Legitimizing diabetes as a community health issue: a case analysis of an Aboriginal community in Canada

The Kahnawake Schools Diabetes Prevention Project (KSDPP) is an ongoing participatory research and intervention project aimed at the primary prevention of type 2 diabetes. Formally initiated in 1994 with strong community support, KSDPP provides a fertile opportunity to learn about how a community came to identify the need for preventive action on a health problem such as diabetes. The purpose of our study was to describe the various conditions in the community of Kahnawake, which gave rise to its mobilization for the prevention of type 2 diabetes. Qualitative data consisted of 12 individual interviews and one focus group with key community members and health professionals living and/or working in the community of Kahnawake, along with historically relevant documents. The data collection and analysis procedures of the grounded theory method were applied. Results describe a preceding phase to formal KSDPP implementation, triggered by returning research results on the community prevalence of type 2 diabetes. This phase of 'legitimizing diabetes as a community health issue' is characterized by a shift in the perceived preventability of diabetes among community members; from a problem that was to be lived with to a problem that was to be prevented. The shift in perceptions was facilitated by the context in the community, described by structural developments, cognitive and relational elements. In addition to reaffirming the critical importance of utilizing lay knowledge during the planning of a health promotion intervention, our study has uncovered some of the key conditions through which individuals in the community came to participate in the identification and planning of a diabetes prevention project.     

Evaluating quality and sustainability: issues and insights from the Minnesota Heart Health Program

Many community-based studies have been implemented nationallyand internationally in the last two decades. Quality and sustainabilityare desirable qualities of such health-promotion programs, yethave received relatively little attention in the literature.This paper begins to address these issues by examining the qualityof programs that were incorporated and continued by the threeintervention communities of the Minnesota Heart Health Program(MHHP). Of the original MHHP programs, 53% were still in operation6 years after formal interventions stopped. Key staff memberswith each of these programs were interviewed regarding changesto the program (57% had been changed substantially), and aspectsof program quality such as ongoing staff training, regular planningand evaluation activities, and management structure. Overall,programs were found to be of good quality. Reflections on theprocess of assessing quality are discussed, and insights onincorporation offered.     

The Effectiveness of a Health Promotion Program for the Low-Income Elderly in Taipei,Taiwan

This study assessed the effectiveness of a health promotion program for low-income elderly provided by trained low-income home health aides. Indicators of the effectiveness of this program included improvement in physical health, psychosocial health and functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL) as well as changes in perceived health promotion needs. This evaluation study used a single group pre- and post-test experiment design. After informed consent forms were signed by participants, 89 purposively selected low-income elderly (aged 64–96) completed pre-test structured surveys, while 60 participants (aged 68–96) completed post-test surveys. Post-test scores indicated improved nutritional status (paired t = 2.64, p < .05) and chore management of IADL abilities (paired t = 2.83, p < .01). No significant difference in psychosocial status were found between pre- and post-test scores. Perceived needs for health promotion services decreased after the intervention. The results show that the health promotion services were effective in improving health status and decreasing perceived needs for services among low-income elderly in Taipei. Recommendations based on this study for developing services for the low-income elderly must take health promotion intervention into consideration.     

People and money matter: investment lessons from the Ontario Heart Health Program, Canada

Resource allocation is a critical issue for public health decision-makers. Yet little is known about the level and type of resources needed to build capacity to plan and implement comprehensive programs. This paper examines the relationships between investments and changes in organizational capacity and program implementation in the first phase (1998-2003) of the Ontario Heart Health Program (OHHP)--a province-wide, comprehensive public health program that involved 40 community partnerships. The study represents a subset of findings from a provincial evaluation. Investments, organizational capacity of public health units and implementation of heart health activities were measured longitudinally. Investment information was gathered annually from the provincial government, local public health units and community partners using standard reports, and was available from 1998 to 2002. Organizational capacity and program implementation were measured using a written survey, completed by all health units at five measurement times from 1994 to 2002. Combining provincial and local sources, the average total investment by year five was $1.66 per capita. Organizational capacity of public health units and implementation of heart health activities increased both before and during the first 2 years of the OHHP, and then plateaued at a modest level for capacity and a low level for implementation after that. Amount of funding was positively associated with organizational capacity, yet this association was overpowered by the negative influence of turnover of a key staff position. Regression analysis indicated that staff turnover explained 23% of local variability in organizational capacity. Findings reinforce the need for adequate investment and retention of key staff positions in complex partnership programs. Better accounting of public health investments, including monetary and in-kind investments, is needed to inform decisions about the amount and duration of public health investments that will lead to effective program implementation.     

