Contextual influences on the use of health facilities for childbirth in Africa

OBJECTIVES: Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries. METHODS: Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries. RESULTS: We found strong community-level influences on a woman's decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified. CONCLUSIONS: Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a woman's decision to seek care during labor, but significant community variation remains unexplained.     

Socioecological influences on community involvement in HIV vaccine research

Objective

This study investigated socioecological factors influencing HIV vaccine research participation among communities living in geographic areas with high HIV prevalence and high poverty rates.

Methods

We surveyed a sample of 453 adults ≤18 years from areas of high poverty and high HIV prevalence in metro Atlanta and differentiated the effects of individual-, social/organizational-, and community-level characteristics on participation in HIV vaccine research via multilevel modeling techniques that incorporated questionnaire, program, and census data.

Results

Models that adjusted for both individual-level covariates (such as race, gender, attitudes, and beliefs concerning HIV research), social/organizational- and community-level factors such as local HIV prevalence rates, revealed that the extent of HIV prevention-related programs and services in census tracts contributed to individuals’ likelihood of participation in an HIV vaccine study. Additionally, neighborhood-based organizations offering HIV medical and treatment programs, support groups, and services (e.g., food, shelter, and clothing) encourage greater HIV vaccine research participation.

Conclusions

The findings support the hypothesis that community-level factors facilitate participation in HIV vaccine research independent of both individual- and social/organizational-level factors.     

Partnering in and for heart health promotion: findings from a survey of community organizations

This paper presents the results of a survey conducted with representatives (n = 283) of community health agencies linked to heart health activity in Ontario in order to: 1) describe their levels of involvement in heart health promotion, 2) describe the nature and extent of partnering undertaken in the context of community-based heart health promotion, and 3) assess the extent to which community development approaches vis-à-vis partnering are being employed in Ontario heart health promotion. The survey included a series of questions regarding level of agency involvement in heart health promotion activities organized around four areas: tobacco, nutrition, physical activity and general heart health. Respondents were also asked to report the nature and extent of partnering that took place. Results indicate that levels of involvement varied significantly across activity area and by organization, although every agency type reported some level of involvement in each of the four activity areas. Overall, agencies surveyed continue to employ traditional settings (i.e., schools and community) as well as strategies (i.e., public education) but report a substantial amount of partnering and collaboration when undertaking community-based heart health promotion activities.     

Understanding the multidimensional nature of health promotion for older adults through the application of a conceptual framework

Over the next three decades, the proportion of Americans over age 65 will grow to exceed 25 percent of the population. Although research has shown that health promotion and disease prevention interventions for older adults can lead to positive health outcomes, our understanding of the effects of health promotion on the health and well-being of older people could be improved through the development and use of a conceptual framework. This article presents a conceptual model for understanding the determinants and consequences of engaging in health promotion activities for older adults, describes how to use the model to estimate the impact of health promotion programs on a variety of individual- and community-level outcomes, and then applies the model to two different health promotion programs for older persons: REACH II and the Senior Wellness Program.     

Individual- and community-level determinants of social acceptance of people living with HIV in Kenya: Results from a national population-based survey

Using the 2003 Kenya Demographic and Health Survey, we investigated the influence of individual- and community-level factors on accepting attitudes toward people living with HIV (PLHIV) using three outcomes: (1) willingness to care for an infected household member, (2) willingness to buy vegetables from an infected vendor, and (3) willingness to allow an infected female teacher to continue teaching. In multilevel logistic regression models, we found that individuals who expressed greater acceptance of PLHIV were more likely to be male, older, more educated, high AIDS knowledge, and exposed to mass media. At the community level, differences in accepting attitudes were associated with community AIDS knowledge, community education, and community AIDS experience, but not for region, or place of residence. The findings suggest the important role of community factors in determining social acceptance of PLHIV. Programmatic strategies aimed at increasing these accepting attitudes should consider both individual- and community-level factors.     

A multilevel non-hierarchical study of birth weight and socioeconomic status

Background  

It is unclear whether the socioeconomic status (SES) of the community of residence has a substantial association with infant birth weight. We used multilevel models to examine associations of birth weight with family- and community-level SES in the Cape Cod Family Health Study. Data were collected retrospectively on births to women between 1969 and 1983 living on Cape Cod, Massachusetts. The sample included siblings born in different residences with differing community-level SES.     

