Determinants of health policy impact: comparative results of a European policymaker study

Summary Objectives: This article will use a new theoretical framework for the analysis of health policy impact introduced by Rütten et al. (2003). In particular, it will report on a comparative European study of policymakers perception and evaluation of specific determinants of the policy impact, both in terms of output (implemented measures) and outcome (health behaviour change). Policy determinants investigated are goals, resources, obligations and opportunities as related to the policymaking process. Methods: Theory is applied to a comparative analysis of prevention and health promotion policy in Belgium, Finland, Germany, The Netherlands, Spain and Switzerland. The study is MED2-part of a project that has developed a Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies (MAREPS) within the EU-BIOprogram. A mail survey of 719 policymakers on the executive and administrative level selected by a focused sample procedure was conducted. This survey used policymakers experience and evaluative expertise to analyse determinants of policy output and outcome. Results: Regression analyses reveal differential predictive power of policy goals, resources, obligations, as well as of political, organisational and public opportunities. For instance, whereas resources, concreteness of goals, and public opportunities have significant importance for health outcome of policy, obligations and organisational opportunities significantly predict policy output. Conclusions: Results are discussed in terms of rationality and effectiveness of health policy. They indicate that six sensitising constructs derived from the theoretical framework represent equivalent structures across nations. They comprise a validated instrument that can be used for further comparative health policy research.     

Determinants of health policy impact: a theoretical framework for policy analysis

Summary This paper addresses the role of policy and evidence in health promotion. The concept of von Wrights logic of events is introduced and applied to health policy impact analysis.According to von Wright (1976), human action can be explained by a restricted number of determinants: wants, abilities, duties, and opportunities. The dynamics of action result from changes in opportunities (logic of events). Applied to the policymaking process, the present model explains personal wants as subordinated to political goals. Abilities of individual policy makers are part of organisational resources. Also, personal duties are subordinated to institutional obligations. Opportunities are mainly related to political context and public support. The present analysis suggests that policy determinants such as concrete goals, sufficient resources and public support may be crucial for achieving an intended behaviour change on the population level, while other policy determinants, e.g., personal commitment and organisational capacities, may especially relate to the policy implementation process. The paper concludes by indicating ways in which future research using this theoretical framework might contribute to health promotion practice for improved health outcomes across populations.     

From public health research to health promotion policy: on the 10 major contradictions

Summary The rise of evidence-based medicine has given impetus to calls for more research evidence to be incorporated into health policy. The difficulty in effecting this research transfer has often been attributed to the different worlds of researchers and policy-makers. There are other contradictions, however, that must be addressed in attempting to bridge public health research and health promotion policy. These include such issues as: what forms of evidence are required, what types of research are usually funded, the limited scope and duration of health promotion programs, how health policies are formulated, contemporary public sector management reforms, and so on. These contradictions need to be recognized and managed if closer links are to be formed between public health research and health promotion policy.     

The role of intimate partner violence, race, and ethnicity in help-seeking behaviors

Objective . Women experiencing intimate partner violence (IPV) have multiple health and social service needs but many, especially Hispanic, women may not access these resources. This research sought to examine the relationship between IPV and health and social services utilization (help-seeking behaviors), with a focus on racial and ethnic disparities.

Design . Case-control study from an urban US emergency department population in which cases (women with IPV) and controls (women without IPV) were frequency matched by age group and race/ethnicity. Logistic regression analyses were performed to examine the relationship between IPV and help-seeking behaviors and between help-seeking behaviors and race/ethnicity among abused women. In addition, a stratified analysis was conducted to examine the relationship between acculturation and help-seeking behaviors among Hispanic women.

Results . The sample included 182 cases and 147 controls. Among the health services, alcohol program, emergency department, and hospital utilization were significantly increased among IPV victims compared to non-victims after taking demographic and substance use factors into account. Similarly, IPV victims were more likely to access social/case worker services and housing assistance compared to non-victims. Specific help-seeking behaviors were significantly associated with race and ethnicity among IPV victims, with non-Hispanic white and black women more likely to use housing assistance and emergency department services and black women more likely to use police assistance compared to Hispanic women. Among all Hispanic women, low acculturation was associated with decreased utilization of social services overall and with any healthcare utilization, particularly among abused women.

Conclusions . Social service and healthcare workers should be alerted to and screen for IPV among all clients. The need for increased outreach and accessibility of services for abused women in Hispanic communities in the USA should be addressed, with cultural and language relevance a key component of these efforts.     

