Testing relationships among determinants of health, health policy, and self-assessed health status in Quebec.

By removing financial barriers, the Canada Health Act (1984) equalized access to health care services in Canada. Yet class, educational, and geographical disparities in individual and population health status persist. Recent health reform policies in Quebec assert that health and well-being are a function of income, educational level, housing conditions, employment, and other socioeconomic factors. They suggest that health policy should encompass social policies that influence individual and community socioeconomic factors which in turn affect health. Against the backdrop of these reforms, this study tests the importance of socioeconomic factors as a determinant of health--while controlling for other known determinants through a logistic regression model--with data from the Santé Quebec health surveys 1987 and 1992-93. The results confirm the importance of economic security as a determinant of individual health. This effect appears to operate through an individual income variable and through the community-level variable of regional unemployment. The importance of the income effect declined between 1987 and 1992-93. This may indicate that an increased focus on the socioeconomic determinants of health has reduced inequalities in health. It may also mean that health inequalities appear inevitable until health care policy merges completely with broader health and social policies. But such integration may well conflict with economic (and political) imperatives of the post-Fordist capitalist system.     

Integrated decision-making about housing,energy and wellbeing: a qualitative system dynamics model

Background

The UK government has an ambitious goal to reduce carbon emissions from the housing stock through energy efficiency improvements. This single policy goal is a strong driver for change in the housing system, but comes with positive and negative “unintended consequences” across a broad range of outcomes for health, equity and environmental sustainability. The resulting policies are also already experiencing under-performance through a failure to consider housing as a complex system.This research aimed to move from considering disparate objectives of housing policies in isolation to mapping the links between environmental, economic, social and health outcomes as a complex system. We aimed to support a broad range of housing policy stakeholders to improve their understanding of housing as a complex system through a collaborative learning process.

Methods

We used participatory system dynamics modelling to develop a qualitative causal theory linking housing, energy and wellbeing. Qualitative interviews were followed by two interactive workshops to develop the model, involving representatives from national and local government, housing industries, non-government organisations, communities and academia.

Results

More than 50 stakeholders from 37 organisations participated. The process resulted in a shared understanding of wellbeing as it relates to housing; an agreed set of criteria against which to assess to future policy options; and a comprehensive set of causal loop diagrams describing the housing, energy and wellbeing system. The causal loop diagrams cover seven interconnected themes: community connection and quality of neighbourhoods; energy efficiency and climate change; fuel poverty and indoor temperature; household crowding; housing affordability; land ownership, value and development patterns; and ventilation and indoor air pollution.

Conclusions

The collaborative learning process and the model have been useful for shifting the thinking of a wide range of housing stakeholders towards a more integrated approach to housing. The qualitative model has begun to improve the assessment of future policy options across a broad range of outcomes. Future work is needed to validate the model and increase its utility through computer simulation incorporating best quality data and evidence. Combining system dynamics modelling with other methods for weighing up policy options, as well as methods to support shifts in the conceptual frameworks underpinning policy, will be necessary to achieve shared housing goals across physical, mental, environmental, economic and social wellbeing.

     

Partnerships among community development, public health, and health care could improve the well-being of low-income people

Safe, vibrant neighborhoods are vital to health. The community development "industry"-a network of nonprofit service providers, real estate developers, financial institutions, foundations, and government-draws on public subsidies and other financing to transform impoverished neighborhoods into better-functioning communities. Although such activity positively affects the "upstream" causes of poor health, the community development industry rarely collaborates with the health sector or even considers health effects in its work. Examples of initiatives-such as the creation of affordable housing that avoids nursing home placement-suggest a strong potential for cross-sector collaborations to reduce health disparities and slow the growth of health care spending, while at the same time improving economic and social well-being in America's most disadvantaged communities. We propose a four-point plan to help ensure that these collaborations achieve positive outcomes and sustainable progress for residents and investors alike.     

