagement of the health system; participant recruitment; and engagement. A total of 1513 children (1216 families) enrolled, with 1122 children (919 families) in the face-to-face program (105 groups in 50 unique venues) and 391 children (297 families) in PEACH Online. Self-referral generated 68% of enrolments. Unexpected, concurrent and, far-reaching public health system changes contributed to poor program uptake by the sector (only 56 [53%] groups delivered by publicly-funded health organisations) requiring substantial modification of the original implementation plan. Process evaluation during the pilot phase and an ongoing quality improvement framework informed program adaptations that included changing from fortnightly to weekly sessions aligned with school terms, revision of parent materials, modification of eligibility criteria to include healthy weight children and provision of services privately. Comparisons between pilot versus state-wide waves showed comparable prevalence of families not attending any sessions (25% vs 28%) but improved number of sessions attended (median?=?5 vs 7) and completion rates (43% vs 56%). Conclusions: Translating programs developed in the research context to enable implementation at scale is complex and presents substantial challenges. Planning must ensure there is flexibility to accommodate and proactively manage the system changes that are inevitable over time ItemThe acceptability of participating in data linkage research: research with older Australians(Wiley, 2018-06-12) Harrison, Stephanie L; Milte, Rachel; Bradley, Clare Eileen; Inacio, Maria C S; Crotty, MariaAustralians are increasingly concerned about the privacy of their data, but the biggest concerns relate to online services and identification fraud. Australians may be supportive of research that uses linked data; however, there have been conflicting findings as to whether formal consent from individuals should be sought, and the views of the older population have not been elicited specifically. A previous survey suggested half of Australians would expect consent to be sought for the use of de‐identified health information for research purposes, but the respondents were not specifically asked if they would expect an opt‐in or opt‐out approach to consent. The objectives of the current study were to determine if older Australians would find it acceptable to be part of the proposed registry and to explore different methods of consent. ItemAdditive and subtractive resilience strategies as enablers of biographical reinvention: a qualitative study of ex-smokers and never-smokers(Elsevier, 2011) Ward, Paul Russell; Muller, Robert; Tsourtos, George; Hersh, Deborah; Lawn, Sharon Joy; Winefield, Anthony H; Coveney, John DavidThe notion of developing resilience is becoming increasingly important as a way of responding to the social determinants of poor health, particularly in disadvantaged groups. It is hypothesized that resilient individuals and communities are able to ‘bounce back’ from the adversities they face. This paper explores the processes involved in building resilience as an outcome in relation to both quitting smoking and never smoking. The study involved 93 qualitative, oral-history interviews with participants from population groups with high and enduring smoking rates in Adelaide, Australia, and was essentially interested in how some people in these groups managed to quit or never start smoking in the face of adversities, in comparison to a group of smokers. Our key findings relate to what we call additive and subtractive resilience strategies, which focus on the practices, roles and activities that individuals either ‘took on’ or ‘left behind’ in order to quit smoking or remain abstinent. The theoretical lenses we use to understand these resilience strategies relate to biographical reinforcement and biographical reinvention, which situate the resilience strategies in a broader ‘project of the self’, often in relation to attempting to develop ‘healthy bodies’ and ‘healthy biographies’. ItemThe alcohol industry, neo-liberalism and the political economy of health(Australasian Medical Journal, 2009) Ward, Paul RussellWriting in the Australasian Medical Journal Bond, Daube, & Chikritzhs present a fascinating analysis of previously confidential, internal industry documents. The documents became available due to the 1998 Master Settlement Agreement, which was originally initiated to allow public access to internal tobacco industry documents, but since some alcohol companies are controlled by tobacco companies (in this case, Phillip Morris), the internal documents of the alcohol companies (in this case, Miller Brewing Company) became available. It is also interesting to note that Kraft foods is also controlled by Phillip Morris, which means that researchers interested in food policy, marketing and regulation can now access potentially useful documentation on the underlying intentions of a particular food company. The paper presented an analysis of a vast array of alcohol industry documents, and the authors discuss a number of key areas with