Building communities that create health

Typically, public health policy, program design, and resource allocation are based on issue-specific, targeted interventions directed at specific populations or sub-populations. The authors argue that this approach fails to meet the goal of public health-to improve health for all--and that the key to health improvement is to create a social context in which healthy choices are the norm. The authors present as case studies two Pennsylvania cities that used multisectoral approaches to achieve community health improvements.     

Addressing social determinants of health through community-based participatory research: the East Side Village Health Worker Partnership.

The authors describe the use of a stress process model by the East Side Village Health Worker Partnership (ESVHWP), a project of the Detroit Community-Academic Urban Research Center, as a framework for understanding social determinants of health. Specifically, the authors describe the development by the ESVHWP Steering Committee of a context-specific stress process model for east side Detroit residents. The authors examine data from in-depth interviews to illuminate actions taken by community members to reduce stressors or minimize their impact on health. Finally, the authors describe the use of this context-specific stress process model and data gathered regarding actions to address community stressors to inform the development of interventions by the ESVHWP to reduce stressors or strengthen the conditioning factors that reduce the impact of stress on health. On the basis of these results, the authors discuss opportunities and challenges for partnership approaches to addressing social determinants of health in urban communities.     

积极推进儿童多源环境暴露的健康影响研究

儿童处于生长发育的关键时期, 器官和系统发育尚不成熟, 是受环境污染危害的脆弱人群。儿童时期的环境危害因子暴露是成人疾病发生的重要风险因素之一, 评估环境暴露对儿童健康带来的风险, 并采取积极的干预措施降低危害, 对于疾病早期预防控制具有重大意义。影响儿童健康的环境因素包括环境污染、气象因素、血铅和环境过敏原等, 多源环境暴露对儿童健康影响的研究结果, 可为制定有针对性的干预措施从而降低对儿童健康的损害提供科学参考。由于环境污染物种类繁多, 且新的污染物不断涌现, 今后应加强新兴污染物多源环境暴露对儿童健康的影响及可能作用机制研究。在此基础上开展干预研究, 降低环境因素暴露对儿童健康的损害。     

Baseline assessment of organizational capacity for health promotion within regional health authorities in Alberta, Canada

This paper provides a baseline profile of organizational capacity for (heart) health promotion in Alberta's regional health authorities (RHAs); and examines differences in perceived organizational health promotion capacity specific to modifiable risk factors across three levels of staff and across capacity levels. Baseline data were collected from a purposive sample of 144 board members, senior/middle managers and service providers from 17 RHAs participating in a five-year time-series repeated survey design assessing RHA capacity for (heart) health promotion. Results indicate low levels of capacity to take health promotion action on the broader determinants of health and risk conditions like poverty and social support. In contrast, capacity for health promotion action specific to physiological and behavioural risk factors is considerably higher. Organizational "will" to do health promotion is noticeably more present than is both infrastructure and leadership. Both position held within an organization as well as overall level of organizational capacity appear to influence perceptions of organizational capacity. Overall, results suggest that organizational "will", while necessary, is inadequate on its own for health promotion implementation to occur, especially in regard to addressing the broader determinants of health. A combination of low infrastructure and limited leadership may help explain a lack of health promotion action.     

Improving organizational capacity to address health literacy in public health: a rapid realist review

Objectives

Despite the growing significance of health literacy to public health, relatively little is known about how organizational capacity may be improved for planning, implementing and sustaining health literacy interventions. This study aimed to connect decision makers in a public health agency with evidence of how organizational capacity may be improved for delivering health literacy services.

Study design

A rapid realist review of published and grey literature was conducted by a partnership between the Public Health Agency of Canada (PHAC) and the InSource Research Group.

Methods

Realist review methodology attempts to understand what works for whom under what circumstances, and is characterized by its focus on strategies/interventions, contexts, mechanisms and their relationship to outcome. This review was completed in collaboration with a reference panel (comprised of a broad range of PHAC representatives) and an expert panel. Literature searching was conducted using three databases supplemented with bibliographic hand searches and articles recommended by panels. Data were extracted on key variables related to definitions, strategies/interventions associated with increased organizational capacity, contextual factors associated with success (and failure), mechanisms activated as a result of different strategies and contexts, key outcomes, and evidence cited.