Contextual effects of community mobilization and communication capacity as a positive factor for self-rated health status: a multi-level analysis

Objectives

We examined relationships between individual-level community participation, two types of contextual effects―community capacity for mobilization and capacity for health communication—and residents’ self-reported health status in order to explore the role health communication may play in community building for health.

Methods

To estimate multi-level effects of the community participation and the two contextual indicators with self-rated health status, we applied hierarchical generalized linear regression to crosssectional data from the Korean National Health and Nutrition Examination Survey.

Results

After adjusting for individual- and community-level confounders, the likelihood of having high self-rated health status is significantly higher among those who live in a region with higher community capacity for mobilization, higher health communication capacity at the community level, and higher participation in community groups at the individual-level.

Conclusions

Our findings suggest that living in a community characterized by higher levels of communication and mobilization capacity is beneficial to residents’ self-rated health status—increasing the odds of high health status by up to 9 %. Thus, building community capacity in mobilization and health communication may help develop better health promotion campaigns.     

Community action and reflective practice in health promotion research

While health promotion practitioners are engaging increasingly in research, there has been little examination of the practical dilemmas they may face in negotiating and collaborating with academics and community members in action research projects. This paper analyses how the practice of health promotion can interact with action research, and considers issues that arise for organizationally based health promotion practitioners and professional researchers. The first section charts types of action research along three dimensions (power, goals/values, resources). The second section examines some of the issues and practical dilemmas which arise in negotiating and researching collaborative projects in community health promotion. The discussion includes the differing perspectives of: practitioners (managerial and frontline), community members and academic researchers. The final section outlines a hybrid model of action research, developed in our work with community members, organizationally based health promoters and academy-based researchers. It combines the reflective practice of practice-based action research with the community participation and control of participatory research. The model is called community reflective action research.     

Environmental education and nursing: a necessary integration

Environmental issue should be discussed in educational actions, because this debate leads people to reflect on what is ecologically healthy. It was aimed to reflect on Health promotion, Environmental education and Nursing. This is a reflexive study on environmental health in three groups: Promotion of environmental and human health; Educational actions in Environmental health; and Nursing and Health education. It was verified that environmental education is a theme that includes human well-being, being necessary actions of health promotion that qualify individual and community to practice their empowerment and autonomy.     

Health promotion in different medical settings: women's health, community health and private practice

This paper describes the health promotion role of doctors in two medical practice settings: women's and community health centres, and fee-for-service practice. It proposes the establishment of divisions of primary health care in Australia which would be multi-disciplinary and focus on community-wide health issues. The paper is based on data from an interview survey of medical practitioners who had worked in metropolitan Adelaide women's and community health centres and from a questionnaire survey of GPs in private practice. The types of health promotion activity by the doctors in the different settings are discussed. It is concluded that private practice GPs are involved primarily in providing health education advice to individual patients. Doctors within women's and community health centres are more likely to report involvement in group health promotion activity and broader community development initiatives. The study concludes that health promotion which focuses on the health of the local community is best conducted within multi-disciplinary health centres. GPs in private practice are limited by the structure of their setting (particularly the fee-for-service basis and reliance on a single discipline) to health promotion which focuses on the needs of individual patients.     

Clinical prevention and population health: curriculum framework for health professions

The Clinical Prevention and Population Health Curriculum Framework is the initial product of the Healthy People Curriculum Task Force convened by the Association of Teachers of Preventive Medicine and the Association of Academic Health Centers. The Task Force includes representatives of allopathic and osteopathic medicine, nursing and nurse practitioners, dentistry, pharmacy, and physician assistants. The Task Force aims to accomplish the Healthy People 2010 goal of increasing the prevention content of clinical health professional education. The Curriculum Framework provides a structure for organizing curriculum, monitoring curriculum, and communicating within and among professions. The Framework contains four components: evidence base for practice, clinical preventive services-health promotion, health systems and health policy, and community aspects of practice. The full Framework includes 19 domains. The title "Clinical Prevention and Population Health" has been carefully chosen to include both individual- and population-oriented prevention efforts. It is recommended that all participating clinical health professions use this title when referring to this area of curriculum. The Task Force recommends that each profession systematically determine whether appropriate items in the Curriculum Framework are included in its standardized examinations for licensure and certification and for program accreditation.     