An Evaluation of the Effects of a Breastfeeding Support Program on Health Outcomes

ObjectiveTo estimate the causal effect of a Michigan peer counselor (PC) breastfeeding support program for low-income women on infant health outcomes.ConclusionsThis Michigan PC breastfeeding support program resulted in improvements in breastfeeding and infant health outcomes as measured by the diagnosis of ailments while increasing health care utilization.     

Evaluation of the Aboriginal and Torres Strait Islander Mental Health First Aid Program

Objective : This study reports findings from an uncontrolled evaluation of a course designed to educate participants in how to recognise and respond to mental health problems until professional help is received. Methods : Utilising a mixed methods design, participants in 21 different courses, delivered across two Australian states, were invited to complete pre‐, post‐, and follow‐up surveys and provide qualitative feedback on their training experiences. Results : Participants reported feeling more confident in their capacity to respond appropriately to a person presenting with a mental health need and believed they would be more likely to provide assistance. Satisfaction was attributed to the skills and sensitivities of instructors who had lived experience of mental health concerns in Aboriginal and Torres Strait Islander communities. Conclusion : This course holds promise in improving mental health literacy in relation to Aboriginal and Torres Strait Islander mental health. Implications for public health : Few courses are available that address issues relating to the social and emotional wellbeing of Aboriginal and Torres Strait Islander People. This study illustrates how community engagement with primary health and specialist mental health services might be strengthened.     

三级医院临床学科带头人胜任力评价模型

目的 构建临床学科带头人胜任力评价指标体系,为客观评价上海市三级甲等综合性医院临床学科带头人提供一定的实践依据.方法 采用目的抽样的方法选取上海市五所三级甲等综合性医院从事临床工作10年以上,具有高级职称的临床医疗专家或医学管理专家共计50名作为样本,应用层次分析法(AHP)对临床学科带头人胜任力评价指标进行权重函询,运用专家咨询法初步构建临床学科带头人胜任力评价指标体系.结果 构建的上海市三级甲等综合性医院临床学科带头人胜任力评价指标包括专业技能、管理能力、人文素质和个性品质4个一级维度,24个二级指标和74个典型行为描述.结论 临床学科带头人评价指标应既体现临床学科带头人的知识及技能,又体现临床学科带头人的个性态度及价值观,职业素养等理念.     

A community education monitoring system: methods from the Stanford Five-City Project, the Minnesota Heart Health Program and the Pawtucket Heart Health Program

Understanding the process of behavior change interventions is critical to achieving campaign effectiveness and successful program replication. The present article presents a community education monitoring system (CEMS) using data from the Stanford Five-City Project (FCP), the Minnesota Heart Health Program (MHHP) and the Pawtucket Heart Health Program (PHHP). CEMS records the number and type of intervention activities, outcome objectives, targets of change (individual, organizational or environmental), channel(s) of dissemination and proportion of programs funded by the community. These data illustrate (1) the application of theory for each project, (2) data-based program administration, (3) feedback for revising programs and (4) type of reach or 'dose' information obtained from intervention monitoring. Process evaluations such as CEMS provide critical links between field realities and evaluation outcomes. This type of evaluation develops standards for measuring program reach and allows comparisons with other programs. CEMS also illustrates how programs enact theory. Validation studies are critical to the continued successful use of CEMS. The first step, however, is to develop a uniform way of describing complex multichannel behavior change programs. CEMS in a refined form should prove invaluable to health promotion program planners whether in research or service settings.     