People, partnerships and human progress: building community capital

The Victorian-era journal The Sanitarian used on its masthead the slogan 'A nation's health is a nation's wealth'. Today, we are re-discovering that wisdom, recognizing that health is indeed a form of wealth. Moreover, we are beginning to understand that wealth is not merely our economic capital, but includes three other forms of capital--social, natural and human capital. Health is one key element of human capital. A healthy community is one that has high levels of social, ecological, human and economic 'capital', the combination of which may be thought of as 'community capital'. The challenge for communities in the 21st century will be to increase all four forms of capital simultaneously. This means working with suitable partners in the private sector, making human development the central purpose of governance, and more closely integrating social, environmental and economic policy. Community gardens, sustainable transportation systems and energy conservation programmes in community housing projects are some of the ways in which we can build community capital.     

Rapid health impact appraisal of eviction versus a housing project in a colony-dwelling Roma community

BACKGROUND: During implementation of a community development project involving a severely disadvantaged Roma community, the community was threatened with eviction. Two scenarios, eviction with placement on the waiting list for social housing versus a replacement housing development, were identified and specified. A health impact assessment (HIA) was carried out to inform subsequent negotiations. AIMS: To assess the health effects of eviction in comparison with that of a housing project for a Roma community; to make recommendations on short-term and long-term benefits of the two scenarios in order to inform the local government; and to develop a demonstration HIA that can act as a model for other disadvantaged Roma populations. METHOD: A prospective assessment, based on a broad model of health, was carried out to assess health effects of a housing project compared with eviction. By design, it ensured full involvement of members of the community, local decision makers and relevant stakeholders. RESULTS AND CONCLUSION: This HIA identified numerous positive and some probable negative health effects of a housing project. Despite the uncertainty around some of its predicted effects, the overall health benefit of a housing project clearly outweighed that of eviction. Although the immediate financial advantages of eviction for the municipal government are clear, this example provides further evidence to support the adoption of a statutory requirement to assess both economic and health outcomes. It also provides an example that other Roma communities can emulate.     

A review of UK housing policy: ideology and public health

OBJECTIVES: The aim of this paper is to review UK public health policy, with a specific reference to housing as a key health determinant, since its inception in the Victorian era to contemporary times. REVIEW: This paper reviews the role of social and private housing policy in the development of the UK public health movement, tracing its initial medical routes through to the current socio-economic model of public health. The paper establishes five distinct ideologically and philosophically driven eras, placing public health and housing within liberal (Victorian era), state interventionist (post World War 1; post World War 2), neoliberal (post 1979) and "Third Way" (post 1997) models, showing the political perspective of policy interventions and overviewing their impact on public health. The paper particularly focuses on the contemporary model of public health since the Acheson Report, and how its recommendations have found their way into policy, also the impact on housing practice. CONCLUSIONS: Public health is closely related to political ideology, whether driven by the State, individual or partnership arrangements. The current political system, the Third Way, seeks to promote a sustainable "social contract" between citizens and the State, public, private and voluntary organizations in delivering community-based change in areas where health inequalities can be most progressively and successfully addressed.     

Housing as an instrument of health care

Housing is a key instrument of health care. This was recognized long ago when the Victorians introduced public health measures to tackle unhealthy city slums. The links between housing and health have since been forgotten by some people, as general housing standards have improved and housing has developed as a separate area of public policy. This paper attempts to show that in the late twentieth century housing is still a fundamental factor in determining health. A number of policy issues now point to the need to rebuild the links between housing and health: evidence of persistent inequalities in health, a recognition that those with the poorest health still live in the worst housing, and the new care in the community policy which demands closer working relationships between agencies. The current political and economic climate does not encourage or foster links between services. The government's approach to health focuses on personal behaviour rather than environmental factors as determinants of health, there is a rift between entrenched professional interest groups which provides no incentive for cooperation, and there is a lack of research which demonstrates clear financial and service benefits from coordinating housing and health planning and provision. However, a renewed concern for public health is becoming more prominent (which recognizes the fundamental links between environment and health). This paper argues that housing is a key factor in individual, and hence public health, and should therefore play a more central role in this debate. The challenge now is to gain wider recognition of the essential policy and financial links between housing and health-care services. This involves clearly identifying exactly what aspects of housing are important for health and in what way, including housing issues in health and public health concerns at all levels, and suggesting priorities for policy makers. It must be demonstrated that expenditure on housing is still an effective way of achieving improvements in health. Housing is an enduring instrument of health care.     