which the alcohol industry stated their concerns. Within this Editorial, I wish to highlight the implications of many of these concerns within two areas of social and political thought: the political economy of health, and the impact of neo-liberalism. ItemAssessing key safety concerns of a Wolbachia-based strategy to control dengue transmission by Aedes mosquitoes(Scientific Electronic Library Online, 2010-12) Popovici, Jean; Moreira, Luciano A; Poinsignon, Anne; Iturbe-Ormaetxe, Inaki; McNaughton, Darlene; O'Neill, Scott LMosquito-borne diseases such as dengue fever, chikungunya or malaria affect millions of people each year and control solutions are urgently needed. An international research program is currently being developed that relies on the introduction of the bacterial endosymbiont Wolbachia pipientis into Aedes aegypti to control dengue transmission. In order to prepare for open-field testing releases of Wolbachia-infected mosquitoes, an intensive social research and community engagement program was undertaken in Cairns, Northern Australia. The most common concern expressed by the diverse range of community members and stakeholders surveyed was the necessity of assuring the safety of the proposed approach for humans, animals and the environment. To address these concerns a series of safety experiments were undertaken. We report in this paper on the experimental data obtained, discuss the limitations of experimental risk assessment and focus on the necessity of including community concerns in scientific research. ItemAssessing the health impact of transnational corporations: its importance and a framework(BioMed Central, 2016) Baum, Fran; Sanders, David; Fisher, Matthew; Anaf, Julia Margaret; Freudenberg, N; Friel, S; Labonte, Ronald; London, L; Monteiro, C; Scott-Samuel, A; Sen, ABackground: The adverse health and equity impacts of transnational corporations’ (TNCs) practices have become central public health concerns as TNCs increasingly dominate global trade and investment and shape national economies. Despite this, methodologies have been lacking with which to study the health equity impacts of individual corporations and thus to inform actions to mitigate or reverse negative and increase positive impacts. Methods: This paper reports on a framework designed to conduct corporate health impact assessment (CHIA), developed at a meeting held at the Rockefeller Foundation Bellagio Center in May 2015. Results: On the basis of the deliberations at the meeting it was recommended that the CHIA should be based on ex post assessment and follow the standard HIA steps of screening, scoping, identification, assessment, decision-making and recommendations. A framework to conduct the CHIA was developed and designed to be applied to a TNC’s practices internationally, and within countries to enable comparison of practices and health impacts in different settings. The meeting participants proposed that impacts should be assessed according to the TNC’s global and national operating context; its organisational structure, political and business practices (including the type, distribution and marketing of its products); and workforce and working conditions, social factors, the environment, consumption patterns, and economic conditions within countries. Conclusion: We anticipate that the results of the CHIA will be used by civil society for capacity building and advocacy purposes, by governments to inform regulatory decision-making, and by TNCs to lessen their negative health impacts on health and fulfil commitments made to corporate social responsibility. ItemAssessment of Multidrug Resistant Organism Related Prevention and Control Policies and Environment at KFHH, Saudi Arabid(European Centre for Research Training and Development UK, 2013-03) Mwanri, Lillian; Essa, AlSalehWorldwide, Healthcare Associated Infections (HAIs) and Multidrug Resistant Organisms (MDROs) cause a significant clinical and economic burden. One of the strategies that have been implemented to reduce antimicrobial resistance is the development of healthcare settings with specific MDROs control policies and guidelines. The aim of this study was to perform an audit in order to assess whether, at the time of writing, the relevant policies and procedures were in place at the King Fahad Hofuf Hospital. The Carter and colleagues’ model, which uses a matrix of acknowledging, auditing, stating of aims, and setting out of actions was used as a model for the assessment of the policies. The researchers conducted site visit rounds of the ICU and the general wards to report on the ratio of rooms for patient care, and the general areas in which hand washing sinks and alcohol-based hand rub products were available. Eight policies related to multidrug resistant organisms were analysed. Inappropriate scientific references were presented in the policies and there were no acknowledgements, auditing, or recommended actions in the majority of these policies according to the Carter and colleagues’ method. The sink to bed ratio was 1:6 in the ICU and 1:25 in the general ward. As well, the