Evaluating food stamp nutrition education: a view from the field of program evaluation

The purpose of this paper is to review current approaches and issues in the field of program evaluation that apply to the effort of improving the evaluation of Food Stamp Nutrition Education (FSNE). As nutrition educators respond to increasing demands for accountability and measuring results, there are challenges to consider, as well as opportunities to capture. This paper includes a focus on the internal and external functions of evaluation, with attention given to evaluation's internal use and value in improving practice. A list of 10 building blocks is offered as essential for planning useful and credible evaluation of FSNE.     

关于建立北京市农村社区卫生服务效果、效益评价指标体系的研究

目的建立一套适宜北京市的农村社区卫生服务效果、效益评价指标体系。方法改进的特尔菲(Delphi)法。结果经两轮专家函询共确定评价指标109项,其中一级指标5项,二级指标34项,三级指标99项。两轮专家权威程度较高,分别为0.7509和0.7319。协调系数分别为0．176和0.195。结合专家权威系数,从重要性和可操作性两方面综合专家评分结果,确定指标最终组合权重,其中投入、服务内容、服务满意度、服务费用和效果效益五项一级指标的权重分别是0．2118、0.1813、0．2145、0.1889和0.2035。结论本指标体系的建立考虑了北京市农村社区卫生服务发展水平,是全方位的评价指标体系,适用于农村地区社区卫生服务中心或社区卫生服务站的评价。     

Baseline Assessment of the Health Status and Health Behaviors of African Americans Participating in the Activities-for-Life Program: A Community-Based Health Intervention Program

Obesity is a serious problem in the United States and is associated with hypertension, diabetes, and other health problems such as heart disease and some forms of cancer. There is a higher prevalence of being overweight among African American adults than among their Caucasian counterparts. The objective of this study was to assess baseline health behaviors and health status (hypertension, body mass indices, cholesterol and blood sugar levels) of African Americans participating in a community-based health education and physical fitness program. The sample consisted of 1.34 African American adults (30% males) from a low-income urban area in the Midwest. A health survey was administered to assess their health behaviors and previously diagnosed health problems. Additional data was obtained from health screenings to obtain current information on height, weight, and blood sugar, blood pressure and cholesterol levels. In addition to the sample being markedly overweight and obese (30% and 60% respectively), the results of the health screenings indicated a disproportionate number of participants (62%) with hypertension; 74% of the male participants had high blood pressure. Moreover, the self-reported data suggested that the participants had poor eating habits, sedentary lifestyles, and previously diagnosed health conditions (hypertension, diabetes, and high cholesterol levels) that were comparable to the results of their health screenings. These findings suggest that culturally-relevant, community-based programs that incorporate both nutritionl education and physical fitness are needed in order to educate and motivate participants to decrease behaviors that put them at risk for obesity and other health related problems.     

The Impact of Subsidized Health Insurance for the Poor: Evaluating the Colombian Experience Using Propensity Score Matching

This paper evaluates the impact of Colombia’s subsidized health insurance program (SUBS) on medical care utilization. Colombia’s SUBS program is a demand-side subsidy intended for low-income families, where the screening of beneficiaries takes place in decentralized locations across the country. Due to the self-selection problems associated with non-experimental data, we implement Propensity Score Matching (PSM) methods to measure the impact of this subsidy on medical care utilization. By combining unique household survey data with community and regional data, we are able to compute propensity scores in a way that is consistent with both the local government’s decision to offer the subsidy, and with the individual’s decision to accept the subsidy. Although the application of PSM using these rich datasets helps to achieve a balance between the treatment and control groups along observable dimensions, we also present instrumental variable estimates to control for the potential endogeneity of program participation. Using both methods, we find that Colombia’s subsidized insurance program greatly increased medical care utilization among the country’s poor and uninsured. This evidence supports the case for other Latin American countries implementing similar subsidy programs for health insurance for the poor.JEL classification:     