Results

Strategies found to be associated with improved organizational capacity for delivering health literacy services may be classified into three domains: (1) government action; (2) organizational/practitioner action; and (3) partnership action. Government action includes developing policies to reinforce social norms; setting standards for education; conducting research; and measuring health literacy levels. Organizational/practitioner action relates to appropriate models of leadership (both high-level government engagement and distributed leadership). Innovative partnership action includes collaborations with media outlets, those producing electronic materials, community organizations and school-based programs. Contextual factors for success include positive leadership models, interorganizational relationships, and a culture committed to experimentation and learning. Potential mechanisms activated by strategies and contextual factors include increased visibility and recognition of health literacy efforts, enthusiasm and momentum for health literacy activities, reduced cognitive dissonance between vision and action, a sense of ownership for health literacy data, and creation of a common language and understanding.

Conclusions

Government initiated interventions and policies are powerful strategies by which organizational capacity to improve health literacy may be affected. Using the foundations created by the government policy environment, organizations may improve the impact of health literacy interventions through supported distributed leadership.     

Environmental degradation and health risks in Beijing, China

As China's capital city, Beijing is experiencing unprecedented environmental degradation accompanied by complex interactions between urbanization and global environmental change, which places human health at risk on a large spatial and temporal scale. For sustainable development that supports environmental and human health in Beijing and during the upcoming "green" Olympic games in 2008, experts and political leaders must acknowledge the urgent health risks from environmental changes related to urbanization. A range of urban health hazards and associated health risks in Beijing result from a variety of factors including heat islands, air pollution, water crisis, soil pollution, infectious diseases, and urban consumerism; in addition, some hazardous health conditions are associated with inequality in living and working conditions. The authors suggest 2 main areas for policy action and research direction: (1) the need to get full-scale information related to environmental monitoring data and health data (and then to provide new methodological approaches and techniques to implement interventions) and (2) the need for effective cooperation among different sectors.     

Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care

Reducing racial and ethnic disparities in health care has become an important policy goal in the United States and other countries, but evidence to inform interventions to address disparities is limited. The objective of this study was to identify important dimensions of interventions to reduce health care disparities. We used qualitative research methods to examine interventions aimed at improving diabetes and/or cardiovascular care for patients from racial and ethnic minority groups within five health care organizations. We interviewed 36 key informants and conducted a thematic analysis to identify important features of these interventions. Key elements of interventions included two contextual factors (external accountability and alignment of incentives to reduce disparities) and four factors related to the organization or intervention itself (organizational commitment, population health focus, use of data to inform solutions, and a comprehensive approach to quality). Consideration of these elements could improve the design, implementation, and evaluation of future interventions to address racial and ethnic disparities in health care.     

Incentives for health

This article discusses incentives to help make healthy choices the easy choices for individuals, operating at the levels of the individual, producers and service providers, and governments. Whereas paying individuals directly to be healthier seems to have a limited effect, offering financial incentives through health insurance improves health. Changing the environment to make healthier choices more accessible acts as an incentive to improve health. Employers can provide incentives to improve the health of their employees. Producers and service providers can take voluntary action to make their products less harmful, and they can be nudged into marketing healthier products within a regulatory environment. International agreements and monitoring systems can incentivize governments to do more for health. Lessons from climate change adaptation suggest that multilevel governance and policy integration are greater obstacles to policy change and implementation than knowing what has to be done. Policy change and implementation are triggered by many drivers, many of which are side effects of other policy pressures rather than of the direct policy goal itself. Effective action to reduce noncommunicable diseases will require leveraging social networks into a new ways of thinking about health; making better health prestigious and aspirational, and giving health and wellness a brand that encourages positive behavior change.     

Status and determinants of individual actions to reduce health impacts of air pollution in US adults

Although regulation of emissions is the primary strategy to reduce air pollution–related morbidity, individual-level interventions are also helpful in mitigating health impacts. We used data from 2007–2008 National Health and Nutrition Examination Survey to study the prevalence of individual-level action among the US adult population if informed of air pollution, and to see if this differed by demographic and health factors. Only 13.5% (95% confidence interval [CI]: 11.6–15.4%) of participants aware of air quality reported changing their individual behaviors. Males (adjusted odds ratio [AOR]: 0.66, 95% CI: 0.56–0.77) and those without cardiovascular disease (AOR: 0.58, 95% CI: 0.47–0.71) were least likely to take action. Results show that individual action was infrequent among the population. Health promotion of individual intervention is necessary, and this effort may need to target specific subgroups of the population. Further studies on effective individual interventions are needed.     