Spatial Modeling and Analysis of Heat-Related Morbidity in Maricopa County,Arizona

The objective of the present study was to examine the effects of a confluence of demographic, socioeconomic, housing, and environmental factors that systematically contribute to heat-related morbidity in Maricopa County, Arizona, from theoretical, empirical, and spatial perspectives. The present study utilized ordinary least squares (OLS) regression and multiscale geographically weighted regression (MGWR) to analyze health data, U.S. census data, and remotely sensed data. The results suggested that the MGWR model showed a significant improvement in goodness of fit over the OLS regression model, which implies that spatial heterogeneity is an essential factor that influences the relationship between these factors. Populations of people aged 65+, Hispanic people, disabled people, people who do not own vehicles, and housing occupancy rate have much stronger local effects than other variables. These findings can be used to inform and educate local residents, communities, stakeholders, city managers, and urban planners in their ongoing and extensive efforts to mitigate the negative impacts of extreme heat on human health in Maricopa County.     

Linking public health, housing, and indoor environmental policy: successes and challenges at local and federal agencies in the United States

We describe the successes and challenges faced by federal and local government agencies in the United States as they have attempted in recent years to connect public and environmental health, housing, community development, and building design with environmental, housing, and building laws, codes, and policies. These policies can either contribute to or adversely affect human physical and mental health, with important implications for economic viability, research, policy development, and overall social stability and progress. Policy impediments include tension between housing affordability and health investment that causes inefficient cost-shifting, privacy issues, unclear statutory authority, and resulting gaps in responsibility for housing, indoor air, and the built environment. We contrast this with other environmental frameworks such as ambient air and water quality statutes where the concept of "shared commons" and the "polluter pays" is more robust. The U.S. experiences in childhood lead poisoning prevention, indoor air, and mold provide useful policy insights. Local programs can effectively build healthy homes capacity through local laws and housing codes. The experience of coordinating remediation for mold, asthma triggers, weatherization, and other healthy housing improvements in Cuyahoga County, Ohio, is highlighted. The U.S. experience shows that policymakers should adopt a prevention-oriented, comprehensive multi-disciplinary approach at all levels of government to prevent unhealthy buildings, houses, and communities.     

Housing, income support and mental health: Points of disconnection

There exists a disconnection between evolving policies in the policy arenas of mental health, housing, and income support in Canada. One of the complexities associated with analysing the intersection of these policies is that federal, provincial, and municipal level policies are involved. Canada is one of the few developed countries without a national mental health policy and because of the federal policy reforms of the 1970s, the provincial governments now oversee the process of deinstitutionalization from the hospital to the community level. During this same period the availability of affordable housing has decreased as responsibility for social housing has been transfered from the federal government to the provincial and/or municipal levels of government. Canada also stands alone in terms of being a developed nation without national housing policy instead what is considered "affordable" housing is partially dependant upon individuals' personal economic resources. As well, over the past decade rates of income supports have also been reduced. Psychiatric survivors have long been identified as being at risk for homelessness, with the disconnection existing between housing, income and mental health policies and the lack of a national policy in any of these policies areas further contributing to this risk.     

Housing,health and master planning: rules of engagement

Objectives

Knowledge about health focussed policy collaboration to date has been either tactical or technical. This article focusses on both technical and tactical issues to describe the experience of cross-sectoral collaboration between health and housing stakeholders across the life of a housing master plan, including but not limited to a health impact assessment (HIA).

Study design

A single explanatory case study of collaboration on a master plan to regenerate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work.

Methods

Data collection included stakeholder interviews, document review, and reflections by the health team. Following a realist approach, data was analysed against established public policy theory dimensions.

Results

Tactically we did not know what we were doing. Despite our technical knowledge and skills with health focussed processes, particularly HIA, we failed to appreciate complexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration.

Conclusions

This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted.     