sinks were not equipped with non-manual control equipment. In conclusion, An audit of policies in the healthcare setting indicated a number of deficiencies regarding best standard policies and guidelines for infection control. Moreover, there were also inadequate environmental control measures for HAIs and MDROs, including hand hygiene facilities ItemAttitudes towards and beliefs about colorectal cancer and screening using the faecal occult blood test within the Italian-Australian community(Asian Pacific Organization for Cancer Prevention, 2009) Severino, Giovanina; Wilson, Carlene J; Turnbull, Deborah; Duncan, Amy; Gregory, Tess AnneStudies with minority ethnic communities worldwide reveal important differences in the content of beliefs about cancer and attitudes towards screening. Current initiatives in colorectal cancer (CRC) screening highlight the importance of identifying any illness-specific beliefs that might influence participation rates within the targeted age-range. We conducted semi-structured interviews with 20 Italian-Australians aged between 50 and 78 years, living in Adelaide, South Australia. Qualitative data from the interviews were analysed using framework analysis. Participants articulated specific beliefs about the nature of cancer, risk factors, prevention possibilities, and variety of potential barriers and benefits to faecal occult blood testing (FOBT). Although participants’ beliefs overlapped with conventional medical models of cancer, the results also demonstrated the presence of specific cultural perceptions that might influence FOBT participation. Our results suggest that models used to inform communication about cancer need to be sensitive to culture specific concerns. Within the context of the older Italian-Australian community, there is a suggestion that self and response efficacy may be serious barriers to screening behavior and that bi-lingual, verbal delivery of information may be the most effective mode of communication to increase screening participation. ItemAustralian children's views about food advertising on television(Elsevier, 2010) Mehta, Kaye Phillips; Coveney, John David; Ward, Paul Russell; Magarey, Anthea Margaret; Spurrier, Nicola Jane; Udell, Tuesday MelissaThis study explored children's views about food advertising on television in the light of recent public interest in childhood obesity and obesogenic environments. Thirty-seven children, aged between 8 and 11 years, discussed their perceptions of food advertising in focus groups. The children engaged as consumers of advertising, noticing technical aspects, and expressing their likes and dislikes of particular techniques. While they understood the persuasive intent of advertising, they nevertheless desired products and made purchase requests. They particularly desired energy-dense nutrient-poor foods. The children demonstrated sophisticated levels of advertising literacy through their articulation of problems such as deception, impacts on children's health and wellbeing, and family conflict. They revealed themselves as sentient beings, with the capacity to react, respond and reflect on their experience of advertising. This study makes a contribution to research on consumer socialisation by introducing the perspective of Australian children. As stakeholders in the childhood obesity problem, the views of children should also be of interest to health policymakers. ItemBarriers and enablers to optimal consumer involvement in research: the perspectives of health and medical researchers in the UK(Health Issues Centre, 2011) Ward, Paul RussellNumerous reasons exist for involving consumers in research, falling mainly into three categories: moral/ethical, methodological, and political. The moral and ethical reasons for involving consumers in research centre on concepts of rights, citizenship and democracy, specifically related to publicly funded research whereby the word ‘consumer’ is seen as a synonym for ‘taxpayer’. The methodological reasons focus on the potential benefits that consumer involvement may have on the research process, including increasing its relevance, credibility, dissemination and transferability of research findings. The political imperative is centred on current policy directives in addition to requirements by research funding agencies, research governance organisations, and research ethics committees (RECs). ItemBarriers to HIV testing among male clients of female sex workers in Indonesia(BioMed Central, 2018-05-30) Fauk, Nelsensius Klau; Sukmawati, Anastasia S; Berek, Pius A L; Ernawati; Kristanti, Elisabeth; Wardojo, Sri S I; Cahaya, Isaias B; Mwanri, LillianAbstract Background Frequent engagement of men in sexual encounters with female sex workers (FSWs) without using condoms places them at a high risk for HIV infection. HIV testing has been noted to be among important strategies to prevent HIV transmission and acquisition. However, it is known that not all men willingly undertake an HIV test as a way to prevent HIV transmission and/or acquisition. This study aimed to identify barriers to accessing HIV testing services