Leveraging quality improvement to achieve equity in health care

INEQUALITY IN QUALITY: Disparities in health care and quality for racial, ethnic, linguistic, and other disadvantaged groups are widespread and persistent. Health care organizations are engaged in efforts to improve quality in general but often make little attempt to address disparities. STANDARD VERSUS CULTURALLY COMPETENT QUALITY IMPROVEMENT (QI): Most QI interventions are broadly targeted to the general population-a "one-size-fits-all" approach. These standard QI efforts may preferentially improve quality for more advantaged patients and maintain or even worsen existing disparities. Culturally competent QI interventions place specific emphasis on addressing the unique needs of minority groups and the root causes of disparities. HOW QI CAN REDUCE DISPARITIES: QI interventions can reduce disparities in at least three ways: (1) In some cases, standard QI interventions can improve quality more for those with the lowest quality, but this is unreliable; (2) group-targeted QI interventions can reduce disparities by preferentially targeting disparity groups; and (3) culturally competent QI interventions, by tailoring care to cultural and linguistic barriers that cause disparities, can improve care for everyone but especially for disparity groups. GUIDELINES FOR CULTURALLY COMPETENT QI: A culturally competent approach to QI should (1) identify disparities and use disparities data to guide and monitor interventions, (2) address barriers unique to specific disparity groups, and (3) address barriers common to many disparity group. CONCLUSIONS: To achieve equity in health care, hospitals and other health care organizations should move toward culturally competent QI and disparities-targeted QI interventions to achieve equity in health care, a key pillar of quality.     

Globalization and social determinants of health: Promoting health equity in global governance (part 3 of 3)

This article is the third in a three-part review of research on globalization and the social determinants of health (SDH). In the first article of the series, we identified and defended an economically oriented definition of globalization and addressed a number of important conceptual and metholodogical issues. In the second article, we identified and described seven key clusters of pathways relevant to globalization's influence on SDH. This discussion provided the basis for the premise from which we begin this article: interventions to reduce health inequities by way of SDH are inextricably linked with social protection, economic management and development strategy.     

Promoting heart health for Southeast Asians: a database for planning interventions

This paper is a report of baseline data that the authors collected on the prevalence of hypertension in a sample of 397 Southeast Asian immigrants residing in central Ohio and the implications of those data for the design of ethnically approved and scientifically valid interventions. The context for collection of these data over a 9-month period in 1989 is described. Baseline demographic characteristics including distributions by ethnicity, sex, age, and length of stay in the United States, as well as family heart health history, hypertension level, and heart health awareness of these subjects are presented. For example, 85 percent of the immigrants did not know what could be done to prevent heart disease. Implications for the design of ethnically approved and scientifically valid prevention strategies are discussed. Based on these data, the authors realized that multiple health education strategies tailored to what they were learning about Southeast Asians would be needed. Through Southeast Asian leaders, they were led to using wall calendars, with words specific to each Southeast Asian language, that had a monthly heart health slogan as one avenue to reach Southeast Asians. Another strategy was to develop videotapes featuring cultural content but including heart health "commercials." The authors concluded that, although scientific validity of risk reduction interventions are important, customizing these strategies to ethnically specific modes of interaction are equally important.     

Trapped in risky behaviour: Empowerment,disabled people and sexual health

The concept of empowerment within care environments has brought the issue of informed choice onto professionals’ and users’ agendas. However, this principle can be frustrated by a range of factors that reveal the tension between the autonomy of service users to take risks and the responsibility of service providers to assess and protect users from risks. This tension between users and providers has been noted within many areas of service but may become heightened where the outcome of risk-related action may be perceived as damaging. The authors’ own research indicated that sexual health education is one such area. Findings presented in this paper reveal that lack of clarity around responsibility for, and efficacy of, sexual health education has negative effects on the choices and behaviour of service users. The relationship between disabled service users and service providers is confused, particularly over issues of responsibility for identifying and addressing sexual health need. Further, organisational policies and structures can frustrate service providers’ attempts to develop and respond to sexual health education. This can create an environment where the emphasis is on risk avoidance or even denial of risk-related behaviour rather than risk protection.     

Advancing health disparities research within the health care system: a conceptual framework

We provide a framework for health services-related researchers, practitioners, and policy makers to guide future health disparities research in areas ranging from detecting differences in health and health care to understanding the determinants that underlie disparities to ultimately designing interventions that reduce and eliminate these disparities. To do this, we identified potential selection biases and definitions of vulnerable groups when detecting disparities. The key factors to understanding disparities were multilevel determinants of health disparities, including individual beliefs and preferences, effective patient-provider communication; and the organizational culture of the health care system. We encourage interventions that yield generalizable data on their effectiveness and that promote further engagement of communities, providers, and policymakers to ultimately enhance the application and the impact of health disparities research.     

Social determinants of health: implications for environmental health promotion.

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities--and associated health disparities--are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.     