Advancing health promotion in Australian general practice.

Health promotion activities, while having the potential to prevent disease and decrease the burden of ill health, often play a minor role in the health care offered by general practitioners. There are several identified barriers to the involvement of Australian general practitioners in health promotion. These include structural barriers and barriers within the practice setting, individual practitioner and patient factors, and difficulties in evaluating the outcomes of health promotion activities. This article explores the barriers to the engagement of Australian general practice with health promotion and reviews several recent initiatives that have the potential to increase the health promotion activities of general practitioners. These initiatives act at the level of the individual practitioner, the practice, and in the community. Despite the lack of a coordinated national approach, these strategies form an important development in general practice.     

Individual,familial and community determinants of child physical abuse among high-school students in China

While many risk factors for child physical abuse are known, little research exists examining these in multilevel contexts including both individual and environmental influences. The authors examined the roles of individual-, family- and community-level factors such as socioeconomic status (SES) in determining the likelihood of child physical abuse in Guangzhou, China. Twenty-four schools were recruited by stratified random sampling, with 6628 junior high-school students aged 13–16 years participating. Parental child physical abuse experience, together with family and community levels of SES among students were measured and their relationships were investigated by applying univariable, multivariable and multilevel logistic regression models. Univariable, multivariable and multilevel logistic regression models were applied. Six-month prevalence of minor, severe and very severe assaults were 23.2%, 15.1% and 2.8%, respectively. A U-shaped association between family SES and likelihood of severe assaults was identified. In the multilevel model, indicators of low family SES, mother's higher occupational and educational status remained significantly independent predictors of physical abuse. Internal migration status was associated with higher risk as was younger age. The authors suggest that previous categories of risk factors for physical abuse may be too simplistic, and that further research on social and environmental influences may usefully inform intervention programs.     

社区卫生服务中心全科团队构成模式分析

目的:分析社区卫生服务中心的全科团队构成模式,为社区卫生服务模式转变提供实践经验.方法:采取目的抽样,选取在社区卫生服务模式探索较早且具有代表性的北京市、上海市、郑州市、成都市共12家社区卫生服务中心进行现场调查.采用定性调查为主、定量调查为辅的方法.结果:所调研社区卫生服务中心的全科团队构成模式可分为四类:(1)全科医生+护士+护士助理+药师;(2)医生(全科医生、中医)+护士+社区志愿者;(3)医生(全科医生/中医)+护士+助理员+社区志愿者;(4)全科医生+护士+辅助团队(公卫医师、妇保医生等)+支持团队(药房、医技等).不同模式下,团队成员的专业类别、职责分工和团队规模有所差异.结论:以全科医生为核心,构建全科团队的做法已基本形成共识;上述四种典型全科团队构成模式各有侧重点,对于提高服务效率和质量、密切医患关系、促进社区参与和防治结合具有积极的影响.     

Research as intervention in heart health promotion

BACKGROUND: Capacity building in health promotion has traditionally involved training interventions to support knowledge, skill and resource building for effective practice. However, there is a need to understand how research can be used to support capacity building and practice. METHODS: Findings are based on a parallel case study comprising qualitative analysis of 66 key informant interviews from five provincial heart health projects (Manitoba, Prince Edward Island, Ontario, Saskatchewan, and Newfoundland and Labrador) as part of the Canadian Heart Health Dissemination Project. FINDINGS: Results indicate research was used primarily to monitor and report results about health promotion capacity and dissemination to stakeholders, and contribute to participatory processes. Respondents noted that research as intervention had an influence on five areas of health promotion capacity and practice: increased heart health promotion knowledge/skills; improved programming, planning and prioritizing; increased motivation for (heart) health promotion initiatives; and cultivation of relationships as well as buy-in. INTERPRETATION: Research was a complementary capacity-building activity, although it did not directly increase program implementation. These findings contribute to linking researchers, practitioners and community decision-makers in the process of enhancing health promotion practice.     

How community-level social and economic developments have changed the patterns of substance use in a transition economy?

