Knowledge synthesis, translation and exchange in public health and health promotion: the role of a Cochrane Review Group

The Cochrane Collaboration is an international non-profit organisation that aims to produce high quality systematic reviews of the effectiveness of health interventions. This work is conducted by 51 Review Groups that span a range of topics (e.g. pregnancy and childbirth, HIV/AIDS). The role of Fields within the Collaboration has been to actively engage relevant stakeholders internationally to improve the quality and relevance of reviews. Since the inception in 1996 of the Cochrane Public Health and Health Promotion Field, the Cochrane Collaboration has begun to embrace reviews related to public health and health promotion and is adapting to the changing needs of end-users. The introduction of a Cochrane health promotion and public health review group will help ensure that reviews will be oriented towards building evidence for equity and reducing inequalities and best meet the needs of decision-makers, practitioners and consumers. Our role as a Field has led to us working with a range of partners including reviewers, researchers, practitioners and consumers. Knowledge synthesis, translation and exchange (KST&E) has emerged as an issue in need of further exploration for practice to influence decision-makers and for policy to influence practitioners. 2007 will be an exciting year for evidence-informed Health Promotion and Public Health (HPPH) both within the Cochrane Collaboration and for our partners in policy, practice and research.     

基层基本公共卫生服务项目管理工作探讨

基本公共卫生服务项目的推行,对促进基本公共卫生服务均等化的实现具有重要意义。基层单位作为公共卫生服务的主体,其服务能力直接影响卫生服务项目的实现,因此基本公共卫生服务管理工作需要落实到基层。基本公共卫生相关服务项目管理工作顺利开展,不仅能够提升基层公共卫生单位管理质量,而且能够有效为基层相关卫生服务单位获得良好社会及管理效益。但是现阶段在实际的基层基本卫生服务项目管理工作中,相关管理工作仍然存在部分问题。为进一步提升基层基本公共卫生服务项目管理水平,该文旨在分析基本公共卫生服务项目的现状,并提出解决问题的方法,通过从项目管理工作需要面向基层单位以及合理利用各种资源和平台的方式,最终达到提高基层单位项目工作管理质量,以及服务项目取得良好的管理效果和社会效益的目的 。     

Practitioner perspectives on tackling health inequalities: Findings from an evaluation of healthy living centres in Scotland

Little is known about how health practitioners tasked with tackling health inequalities account for their own programmes and actions. This paper attempts to address this gap by drawing on data collected in the course of an evaluation of the Healthy Living Centre (HLC) programme, which was designed to address the wider determinants of health, in particular social exclusion and socioeconomic disadvantage, through targeting services at the most deprived local communities. Six Scottish HLC case studies explored in depth how HLC practitioners conceptualised ‘health inequalities’ and applied the construct to legitimate their public health and health improvement work. Practitioners drew on multiple explanations of health inequalities, sought to apply holistic approaches to service provision, and developed activities that took account of classed practices intended to overcome class-related disempowerment and stigma. They discussed the challenges of positioning services to appeal to and reach target groups and the difficulties in assessing the impact of their work on reducing health inequalities. Responses to tackling inequalities were variable across time and between HLCs, resulting from uneven learning about target groups and their changing needs, an evolving policy agenda and consideration given to the longer-term sustainability of HLC sites. Although practitioners' work to address health inequalities was limited by the programme's focus on working with disadvantaged groups, findings illustrate how classed practices are linked to the challenges of attracting and successfully engaging with such groups. Practitioner accounts highlighted the importance of gaining acceptance to overcome barriers to engagement with disadvantaged communities, the time required to achieve a satisfactory level of engagement, the proximity of service providers to clients and the adaptability of services necessary to address evolving needs.     