Determinants of health policy impact: comparative results of a European policymaker study

Objectives: This article will use a new theoretical framework for the analysis of health policy impact introduced by Rütten et al. (2003). In particular, it will report on a comparative European study of policymakers perception and evaluation of specific determinants of the policy impact, both in terms of output (implemented measures) and outcome (health behaviour change). Policy determinants investigated are goals, resources, obligations and opportunities as related to the policymaking process. Methods: Theory is applied to a comparative analysis of prevention and health promotion policy in Belgium, Finland, Germany, The Netherlands, Spain and Switzerland. The study is MED2-part of a project that has developed a Methodology for the Analysis of the Rationality and Effectiveness of Prevention and Health Promotion Strategies (MAREPS) within the EU-BIOprogram. A mail survey of 719 policymakers on the executive and administrative level selected by a focused sample procedure was conducted. This survey used policymakers experience and evaluative expertise to analyse determinants of policy output and outcome.     

Integrierte Gesamtansätze kommunaler Gesundheitsförderung für Kinder

Background

Integrated and comprehensive community-based health promotion approaches aimed at children are systematically supported in North Rhine-Westphalia. The goal is a community-based approach that focuses on health promotion from the prenatal phase to career entry. Findings regarding the effects on health and the scope of this approach are lacking so far.

Objectives

The main focus is on the analysis of community-based health promotion approaches in the pilot communities of Moers and Oberhausen with special attention given to the daycare center, primary school, and urban neighborhood settings. The implementation process, awareness, and utilization of health promotion measures by vulnerable families, and the links between utilization and child health will be investigated specifically.

Methods and Materials

The research consortium “Growing up healthy” funded by the German Federal Ministry of Education and Research has developed a joint study design that integrates different dimensions of child health (i.e., physical, mental, social, and behavioral) and key factors (urban neighborhood, daycare center/school, family). It is a hybrid research approach combining a nonrandomized cluster-controlled study design with qualitative investigations and participatory quality development.

Results

The integrative study approach enables the examination of complex hypotheses regarding healthy child development and the links between different health dimensions, health promotion measures, and settings.

Conclusion

The research consortium “Growing up healthy” contributes to the continued development and design of needs-based and comprehensive local interventions for children’s health promotion and primary prevention.

     

Bicultural stress and adolescent risk behaviors in a community sample of Latinos and non-Latino European Americans

Objectives . The study examined the relation between adolescent risk behaviors and bicultural stress due to discrimination, immigration, and acculturation factors. We hypothesized bicultural stress would be related to increased risk behavior and depressive symptoms independent of socioeconomic status, ethnic self-identification, and acculturation.

Design . Middle school student participants (n=519; median age 14) completed a self-report questionnaire on their risk behaviors, psychosocial antecedents, and socio-demographic factors. Latino (304) and non-Latino European American (215) students were surveyed through a large, urban, West Coast US school district.

Results . More bicultural stress was significantly related to reports of all risk behaviors (i.e. smoking, drinking, drug use, and violence) and depressive symptoms. Further, bicultural stress was a robust explanatory variable across sub-groups, and appears largely independent from depressive symptoms.

Conclusion . The hypotheses were supported. Bicultural stress appears to be an important underlying factor for health disparities among US adolescents. Future research may consider promoting well-being in majority, as well as minority adolescents, through targeting sources of bicultural stressors or examining ways to moderate their effects on adolescent risk behaviors.     

Investigation of health promotion status in specialized hospitals associated with Hamadan University of Medical Sciences: health-promoting hospitals

Objectives: The prophecy of health promoting hospitals (HPH) is bringing about a change and transition from treatment-oriented to health-oriented attitudes. In Iran, hospitals usually play the traditional roles. The present study was aimed at the evaluation of the health promotion status in specialized hospitals associated with Hamadan University of Medical Sciences (HUMS).

Methods: This applied study was conducted in two Hamadan specialized hospitals in the Hamadan city. The health promotion status was evaluated using a self-assessment checklist designed by the World Health Organization’s HPH. The evaluation was done in five standards including management policy, patient assessment, patient information and intervention, promotion of a healthy workplace and continuity and cooperation.

Results: The results showed that both the hospitals studied had a poor status in terms of promoting a healthy workplace (average = 31.24%) and management policy standards (average = 35.29%) in comparison with the other relevant standards: patient assessment (53.12%), patient information and intervention (62.5%), continuity and cooperation (65.78%)). The results of the standards and sub-standards status displayed better performance in the cardiovascular hospital (53.67%) compared to the women and parturition hospital (42.64%).