among men who are clients of FSWs (clients) in Belu and Malaka districts, Indonesia. Methods A qualitative inquiry employing face to face open ended interviews was conducted from January to April 2017. The participants (n = 42) were clients of FSWs recruited using purposive and snowball sampling techniques. Data were analysed using a qualitative data analysis framework. Results Findings indicated three main barriers of accessing HIV testing services by clients. These included: (1) personal barriers (lack of knowledge of HIV/AIDS and HIV testing availability, and unwillingness to undergo HIV testing due to low self-perceived risk of HIV and fear of the test result); (2) health care service provision barriers (lack of trust in health professionals and limited availability of medication including antiretroviral (ARV)); and (3) social barriers (stigma and discrimination, and the lack of social supports). Conclusions These findings indicated multilevelled barriers to accessing HIV testing services among participants, who are known to be among key population groups in HIV care. Actions to improve HIV/AIDS-related health services accessibility are required. The dissemination of the knowledge and information on HIV/AIDS and improved available of HIV/AIDS-related services are necessary actions to improve the personal levelled barriers. System wide barriers will need improved practices and health policies to provide patients friendly and accessible services. The societal levelled barriers will need a more broad societal approach including raising awareness in the community and enhanced discussions about HIV/AIDS issues in order to normalise HIV in the society. ItemBurden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990–2015: findings from the Global Burden of Disease Study 2015(BioMed Central, 2018-04-25) Melaku, Yohannes Adama; Wassie, Molla Mesele; Gill, Tiffany; Zhou, Shao J; Tessema, Gizachew Assefa; Amare, Azmeraw T; Lakew, Yihunie; Hiruye, Abiy; Bekele, Tesfaye Hailu; Worku, Amare; Seid, Oumer; Endris, Kedir; Lemma, Ferew; Tesfay, Fisaha Haile; Yirsaw, Biruck Desalegn; Deribe, Kebede; Adams, Robert J; Shi, Zumin; Misganaw, Awoke; Deribew, AmareAbstract Background Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries. Methods Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models. Results In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653–76,020] or 8.9% [95% UI: 6.1–12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367–106,512] or 9.7% [95% UI: 7.4–12.3] to dietary risks, 105,057 [95% UI: 66,167–157,071] or 15.4% [95% UI: 12.8–17.6] to metabolic risks and 5808 [95% UI: 3449–9359] or 0.9% [95% UI: 0.6–1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8–13.3] to 14.5% [95% UI: 11.7–18.0] for dietary risks and from 17.0% [95% UI: 15.4–18.7] to 24.2% [95% UI: 22.2–26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks. Conclusions In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country. ItemA case for reorienting health systems and investing in primary health care in Australia(Australasian Medical Journal, 2009) Ward, Paul RussellIn recent times, many developing countries have been going through a process of re-orienting health policy and services towards early detection and prevention, rather than solely on the treatment and on-going management, of illness and disease. For example, in the UK, the fundamental philosophy underpinning the approach to funding primary healthcare is analogous to the adage ‘prevention is better than cure’, with the NHS Improvement Plan stating that “If England is to secure world-class standards of health, the enormous human, financial and physical resources available to the NHS need to be focussed on the prevention of disease and not just its treatment”. Within Australia, there are similar shifts in thinking and policy, with the development of the National Preventative Health Taskforce, which has been tasked with developing a National Preventative Health Strategy. ItemCharitable food systems’ capacity to address food Insecurity: an Australian capital city audit(MDPI, 2018-06-12) Pollard, Christina M; Mackintosh, Bruce; Campbell, Cathy; Kerr, Deborah A; Begley, Andrea; Jancey, Jonine; Caraher, Martin; Berg, Joel; Booth, SueAustralian efforts to address food insecurity are delivered by a charitable food system (CFS) which fails to meet demand. The scope and nature of the CFS is unknown. This study audits the organisational capacity of the CFS within the 10.9 square kilometres of inner-city Perth, Western Australia. A desktop analysis of services and 12 face-to-face interviews with representatives from CFS organisations was conducted. All CFS organisations were not-for–profit and guided by humanitarian or faith-based values. The CFS comprised three indirect services (IS) sourcing, banking and/or distributing food to 15 direct services (DS) providing food to recipients. DS offered 30 different food services at 34 locations feeding over 5670 people/week via 16 models including mobile and seated meals, food parcels, supermarket vouchers, and food pantries. Volunteer to paid