Whose health,whose care,whose say? Some comments on public involvement in new NHS commissioning arrangements

Recent health policy in England has demanded greater involvement of patients and the public in the commissioning of health and social care services. Public involvement is seen as a means of driving up service quality, reducing health inequalities and achieving value in commissioning decisions. This paper presents a summary and analysis of the forms that public involvement in commissioning are to take, along with empirical analysis from a qualitative study of service-user involvement. It is argued that the diversity of constituencies covered by the notion of ‘public involvement’, and the breadth of aims that public involvement is expected to achieve, require careful disaggregation. Public involvement in commissioning may encompass a variety of interest groups, whose inputs may include population needs assessment, evaluation of service quality, advocacy of the interests of a particular patient group or service, or a combination of all of these. Each of these roles may be legitimate, but there are significant tensions between them. The extent to which the structures for public involvement proposed recognize these possible tensions is arguably limited. Notably, new Local Involvement Networks (LINks), which will feed into commissioning decisions, are set as the arbiters of these different interests, a demanding role which will require considerable skill, tenacity and robustness if it is to be fulfilled effectively.     

Health promotion and the common good: Towards a politics of practice

One of the ethical dilemmas facing health promotion and disease prevention (HP/DP) practitioners is ensuring that programmes undertaken in the name of health as a ‘common good’ do not unnecessarily restrict individual liberties. This dilemma is compounded by theories of the common good being essentially normative and broadly categorized as libertarian (individual rights) or social justice (collective responsibilities). Both of these common good theories are described and critiqued. While the libertarian theory offers an important caution against the tendency of state institutions to undermine individual autonomy, a social justice theory is more consistent with research on health determinants and the historical practice of public health. The problem of individual liberties becomes most acute when HP/DP is restricted to efforts to curb or proscribe individual health behaviours. A social justice approach to HP, however, must be complemented by a ‘deliberative democratic’ practice. Such a practice recognizes the contingency involved in most HP/DP decision making, and the need for inequalities in opportunity for poor or socially disadvantaged (oppressed) groups in order to achieve greater equality in health outcomes. The argument presented draws primarily from debates within the public health, health promotion and disease prevention literature, and is illustrated by reference to two recent attempts in Canada to formulate ethical principles for health promotion practice.     

Practical measures that improve human rights – towards health equity for Aboriginal children

If Australian public health policy is driven by the need for health equity then program gaps and the unaddressed, health needs of Aboriginal children should be providing unambiguous direction for health sector investments. This, however, is not the case. This paper details the urgent effort required to meet the needs of Aboriginal children and refers to lessons from within Australia and international studies. It provides examples where health policy and programs can be improved in the areas of child nutrition, hearing loss, immunisation coverage, and preventive health assessments. Recommendations include the need for the adoption of a policy framework for maternal and child health, concomitant national performance indicators, nutritional supplementation programs in order to ensure that no Aboriginal child shall suffer from malnutrition in rural and remote Australia, multifaceted measures to enhance the immunisation coverage of Aboriginal children and preventive child health assessments. Underpinning these measures is a need to augment the capacity of Aboriginal Community Controlled Health Services across Australia as these services play a predominant role in delivering preventive health care, community development and support services to the Aboriginal population. Stated commitments to social justice principles have not translated into ‘practical measures’ in Australia for Aboriginal children. There must be unequivocal commitment of a sufficient scale for practical measures to reduce health inequalities.     

Community care: changing the role of hospital social work

Health and social services have been subjected to many changes over the past decade. Legislative reforms in the National Health Service (NHS), the implementation of policies for care in the community, and the transfer of funding for social care have given Local Authorities the lead role in the assessment of need and development of a mixed economy of care. The challenge for the organization and management of health social work is how to adjust to the change, whilst ensuring that increased choices are made available to users. It raises questions as to whether the reforms will provide a real opportunity for innovation or lead to a different form of rationing of services—a ‘top-down’, imposed, technocratic solution to reducing public spending. This paper presents the findings of an exploratory research study which considers the effect of organizational change on the provision of hospital-based social-work services to adults with health and social care needs in four Local Authorities in England. Local Authorities have responded differently; some have integrated care management within a social-work perspective; others have moved towards employing care managers who need not be qualified social workers. Change is proceeding slowly, not surprisingly, for none has been wholeheartedly enthusiastic. This paper examines the limited evidence on how social-work managers and practitioners are meeting the changes imposed upon them. Managers are more optimistic and see the changes as challenging, offering opportunities for acquiring new knowledge and different skills; workers are more pessimistic, fearing that preventive, professional practice will be eroded, disempowering users. Both are in agreement that the process has been stressful and that the practice of social work in hospitals has changed.     