Science-based health innovation in Uganda: creative strategies for applying research to development

Background

Uganda has a long history of health research, but still faces critical health problems. It has made a number of recent moves towards building science and technology capacity which could have an impact on local health, if innovation can be fostered and harnessed.

Methods

Qualitative case study research methodology was used. Data were collected through reviews of academic literature and policy documents and through open-ended, face-to-face interviews with 30 people from across the science-based health innovation system, including government officials, researchers in research institutes and universities, entrepreneurs, international donors, and non-governmental organization representatives.

Results

Uganda has a range of institutions influencing science-based health innovation, with varying degrees of success. However, the country still lacks a coherent mechanism for effectively coordinating STI policy among all the stakeholders. Classified as a least developed country, Uganda has opted for exemptions from the TRIPS intellectual property protection regime that include permitting parallel importation and providing for compulsory licenses for pharmaceuticals. Uganda is unique in Africa in taking part in the Millennium Science Initiative (MSI), an ambitious though early-stage $30m project, funded jointly by the World Bank and Government of Uganda, to build science capacity and encourage entrepreneurship through funding industry-research collaboration. Two universities – Makerere and Mbarara – stand out in terms of health research, though as yet technology development and commercialization is weak. Uganda has several incubators which are producing low-tech products, and is beginning to move into higher-tech ones like diagnostics. Its pharmaceutical industry has started to create partnerships which encourage innovation.

Conclusions

Science-based health product innovation is in its early stages in Uganda, as are policies for guiding its development. Nevertheless, there is political will for the development of STI in Uganda, demonstrated through personal initiatives of the President and the government’s willingness to invest heavily for the long term in support of STI through the Millennium Science Initiative. Activities to support technology transfer and private-public collaboration have been put in motion; these need to be monitored, coordinated, and learned from. In the private sector, there are examples of incremental innovation to address neglected diseases driven by entrepreneurial individuals and South-South collaboration. Lessons can be learned from their experience that will help support Ugandan health innovation.

     

The community action model: a community-driven model designed to address disparities in health

The community action model is a 5-step, community-driven model designed to build communities' capacity to address health disparities through mobilization. Fundamental to the model is a critical analysis identifying the underlying social, economic, and environmental forces that create health and social inequities in a community. The goal is to provide communities with the framework necessary to acquire the skills and resources to plan, implement, and evaluate health-related actions and policies. The model was developed in the context of tobacco-related health disparities. Concrete policy outcomes demonstrate the model's potential application to a wide variety of grassroots policy development efforts.     

我国部分地区健康服务业发展经验与启示

为了总结部分地区健康服务业发展经验,探索健康服务业发展模式,本研究通过比较上海、杭州、青岛、深圳四地健康服务业的发展规划及现状,总结它们的发展思路与经验:上海、杭州、青岛、深圳四地健康服务业的发展水平相对较高的原因在于规划科学,政策到位。鉴于此,提出发展健康服务业要因地制宜、产业集群化的建议。同时,政策扶持和商业健康保险协调发展也不可或缺。     

El impacto de la crisis en la relación entre vivienda y salud. Políticas de buenas prácticas para reducir las desigualdades en salud asociadas con las condiciones de vivienda

Housing conditions can impact on physical and mental health through 4 interrelated dimensions: 1) the home (the emotional housing conditions), 2) the physical housing conditions, and 3) the physical environment, and 4) the social (community) environment of the neighborhood where the house is located. In Spain, the use of the construction market as an engine for economic growth and the promotion of private property as the main type of housing tenure has led to the use of housing as a speculative good instead of its being considered a first-necessity good. While Spain is the Organisation for Economic Co-operation and Development (OECD) country with the largest housing stock per inhabitant, this stock is highly underutilized, thus excluding the most deprived sector of the population from access to housing. The impact of the current economic crisis on housing has mainly been due to a reduction in household income, which has increased the number of families or persons struggling to cover their housing costs or being evicted. Evidence indicates that this type of problem has a negative impact on health, especially on mental health, but financial problems also make it difficult to meet other basic needs such as eating. There are several instruments to reduce the impact of the economic crisis, such as debt financing or deed of assignment in payment. In the long-term, the creation of a social housing stock should be promoted, as well as rental assistance mechanisms.     

