Mac MacLachlanProfessor of Global Health

Trinity College Dublin

We specialise in multi-country comparative

interdisciplinary research seeking to strengthen health systems &

ensure equitable access, for all.

http://global-health.tcd.ie

CENTRE FOR GLOBAL HEALTH

Overview

• 1. Linking Maritime & Global Health• 2. Demand – greater inclusion in global health• 3. Supply – new models in global health• 4. Demand & Supply – psychosocial problems• 5. Being more Positive - Wellbeing &

Performance

1. Linking Maritime & Global Health

What is Maritime Medicine?

• Aksel Schreiner in Preface to • Textbook of Maritime Medicine• “…concerning the employment, working

conditions, living conditions, health and safety of workers at sea”

• Strong ‘occupational medicine’ ethos

MacLachlan, Kavanagh, & Kay (2012)Maritime Health: a review with suggestions for research.

International Maritime Health, 63, 1-6.

What is global health?Koplan et al Lancet,2009

• “global health … places a priority on improving health and achieving equity in health for all people worldwide. Global health emphasises transnational health issues, determinants, and solutions; involves many disciplines within and beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of population based prevention with individual-level clinical care”

• Doesn’t have much of an ‘occupational health’ focus

The Millenium Development Goals MDGs – up to 2015

• Now, frantic discussions and lobbying on the Post 2015 Agenda – the “Sustainable Development Goals”

• More ‘one world’ than ‘developing world’• More focus on inclusion – “leave no-one

behind” – inclusive health - WHO• More focus on “decent work” – ILO• More in common with maritime health

2. Demand – greater inclusion in global health

• The MDGs have been successful at targeting the mainstream – e.g. maternal & infant death; HIV, TB & Malaria

• WE KNOW WHAT WORKS– The lower hanging ‘fruit’

• FOR THOSE WITH EASY ACCESS

• Less successful in reaching the most disadvantaged and marginalised – who have proportionately much greater health problems.

• Vulnerable groups – E.g. people with disabilities, ethnic minorities, single-headed

households,……people living away from services.

3. Supply – new models in global health• WHILE WE KNOW WHAT WORKS,

WE DON’T KNOW HOW TO DO IT• One Example of a ‘new model’ : Alternative cadre

– Research now provide strong evidence for the clinical efficacy (Chilopora et al., 2007; Pereira et al., 2007; McCord et al, 2009) and economic value (Kruk, Pereira, Vaz, Bergstrom, & Galea, 2007) of mid-level cadres, particularly in the provision of emergency obstetric care.

• People with much less lengthy training can provide services effectively– Supporting, supervising, motivating alternative cadre in remote

locations – eHealth/mHealth.• WHO recommendations re global rehabilitation work force.

4. New supply models of psychosocial health

• Modes of delivering psychological treatment (therapy/counselling) for e.g. depression/anxiety:– 1. Face-to-face, with a therapist– 2. Over the internet, with a therapist– 3. With a computer (with a therapy programme)

• Which works best?

Richards et al (2012): A comparison of two online cognitive-behavioural interventions for symptoms of depression in a student population: The role of therapist responsiveness.

Counselling and Psychotherapy Research

• cCBT = eCBT• Computerised (self-administered CBT)• E-mail (therapists administered CBT)• 32 week follow-up.

Andersson et al 2013 Journal of Affective Disorders

Clinical Psychology Review, 2012

• They work• Supported interventions yielded better

outcomes, along with greater retention. • The review and meta analysis support the

efficacy and effectiveness of computer-based psychological treatments for depression, in diverse settings and with different populations.

Wagner et al (2013) Internet-based versus face-to-face cognitive-behavioural intervention for

depression: A randomized controlled non-inferiority trial.Journal of Affective Disorders

• An 8 week intervention in both cases • Patients in both groups received the same treatment

modules in the same chronological order and time-frame.

• Results: The intention-to-treat analysis yielded no significant between-group difference (online vs. face-to-face group) for any of the pre-to post-treatment measurements.

• At post-treatment both treatment conditions revealed significant symptom changes compared to before the intervention.

• However ….

5. Being More Positive

• So, computer or internet mediated psychological interventions have a significant beneficial effect on reducing psychological problems.

• These interventions could certainly be used in the maritime context.

• But is more possible?

Positive Psychology

• Not just treating or preventing problems, but facilitating well-being and enhancing performance.

• Simple things, make a dramatic difference:– e.g. “3 good things”

• Is there potential for positive psychology interventions to facilitate work and wellbeing at sea?

• Coaching/Career development/Support …..• Ships are natural laboratories – floating RCTs!

And so…• In global health

– Demand factors – globally – are reaching towards more marginalised groups.

– Supply factors – globally – are incorporating new models of delivery (and challenging ‘professions’)

• In maritime health– the enveloping of health and work and living provide a unique

environment to create a positive approach to health & performance at sea.

• We would welcome the opportunity to explore possibilities in this area.

Thank You!

• malcolm.maclachlan@tcd.ie

Abstract• Equity in healthcare has become a clarion call for health policy globally.

Such equity requires that those margainalised by distinctive challenges are able to access healthcare appropriate to their needs. This challenge extends to a number of quite different contexts. Research on how best to provide healthcare in these contexts has provided some useful and perhaps surprising insights which are relevant to the challenge of promoting health in remote locations. We consider demand (Who is most likely to need health care?) and supply (How can health care best be provided with scarce resources?) factors in several resource-poor settings. We also consider ‘improvement’ factors (How can health, well-being and performance be enhanced though systems intended largely to manage illness?). Maritime health presents global health with opportunities to develop its scope not only to remote occupational environments but also to engage with a more ‘positive psychology’ ethos that can promote well being.