Health impacts of climate change and health and social inequalities in the UK

This article examines how social and health inequalities shape the health impacts of climate change in the UK, and what the implications are for climate change adaptation and health care provision. The evidence generated by the other articles of the special issue were interpreted using social justice reasoning in light of additional literature, to draw out the key implications of health and social inequalities for health outcomes of climate change. Exposure to heat and cold, air pollution, pollen, food safety risks, disruptions to access to and functioning of health services and facilities, emerging infections and flooding are examined as the key impacts of climate change influencing health outcomes. Age, pre-existing medical conditions and social deprivation are found to be the key (but not only) factors that make people vulnerable and to experience more adverse health outcomes related to climate change impacts. In the future, climate change, aging population and decreasing public spending on health and social care may aggravate inequality of health outcomes related to climate change. Health education and public preparedness measures that take into account differential exposure, sensitivity and adaptive capacity of different groups help address health and social inequalities to do with climate change. Adaptation strategies based on individual preparedness, action and behaviour change may aggravate health and social inequalities due to their selective uptake, unless they are coupled with broad public information campaigns and financial support for undertaking adaptive measures.     

上海市嘉定区政府购买社会组织精神卫生服务的实践探索

近年来,随着政府购买服务发展社会公共事业的不断推进,引进社会组织补充服务日渐成为当代公共服务的重要机制。上海嘉定区政府购买精神卫生服务经过5年的探索与实践,逐步摸索出一套系统、完善的项目化工作流程机制。政府购买精神卫生服务,不仅突破精神卫生服务资源严重不足的困境,也是提供专业、多元精神健康服务的绩优选择。但在实际运行过程中,也发现一些问题,如绩效考核评价机制有待完善、社会组织自我发展能力有待提高、监管机制有待加强等。     

How does evidence influence public health policy? Tackling health inequalities in England

This paper examines the place of evidence in the policy‐making process, considering as a case study the development of a Programme for Action to tackle health inequalities in England. It attempts to identify ways in which we can maximise the use of evidence in the development of policies to support public health, and the ways in which research can be managed to support public health policy development. It identifies that evidence‐based policy is an aspirational goal rather than something that will easily be achieved in the complex, politicised environment of policy making. Key challenges include the need to develop public health evidence that is ‘fit for purpose’ – research that is more overtly directed towards informing policy and producing evidence derived from practical interventions that would allow examination of the relative costs and benefits of different policy options. Research evidence also needs to be provided at the time it is needed, and improved techniques need to found for communicating and managing the uncertainties that arise through scientific research. For the public servants who use evidence in policy making, there is the challenge to develop skills in the critical appraisal of evidence and to judge how to achieve the best ‘fit’ between available evidence, current political priorities, and practical actions to achieve the desired outcomes. In this more complex environment, the development of networks and cultivation of relationships between public health practitioners, advocates and policymakers (public servants and their political masters) will often provide more adaptable and durable opportunities to influence the policy process.     

Measuring the value of public health systems: the disconnect between health economists and public health practitioners

We investigated ways of defining and measuring the value of services provided by governmental public health systems. Our data sources included literature syntheses and qualitative interviews of public health professionals. Our examination of the health economic literature revealed growing attempts to measure value of public health services explicitly, but few studies have addressed systems or infrastructure. Interview responses demonstrated no consensus on metrics and no connection to the academic literature. Key challenges for practitioners include developing rigorous, data-driven methods and skilled staff; being politically willing to base allocation decisions on economic evaluation; and developing metrics to capture "intangibles" (e.g., social justice and reassurance value). Academic researchers evaluating the economics of public health investments should increase focus on the working needs of public health professionals.     