Most social changes take place at the community level before indirectly affecting individuals. Although the contextual effect is far-reaching, few studies have investigated the important questions of: how do community-level developments affect drinking and smoking, and how do they change the existing gender and income patterns of drinking and smoking, particularly in transition economies? In this study, I used a Chinese panel dataset between 1991 and 2011 to reveal the moderating effects of community developments. Through multilevel growth curve modeling that controls for age, period, and cohort effects, as well as individual- and community-level covariates, I found that community-level economic development and social development are negatively associated with drinking and smoking. Moreover, economic and social developments also moderate the important influences of income and gender: women start to drink more in communities with higher economic development; the traditionally positive association between income and smoking/drinking is also reversed, i.e. the rich start to smoke and drink less in communities with higher social development. This study concludes that the rapid changes in communal social and economic structures have created new health disparities based on the gender and socioeconomic hierarchy.     

Community- and individual-level socioeconomic status and breast cancer risk: multilevel modeling on Cape Cod, Massachusetts

BACKGROUND: Previous research demonstrated increased risk of breast cancer associated with higher socioeconomic status (SES) measured at both the individual and community levels. However, little attention has been paid to simultaneously examining both measures. OBJECTIVES: We evaluated the independent influences of individual and community SES on the risk of breast cancer using case-control data. Because our previous work suggests that associations may be stronger after including a latency period, we also assessed the effect of community-level SES assuming a 10-year latency period. METHODS: We obtained individual education for cases and matched controls diagnosed between 1987 and 1993 on Cape Cod, Massachusetts (USA). We acquired community-level SES from census data for 1980 and 1990. Using SES data at diagnosis and 10 years earlier, we constructed models for breast cancer risk using individual-level SES only, community-level SES only, and a multilevel analysis including both. We adjusted models for other individual-level risk factors. RESULTS: Women with the highest education were at greater risk of developing breast cancer in both 1980 and 1990 [odds ratio (OR) = 1.17 and 1.19, respectively]. Similarly, women living in the highest-SES communities in 1990 had greater risk (OR = 1.30). Results were stronger in the analyses considering a latency period (OR = 1.69). Adjusting for intragroup correlation had little effect on the analyses. CONCLUSIONS: Models including individual- or community-level measures of SES produced associations similar to those observed in previous research. Results for models including both measures are consistent with a contextual effect of SES on risk of breast cancer independent of individual SES.     

Closing the chasm between research and practice: evidence of and for change

The usual remedy suggested for bridging the science‐to‐practice gap is to improve the efficiency of disseminating the evidencebased practices to practitioners. This reflection on the gap takes the position that it is the relevance and fit of the evidence with the majority of practices that limit its applicability and application in health promotion and related behavioural, community and population‐level interventions where variations in context, values and norms make uniform interventions inappropriate. To make the evidence more relevant and actionable to practice settings and populations will require reforms at many points in the research‐to‐practice pipeline. These points in the pipeline are described and remedies for them suggested.     

Individual-, family- and community-level determinants of full vaccination coverage among children aged 12–23 months in western Kenya

To identify individual-, family-, and community-level determinants of full vaccination status at most challenging areas in Kenya, we conducted a cross-sectional study among children aged 12–23 months and their mothers. 1965 children were involved in this research and their mothers completed a questionnaire. Middle or high knowledge of vaccination schedule (Adjusted Odds Ratio (AOR) = 2.69, 95%CI: 2.01–3.60 or AOR = 8.12, 95%CI:5.50–11.97), medium/long birth interval or first birth (AOR = 2.46, 95%CI: 1.29–4.69 or AOR = 1.84, 95%CI:1.10–3.09 or AOR = 2.14, 95%CI: 1.20–3.84), less than 5 children under five years old (AOR = 1.39, 95%CI: 1.04–1.88) and highest community health worker's (CHWs) performance (AOR = 2.20, 95%CI: 1.39–3.47) were significantly associated with complete vaccination status in the final multiple regression model. In addition, a interaction between literacy and wealth was significantly related in full vaccination status (AOR = 1.38, 95%CI: 1.08–1.75). Increased frequency and quality of CHW visits could be effective intervention to enhance vaccination coverage. Future interventions focusing on vaccination coverage should be given more attention especially to high risk group identified in this study.