Conclusion: The findings indicated that HPH standards are very low in the studied hospitals. The reason behind this wide gap might be due to the fact that hospitals in Iran are more treatment-oriented and patient-oriented and they do not play an active part in health promoting. It was found that management policy and promoting healthy workplace standards had the worst status and must be improved.     

Active health promotion in old age: methodology of a preventive intervention programme provided by an interdisciplinary health advisory team for independent older people

People live longer today and, therefore, have more opportunity to a quire non-fatal disabilities in old age. Disability in old age has multifactorial causes, including physiological, psychological and social risk factors. An innovative health promotion and prevention programme designed for elderly people was developed at the Albertinen-Haus Geriatrics Centre in Hamburg in 2001 and offered to residents of the city aged 60 years and over who were living in their own homes. Eligible individuals were independent, i.e. without disabilities (not in need of care or support according to the German health systems categorization), and without cognitive impairment. The programme focuses on areas of health behaviour that are interrelated and target self-efficacy and empowerment. The programme used an interdisciplinary approach in group sessions. The team of health promotion advisers (Gesundheitsberater-Team) consisted of members of four professions, i.e. physician, social worker, physiotherapist, and nutrition and home economics specialist. We decided to work in group sessions because of the potential for positive dynamic effects between group participants and for reasons of cost. We also developed a curriculum to train professional members of interdisciplinary geriatric teams to work as health promotion advisers for elderly people.

Community, social capital and Indigenous health in the Northern Territory

Objective. The objective of this paper is to explore the discourse of ‘community’ and its offshoots, ‘social capital’ and ‘community capacity building’, in the contexts of health service delivery to, and the health status of, Indigenous people in the Northern Territory of Australia, and to link this discourse to the wider context of social control and the management of diversity in a multicultural society.

Design. The discourse is subjected to critical theoretical and historical analysis and comparisons are drawn between this and similar discourses in the immigration and settlement area.

Results/conclusions. The constitution of Indigenous society as a series of ‘communities’ and the orientation of primary health care policy towards ‘capacity building’ has the effect, if not the intention, of depoliticising Indigenous health, whilst reproducing, legitimising and mystifying relations of white dominance and permitting the maintenance of a health service delivery system for Indigenous people which, in relation to need, is grotesquely underfunded and incapable of making serious inroads into the appalling health problems of the Indigenous population.     

Changing definitions altered multimorbidity prevalence,but not burden associations,in a musculoskeletal population

ObjectivesThe inclusion of musculoskeletal conditions within multimorbidity research is inconsistent, and working-age populations are largely ignored. We aimed to: (1) estimate multimorbidity prevalence among working-age individuals with a range of musculoskeletal conditions; and (2) better understand the implications of decisions about the number and range of conditions constituting multimorbidity on the strength of associations between multimorbidity and burden (e.g., health status and health care utilization).Study Design and SettingUsing data from the Australian National Health Survey 2007–08, the associations between burden measures and three ways of operationalizing multimorbidity (survey, policy, and research based) within the working-age (18–64 years) musculoskeletal population were estimated using multiple logistic regression (age and gender adjusted).ResultsDepending on definition, from 20.2% to 75.4% of working-age individuals with musculoskeletal conditions have multimorbidity. Irrespective of definition, multimorbidity was associated with increased likelihood of subjective health burden, pain or musculoskeletal medicines use, nonmusculoskeletal specialist and pharmacist (advice only) consultations, and reduced likelihood of not consulting health professionals. A group with intermediate health outcomes was considered multimorbid by some, but not all definitions. With the restrictive policy and research multimorbidity definitions, this intermediate group is included within the reference population (i.e., are considered nonmultimorbid). This worsens the reference group's apparent health status thereby leveling the comparative burden between those with and without multimorbidity. Consequently, dichotomous cut points lead to similar associations with burden measures despite the increasingly restrictive multimorbidity definitions used.ConclusionsAll multimorbidity definitions were associated with burden among the working-age musculoskeletal population. However, dichotomous cut points obscure the gradient of increased burden associated with restrictive definitions.     

Mental health services in Ethiopia: emerging public health issue

Objectives

Examine the mental health issues in Ethiopia in relation to services offered in this direction.

Study Design

Retrospective.

Methods

Results of the 2005 Ethiopian Demographic and Health Survey and other secondary data sources were explore dimensions of to understand the mental health issues.