Primary prevention of cardiovascular disease by an occupational health service

BACKGROUND: Worksites are considered to be a key channel for the delivery of interventions to prevent cardiovascular disease. The aim of this study was to evaluate the effect on the blood cholesterol levels of an intervention program offered by an occupational health service. METHODS: The intervention group consisted of 95 employees and the reference group consisted of 74 employees, in all, 169 subjects, with a serum cholesterol > or = 5.2 mmol/l. Both groups completed a standardized questionnaire. Occupational health nurses carried out the blood sampling before and after the program. The intervention group was then offered counseling on physical activity and a dietician offered individual counseling on healthy food habits. The reference group was not the subject of the intervention program. RESULTS: The mean cholesterol level decreased by 0.3 mmol/l (5%) in the intervention group and for the men the decrease was 0.5 mmol/l, while the mean level of the reference group was unchanged. Furthermore, there was a nonsignificant decrease of the mean triglyceride level in the intervention group. CONCLUSION: The results of this controlled trial indicates that risk factors for cardiovascular disease can be reduced by interventions at the worksite. Even modest reductions of cholesterol levels may reduce the risk to a tangible degree.     

Improving adherence to hand hygiene among health care workers

Increased adherence to hand hygiene is widely acknowledged to be the most important way of reducing infections in health care facilities. Despite evidence of benefit, adherence to hand hygiene among health care professionals remains low. Several behavioral and organizational theories have been proposed to explain this. As a whole, the success of interventions to improve adherence to hand hygiene among health care professionals has been limited. Recent data suggest that a multifaceted intervention, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations. Although the "active ingredient" of such an intervention is unknown, there is evidence that the use of feedback may be the key to increasing adherence. In this article, we review the theoretical basis for interventions and provide an overview of the evidence for interventions. Coherent and methodologically sound research is required to better understand the factors contributing to hand-hygiene behavior among health care professionals.     

The impact of two organizational interventions on the health of service sector workers.

Studies focusing on interactive service work that involves face-to-face interactions between employees and customers/clients have shown that employees tend to show symptoms of job dissatisfaction, stress, and emotional exhaustion because they are expected to display or suppress certain emotions in the performance of their jobs. To meet the health challenges and reduce sickness absenteeism among employees in this sector, two organizational interventions were implemented among service workers employed by the municipality and in a shopping mall in a medium-sized Norwegian city. In a field experiment, the authors evaluated the effect of this type of intervention on employee health. The experiment combined survey measures (pre- and post-intervention) with observations and unstructured interviews. The survey data showed positive changes on only two of the measured variables among the shopping mall employees, and no effect on the municipal employees. This article focuses on the qualitative data, which show how constraints related to time and to interactional and organizational practices impeded full involvement of the employees during implementation of the interventions. The authors discuss the results from the perspective of the general challenges of implementing interventions in the service sector.     

Information processes mediate the effect of a health communication intervention on fruit and vegetable consumption

Health communication interventions have been effective in promoting fruit and vegetable consumption (FVC). To explore mechanisms underlying health communication effectiveness, the authors investigated whether information processes mediated the relationship between health communication and FVC, using data from NC STRIDES. NC STRIDES tested the efficacy of two health communication strategies to promote FVC among a diverse population-based sample of older adults. Participants were randomized to 1 of 4 groups: control, tailored print communication (TPC), telephone motivational interviewing (TMI), or combined (TPC?+?TMI). To analyze data from 469 participants, the authors constructed multi-sample structural equation models. Information processes mediated the effect of TMI and TPC?+?TMI on FVC. TMI had an indirect effect on FVC through relevance of the communications. TPC?+?TMI influenced FVC through perceived relevance of the communications, trust in the communications, and dose recall via two paths. In the first path, relevance was associated with trust. Trust was associated with recall, and greater recall predicted FVC. In the second path, relevance was associated with dose recall, and more recall predicted FVC. Thus, the authors found that key information processes mediated the relationship between a health communication intervention and FVC. Further research should investigate ways to enhance relevance, trust, and recall during the delivery of interventions.     

Local stakeholders' perspectives on improving the urban environment to reduce child pedestrian injury: implementing effective public health interventions at the local level

Local-level public health interventions require action from multiple agencies, organizations and individuals, yet little is known about how best to work with stakeholders to facilitate change. We sought local stakeholders' perspectives on how best to address impediments to implementing interventions designed to reduce child pedestrian injury by improving the pedestrian environment. We conducted 20 in-person, key informant interviews with people who would be the likely advocates for environmental change to improve the pedestrian environment in one US city, Baltimore, Maryland. We discuss the importance of reframing child pedestrian injury risk as a livability issue, increasing awareness about the potential impact of environmental changes to improve public safety, and the need for a formal efficient process to facilitate communication between local government and other stakeholders. These findings provide public health professionals and advocates with useful insight into how local stakeholders view the issue and their perspectives on how best to achieve change.