政府在公共卫生服务中的价值选择和职责定位

组织社会资源向社会大众提供方便、可及和均等化的公共卫生服务,是政府的一项重要社会职责.我国公共卫生服务表现出不公平与低效率的现象,本质上折射出政府在公共卫生服务领域价值选择扭曲与责任缺失.因此,在“新医改”形势下,实现全面加强我国公共卫生服务体系建设的目标,必须在社会公正的价值选择指导下,通过明确公共卫生体制改革目标、改革公共财政体制以及加强公共卫生服务体制建设等强化政府职责.     

Inequalities in health: what health systems can and cannot do

Health promotion activities are actively encouraged in most countries, including the UK. Meanwhile many health care providers and health experts are becoming increasingly concerned about the growing evidence of significant health inequalities between social groups in the UK, and in particular the strong association between relative deprivation and poor health. In 1995, a report for the British government entitled 'Variations in health: what can the Department of Health and the NHS do?', identified the need for the Department of Health and the NHS to play a key role in coordinating and implementing public health programmes intended to reduce inequalities in health. Examination of existing evidence on the effectiveness of health promotion and prevention programmes designed to improve the health status of the most vulnerable groups in society reveals very little evidence to support current enthusiasm for adopting public health strategies in order to reduce variations in health status between the affluent and the poor. Alternative and potentially more effective health care responses to inequalities in health status need to be considered.     

“健康中国战略”下社区精神健康服务协同供给的实现框架及路径

精神健康问题已成为影响经济社会发展的重大公共卫生问题和社会问题。基于社区的精神健康服务有利于精神疾病的早发现、早治疗、早控制,是促进精神健康的重要途径。我国当前的社区精神健康服务需综合运用健康治理、优势治理和协同治理的规律和方法,重组社区事务,建立协同平台,完善监护制度,加强考核评估的协同,提升服务能力,对社区居民不同的精神健康服务需求进行多层次、整体性回应。     

Implementing the Marmot Commission's Recommendations: Social Justice Requires a Solution to the Equity-Efficiency Trade-Off

The WHO Commission on Social Determinants of Health has documentedpervasive inequalities in health in many countries. These areclearly associated with unfair distribution of the social determinantsof health. Policies directed at reducing this unfair distributionshould be promoted across all sectors and institutions responsiblefor securing equal opportunities and freedom for all citizens.This article argues that such policies will need to balancethe competing goals of reducing social group inequalities inhealth and improving average health. We need a public debateabout how to make such difficult choices. This paper outlinesa framework that can help us structure our thinking about thisdilemma.     

Health planning and health care for the poor: the internal ethic of public health

Health planning involves assessing health care needs of a defined population, setting priorities, then developing, implementing,m and evaluating programs that address priority needs. The concepts of health planning are central to the 1988 report of the Institute of Medicine on the Future of Public Health, which defined the three core functions of public health as assessment, policy development, and assurance. Generally, when health planning is instituted, poor people are identified as having the poorest health status and the greatest need. An internal ethic is therefore created for public health to focus on the health care needs of those in poverty. This internal ethic of public health health can become the driving force for reforming the present U.S. health care system. A reformed health care system would be guided by the principle of care according to need, which not only has a basis in health planning, but in social justice as well.     

Improving primary mental health care: impact of a nationwide programme

OBJECTIVE: To determine the impact of a nationwide programme on primary mental health care practices. DESIGN: Cohort study involving two surveys conducted in 2001 and 2003. SETTING AND SUBJECTS: Random sample of 2757 general practitioners. INTERVENTION: In 2001, a nationwide programme was initiated to improve primary mental health care. The programme used a participatory approach with regional needs assessment and regional selection of the interventions. MAIN OUTCOME MEASURES: Perceived need, availability and participation in the interventions; self-reported mental health performance (self-reported diagnosis and management of mental health disorders); perceived barriers to optimal care. RESULTS: Baseline and follow-up questionnaires were returned by 1336 and 1358 general practitioners, respectively. Interventions did not entirely match general practitioners' needs. Mental health performance did not change consistently while perceived barriers to optimal care decreased considerably. Actual participation in the interventions was not associated with improved mental health performance or decreased perception of barriers. CONCLUSIONS: The application of the nationwide programme had no considerable impact on the professional practices of general practitioners with regard to mental health care. This finding challenges the assumption that a bottom-up approach to quality improvement is effective. Extensive coordination at a national level and the provision of specific supportive products and services appears to be necessary to achieve improvement.     