Which incentive package will retain regionalized health personnel in Burkina Faso: a discrete choice experiment

Background

The lack of motivation of health workers to practice in rural areas remains a crucial problem for decision-makers, as it deprives the majority of access to health care. To solve the problem, many countries have implemented health worker retention strategies. However, the development of such strategies requires an understanding of the preferences of health workers. The objective of the study was to identify a package for attracting and retaining health workers in underserved areas.

Methods

A cross sectional study was conducted in three health regions of Burkina Faso in 2012. A discrete choice experiment was used to investigate preferences for incentive packages among health workers recruited under the regionalized policy. In-depth interviews and focus group discussions with health workers currently working in the East and Sahel regions and policy makers, and a literature review on attraction and retention in low income countries, were performed to identify the attributes and levels. These attributes were: the regionalized recruitment policy, health insurance, work equipment, housing, and specific incentive compensation. The final design resulted in 16 choice sets. A multinomial logistic regression was used to determine the influence of socio-demographic characteristics on choice of a given option. A probit logistic regression model was then used to analyze the effect of these difference variables on choice, to identify the incentive package best suited to health workers. In total, questionnaires were administered to 315 regional health workers.

Results

For all participants, choice of package was strongly influenced by length of commitment under the policy and provision of housing. Sex, number of years in profession, and location also influenced the choice of package. Women are twice more likely to choose a package with free housing and the cancellation of the policy.

Conclusion

It is important that governments consider health worker preferences in crafting policies to address attraction and retention in underserved areas. In addition, the methodology of discrete choice experiment has been particularly useful, not only for better understanding the factors explaining the reluctance of health workers to work in underserved areas, but also to provide practical advice to the government, to improve its retention policy.

     

The health status of HOPE VI public housing residents

The purpose of this study is to provide new data on the relationship between housing quality and health status for people in five HOPE VI public housing developments around the country. HOPE VI is a federal program to replace or redevelop some of the poorest quality public housing in the country. A special survey of residents of these developments was conducted while they lived in HOPE VI housing before its redevelopment. Data for these individuals provides a profile of the quality of housing and the health status of people in HOPE VI housing before its renovation, of residents of publicly assisted housing across the nation, of other people living below the federal poverty level, and of non-poor people. Previously, the lack of data sets that included both housing quality and health status measures has prevented such an analysis. We examined two indicators of health status-perceived overall health status and medically diagnosed asthma. The health status of HOPE VI residents is decidedly worse than that of others in assisted housing and other poor people, despite their similarity in terms of economic deprivation. The difference in the level of asthma prevalence, a condition that has been tied to various measures of housing quality, is especially pronounced. Our analysis indicates that one major benefit of improving housing quality may be improved health status.     

Perceptions on use of sulfadoxine-pyrimethamine in pregnancy and the policy implications for malaria control in Uganda

In malaria endemic areas intermittent treatment with sulfadoxine-pyrimethamine (SP) is recommended for malaria prevention in pregnancy. Yet, data on perceptions regarding use of this drug are scarce. An exploratory study was conducted to assess perceptions on SP in Mukono district, Uganda. This is an initial step towards a review of the policy aimed at improving access and use of SP in pregnancy, which is currently low. Results show that SP is perceived to be an effective drug that cures malaria quickly. However there are negative perceptions related to its use in pregnancy. SP is believed to be strong and weakens pregnant women, causes abortions and foetal abnormalities. There is also a perception that resorting first to SP for malaria treatment may lead to the development of drug resistance. This perception may limit access to effective treatment of malaria in this community since the policy in Uganda recommends SP in combination with chloroquine as the first-line treatment. The policy implications of these findings include developing a health promotion package to demystify the misconceptions on the strength of SP, to explain its benefits and side-effects. This package will involve giving health workers refresher training on communication and counselling on use of SP in pregnancy targeting special groups like pregnant adolescents. These results provide important lessons to policy makers and programme managers who aim at scaling up access of SP for malaria prevention in pregnancy.