staff ratios were 33:1 (DS) and 19:1 (IS). System-wide, food was mainly donated and most funding was philanthropic. Only three organisations received government funds. No organisation had a nutrition policy. The organisational capacity of the CFS was precarious due to unreliable, insufficient and inappropriate financial, human and food resources and structures. System-wide reforms are needed to ensure adequate and appropriate food relief for Australians experiencing food insecurity. ItemCholinesterase research outreach project (CROP): point of care cholinesterase measurement in an Australian agricultural community(BioMed Central, 2018-04-02) Cotton, Jacqueline; Edwards, John William; Rahman, Muhammad Aziz; Brumby, Susan AAbstract Background Australian farmers are routinely exposed to a wide variety of agrichemicals, including herbicides and insecticides. Organophosphate (OP) insecticides are widely used for agricultural production, horticulture and animal husbandry practices. Symptoms of OP toxicity are the results of inhibition of the enzyme acetylcholinesterase (AChE) which is found in many types of conducting tissue in human bodies such as nerve and muscle, central and peripheral tissues, motor and sensory fibres. Cholinesterase can be measured in red blood cells/erythrocytes (AChE) and plasma (PChE). This study aims to explore integration of AChE monitoring into routine health checks for those at risk and also to examine any association between AChE activity and agrichemical use in a Victorian farming community in Australia. Methods This was a prospective cohort study, where farmers and non-famers were compared on the levels of AChE at four time points of baseline, 3–4 weeks, 6-weeks and at 9-weeks. Study participants (N = 55) were residents from South West Victoria, aged between 18 and 75 years, spoke English, and had not had a previous known acute chemical accident. A total of 41 farming (had been farming for more than 5 years) and a convenience sample of 14 non-farming individuals met the inclusion criteria. Testing of AChE was repeated for all participants with a maximum of three times over 10 weeks. Results The integration of AChE monitoring was very well accepted by all participants. There was no significant difference in average AChE activity between farming and non-farming participants (one-way ANOVA p > 0.05) in this study. There was no significant difference between personal use of agricultural chemicals on farm and the levels of AChE at baseline (measurement 1) or any of the follow up periods (p > 0.05). However, the mean activity of AChE was significantly lower within follow up periods [F (2.633, 139.539) = 14.967, p < 0.001]. There was a significant reduction of AChE between the follow up at 3-weeks and 6-weeks period (p = 0.015). Conclusions The routine monitoring of AChE may allow for early recognition of chronic low-level exposure to OPs when they are used by farmers, provided a reasonable estimate of baseline AChE is available. This work provides an evidence for recommending the integration of AChE monitoring into point of care (POC) procedures in rural health clinics and quantifying pesticide exposure and personal protection both on the farm and in the home. Farmer engagement is crucial to the successful integration of AChE monitoring into rural health clinics in Australia. Trial registration ACTRN12613001256763 . ItemColorectal cancer screening in rural and remote areas: analysis of the National Bowel Cancer Screening Program data for South Australia.(James Cook University, 2011) Martini, Angelita; Javanparast, Sara; Ward, Paul Russell; Baratiny, Genevieve; Gill, Tiffany; Cole, Stephen Russell; Tsourtos, George; Aylward, Philip Edmund; Jiwa, Moyez; Misan, Gary; Wilson, Carlene J; Young, Graeme PaulIn Australia, colorectal cancer is the second most commonly diagnosed cancer and cause of death from malignant diseases, and its incidence is rising. The aim of this article was to present an analysis of National Bowel Cancer Screening Program (NBCSP) data for rural and remote South Australia (SA), in order to identify geographical areas and population groups that may benefit from targeted approaches to increase participation rates in colorectal cancer screening.The findings of this study suggest lower NBCSP participation rates for people from metropolitan and remote areas, compared with those from rural areas. The uptake of cancer screening is lower for older rural and remote residents, men, Indigenous people, lower socioeconomic groups and those living in the Far North subdivision of SA. ItemComparative examination of trust during times of a food scandal in Europe and Australia(Scientific & Academic Publishing, 2012) Coveney, John David; Mamerow, Loreen; Taylor, Anne; Henderson, Julie Anne; Meyer, Samantha B; Ward, Paul RussellThis study compared public confidence in truth-telling by food chain actors in selected EU countries where there have been a number of food safety problems, with consumers in Australia where there have been fewer food crises. A computer-assisted telephone interviewing survey was used to