Interventions to improve access to health and social care after discharge from hospital: a systematic review

OBJECTIVES: To determine the effectiveness and costs of interventions intended to improve access to health and social care for older patients following discharge from acute hospitals. METHOD: Systematic literature review, following NHS Centre for Reviews and Dissemination guidelines, of randomised controlled trials evaluating needs assessment methods and patient discharge co-ordinator roles. These services targeted patients aged 60 years and over and varied depending on whether or not they selected frail patients (e.g. those at risk of needing nursing home care). Outcomes assessed included: referrals to or use of health and social care (15 studies); mortality (13 studies); patients' functional health status and disability (13 studies); and patient perceptions of health (five studies), quality of life (three studies), cognitive functioning and psychological well-being (ten studies), social support (two studies) and the adequacy of services (four studies). RESULTS: Fifteen randomised controlled trials (23 papers), mainly from the USA, were identified. The interventions provided and patient groups targeted by these services were heterogeneous. There was, however, some evidence that services combining needs assessment, discharge planning and a method for facilitating the implementation of these plans were more effective than services that do not include the latter action. CONCLUSIONS: The assessment of need may be insufficient in itself for the adequate provision of post-discharge care. Needs assessment should be combined with a service that facilitates the implementation of care plans.     

Child poverty and environmental justice

BACKGROUND: Child poverty and social inequality in Western countries are growing both in scope and in complexity. The clustering of income poverty in urban settings reflects the complex process of residential segregation. Living in segregated neighbourhoods with much poverty and predominantly substandard housing is usually associated with poor physical, chemical and social environmental living conditions at the individual and community level which influence and shape children's health both directly and indirectly. OBJECTIVE: This paper shows research data on the link between child poverty and income-related health inequalities according to the unequal exposure to environmental hazards as well as the unequal distribution of environmental resources in the domestic environment and within the local context as an increasing public health issue in Germany. The links between these factors are drawn from the conceptual framework of environmental justice. Examples are shown of integrated approaches to alleviate social and environmental disparities at the community level. CONCLUSION: The implications of environmental justice for public health include the need to uncover the link between socioeconomic factors and environmental health disparities related to the man-made environment. Developing relevant indicators for environmental inequalities in the context of housing and health is an important task for public health research. More emphasis should be placed on a comprehensive holistic approach to understand the mechanisms by which socioeconomic factors modify children's susceptibility and exposure to environmental hazards, particularly in low-income areas.     

Health inequality: an introduction

There is unequivocal evidence from across Australia of entrenched patterns of socio‐economic related health inequality. These patterns are seen in mortality, morbidity, health risk factors and access to preventive health services. Discussing the potential role of health promotion in addressing these health inequalities needs to be based on an agreed definition of health inequality and an understanding of the differences between health inequity and health inequality. This involves making value judgements on whether opportunities for health are fairly distributed. Health promotion practitioners need to be able to argue why they think health inequalities are important, have a clear understanding of what they think are the causes of health inequality and be informed on action that can be taken to reduce health inequality. The ever‐increasing level of information on patterns of health inequality within Australian society are likely to place increased pressure on health promotion policymakers and practitioners to ensure that their actions reduce health inequality – or at least not contribute to widening health inequality. The way in which these issues are approached will be strongly influenced by our values, the values of the organisations in which we work and the wider community. This requires each of us to be proactive in articulating our values and beliefs and being open to them being challenged.