Evaluating occupational health and safety programs in the public sector

Background Two case studies are presented of public sector occupational health and safety (OHS) program evaluations, one of an occupational medicine and safety program (OMSP), one of an employee assistance and wellness program (EAWP). Methods Both audits involved interviews with key personnel, review of written documentation and physical resources, chart audits, and surveys of the programs' stakeholders. Results Key findings of the OMSP evaluation were that the various functions were substantially hampered by the absence of an integrated information system. Mechanisms for effective coordination, communication, and feedback were also lacking. The EAWP audit concluded that it provided a valuable and needed service. The mission, staff, facilities, and services offered were in line with the needs of the served community. Discussion Differences between private and public sector OHS program evaluation include programmatic and environmental factors such as resource availability, organizational structure, and accountability. Similarities include trends in both sectors forcing programs to justify themselves in terms of economic benefits to their respective organizations. Am. J. Ind. Med. 34:600–606,1998. © 1998 Wiley-Liss, Inc.     

Critical realism: a philosophical framework for the study of gender and mental health

Abstract  This paper explores gender and mental health with particular reference to the emerging philosophical field of critical realism. This philosophy suggests a shared ontology and epistemology for the natural and social sciences. Until recently, most of the debate surrounding gender and mental health has been guided either implicitly or explicitly within a positivist or constructivist philosophy. With this in mind, key areas of critical realism are explored in relation to gender and mental health, and contrasted with the positions of positivism and constructivism. It is argued that critical realism offers an alternative philosophical framework for the exploration of gender issues within mental health care.     

Local Experiences in Community Health: Examples from Canada,Brazil and Mali,and an Experiment in France

This paper presents the findings of international research with an original approach anchored in health geography, which illustrates the importance of place as a dimension in community health. The aim of the research is to identify the success factors in the processes used to build community health initiatives at the local level. The study is based on interviews encoded and analysed using the framework of the grounded theory. Three main themes—the place, the community and healthcare supply—and two cross-cutting issues referring to 18 explanatory dimensions are identified. These findings are then put to the test in France through an action research approach. Overall, the work suggest avenues to enable the transferability of successful elements of community health initiatives.     

Evaluating a program of psychological interventions in primary health care: consumer distress, disability and service usage

OBJECTIVE: To evaluate a Better Outcomes of Mental Health Care Access to Allied Psychological Services Program for general practice patients referred for high-prevalence mental disorders. METHODS: Participants were South Australian general practitioners (GPs; n=26) and their patients referred for treatment of high-prevalence psychological disorders, of whom 229 provided baseline measures, 106 provided post-treatment measures, and 85 provided follow-up data three months after termination of treatment. Interventions were Focused Psychological Strategies supplied by mental health specialists; outcome variables included GP satisfaction, patient satisfaction, psychological distress, life impairment, and health service usage. RESULTS: Satisfaction with the treatment program was high for both the GPs and the referred patients. Patients who attended three or more treatment sessions showed reduced distress and disability, and gains were maintained three months later. Health service usage declined with acceptance of referral regardless of treatment experience. CONCLUSIONS: Lack of controls and missing data were methodological weaknesses. Results support the effectiveness of integrated primary mental health care to reduce psychological distress and disability, while impact on service usage warrants further investigation. IMPLICATIONS: Reduction of suffering and increased economic productivity may both result from this public health initiative to increase access to effective treatments for common chronic mental conditions.     

Long-Term Effectiveness of a Multifactorial Fall and Fracture Prevention Program in Bavarian Nursing Homes: An Analysis Based on Health Insurance Claims Data

Objective

Femoral fractures are frequently consequences of falls in nursing homes and are associated with considerable costs and unfavorable outcomes such as immobility and mortality. The purpose of this study was to examine the long-term effectiveness of a multifactorial fall and fracture prevention program in nursing homes in terms of reducing femoral fractures.