address aspects of truth-telling at times of a food scandal with a random sample of 1109 participants across all Australian states (response rate 41.2%). Results were compared with a survey in six EU countries which had asked similar questions. Australians' trust in truth-telling by food chain actors was low, with 14.2% of the sample expecting various institutions and individuals to tell the whole truth during times of a food scandal. When compared with EU countries, Australia occupied a middle position in trust distribution, and was more similar to Great Britain in giving farmers the most trust in truth-telling. This study has demonstrated that in Australia, as in many EU countries, trust in truth-telling at a time of food scandal is low. The credibility of the food system is highly vulnerable under times of food crisis and once trust in broken, it is difficult to restore. ItemComparison of measures of comorbidity for predicting disability 12-months post-injury(BioMed Central Ltd., 2013-01-26) Gabbe, Belinda J; Harrison, James Edward; Lyons, Ronan; Edwards, Elton R; Cameron, Peter A; Victorian Orthopaedic Trauma Outcomes RegistryUnderstanding the factors that impact on disability is necessary to inform trauma care and enable adequate risk adjustment for benchmarking and monitoring. A key consideration is how to adjust for pre-existing conditions when assessing injury outcomes, and whether the inclusion of comorbidity is needed in addition to adjustment for age. This study compared different approaches to modelling the impact of comorbidity, collected as part of the routine hospital episode data, on disability outcomes following orthopaedic injury. ItemCompetence of health workers in emergency obstetric care: an assessment using clinical vignettes in Brong Ahafo region, Ghana(BMJ Publishing Group, 2016-06) Lohela, T J; Nesbitt, R C; Manu, A; Vesel, L; Okyere, Eunice; Kirkwood, B; Gabrysch, SObjectives: To assess health worker competence in emergency obstetric care using clinical vignettes, to link competence to availability of infrastructure in facilities, and to average annual delivery workload in facilities. Design: Cross-sectional Health Facility Assessment linked to population-based surveillance data. Setting: 7 districts in Brong Ahafo region, Ghana. Participants: Most experienced delivery care providers in all 64 delivery facilities in the 7 districts. Primary outcome measures: Health worker competence in clinical vignette actions by cadre of delivery care provider and by type of facility. Competence was also compared with availability of relevant drugs and equipment, and to average annual workload per skilled birth attendant. Results: Vignette scores were moderate overall, and differed significantly by respondent cadre ranging from a median of 70% correct among doctors, via 55% among midwives, to 25% among other cadres such as health assistants and health extension workers ( p<0.001). Competence varied significantly by facility type: hospital respondents, who were mainly doctors and midwives, achieved highest scores (70% correct) and clinic respondents scored lowest (45% correct). There was a lack of inexpensive key drugs and equipment to carry out vignette actions, and more often, lack of competence to use available items in clinical situations. The average annual workload was very unevenly distributed among facilities, ranging from 0 to 184 deliveries per skilled birth attendant, with higher workload associated with higher vignette scores. Conclusions: Lack of competence might limit clinical practice even more than lack of relevant drugs and equipment. Cadres other than midwives and doctors might not be able to diagnose and manage delivery complications. Checking clinical competence through vignettes in addition to checklist items could contribute to a more comprehensive approach to evaluate quality of care. Trial registration number: NCT00623337. ItemComplex problems require complex solutions: the utility of social quality theory for addressing the Social Determinants of Health(BioMed Central Ltd., 2011) Ward, Paul Russell; Meyer, Samantha B; Verity, Fiona Elizabeth; Gill, Tiffany; Luong, Tini C NIn order to improve the health of the most vulnerable groups in society, the WHO Commission on Social Determinants of Health (CSDH) called for multi-sectoral action, which requires research and policy on the multiple and inter-linking factors shaping health outcomes. Most conceptual tools available to researchers tend to focus on singular and specific social determinants of health (SDH) (e.g. social capital, empowerment, social inclusion). However, a new and innovative conceptual framework, known as social quality theory, facilitates a more complex and complete understanding of the SDH, with its focus on four domains: social cohesion, social inclusion, social empowerment and socioeconomic security, all within the same conceptual framework. This paper provides both an overview of social quality theory in addition to findings from a national survey of social quality in Australia, as a means of demonstrating the operation of the theory.