Results

The average prevalence of mental disorders in Ethiopia was 18 % for adults and 15% for children. People are now more than ever aware of the importance of mental health. Families now do not need much agitation to seek medical help for their mentally ill members. Unfortunately, the mental health services are available only in Addis Ababa the capital city of Ethiopia. By consequence, a large number of the adolescent is homeless, and lives on the street. Low status of women in Ethiopia underpins and often directly undermines utilization of reproductive health services. Even though, the policy makers or research managers are giving more importance to the reproductive health issues. But, mental health services are emerging issues which determines the development goals of the country.

Conclusion

A critical requirement for the mental health promotion is to have information, increase mental health services, trained skilled workers, education and self-confidence to access available services. The key policy rapid actions needed.     

Health literacy among university students in Greece: determinants and association with self-perceived health,health behaviours and health risks

Background

Health literacy is widely considered as a key determinant of health and a priority in the public health policy agenda. Low health literacy has been associated with poorer health states, broader inequalities and higher health systems’ costs. In the present study we bring into focus the functional health literacy among university students in Greece, researching and assessing mainly their ability to apply basic knowledge in a health context.

Methods

The study was carried out during the period 15–30 April 2013, among a random sample of 1,526 students of 14 Higher Tertiary Public universities and Technological Educational Institutes in Greece. The objective of the study was to assess the functional health literacy among university students in Greece, adopting the short four-item comprehension test of Bostock and Steptoe. Summary statistics, correlations and regressions were used to assess the determinants of health literacy and the association with self-perceived health, health behaviours and health risks.

Results

Economic factors, such as family income, demographic factors, such as gender, and health behaviours and risks, namely consumption of alcohol, smoking and physical workout are associated with the level of health literacy and health status of the participant. While the results of the study are consistent with previous work in this area, several findings worth further research.

Conclusions

Though, health promotion interventions in Greece include health literacy as one of the basic pillars of the public health policy agenda, it is clear, that health literacy needs to become a key policy issue in Greece, mainly focusing in young ages, where healthy (or unhealthy) behaviours are established affecting the health through the life span.     

'Making evidence count': a framework to monitor the impact of health services research

Objectives: The objective of this study is to develop a framework to measure the impact of primary health care research, describe how it could be used and propose a method for its validation. Design: Literature review and critical appraisal of existing models of research impact, and integration of three into a comprehensive impact framework. Setting: Centre of Research Excellence focusing on access to primary health care services in Australia. Participants: Not applicable. Interventions: Not applicable. Main outcome measure: The Health Services Research Impact Framework, integrating the strengths of three existing models of research impact. Conclusion: In order to ensure relevance to policy and practice and to provide accountability for funding, it is essential that the impact of health services research is measured and monitored over time. Our framework draws upon previously published literature regarding specific measures of research impact. We organise this information according to the main area of impact (i.e. research related, policy, service and societal) and whether the impact originated with the researcher (i.e. producer push) or the end‐user (i.e. user pull). We propose to test the utility of the framework by recording and monitoring the impact of our own research and that of other groups of primary health care researchers.     

Government,politics and health policy: A quantitative analysis of 30 European countries

RationalePublic health policies are often dependent on political decision-making, but little is known of the impact of different forms of government on countries’ health policies. In this exploratory study we studied the association between a wide range of process and outcome indicators of health policy and four groups of political factors (levels of democracy, e.g. voice and accountability; political representation, e.g. voter turnout; distribution of power, e.g. constraints on the executive; and quality of government, e.g. absence of corruption) in contemporary Europe.Data and methodsData on 15 aspects of government and 18 indicators of health policy as well as on potential confounders were extracted from harmonized international data sources, covering 30 European countries and the years 1990–2010. In a first step, multivariate regression analysis was used to relate cumulative measures of government to indicators of health policy, and in a second step panel regression with country fixed effects was used to relate changes in selected measures of government to changes in indicators of health policy.ResultsIn multivariate regression analyses, measures of quality of democracy and quality of government had many positive associations with process and outcome indicators of health policy, while measures of distribution of power and political representation had few and inconsistent associations. Associations for quality of democracy were robust against more extensive control for confounding variables, including tests in panel regressions with country fixed effects, but associations for quality of government were not.ConclusionsIn this period in Europe, the predominant political influence on health policy has been the rise of levels of democracy in countries in the Central & Eastern part of the region. In contrast to other areas of public policy, health policy does not appear to be strongly influenced by institutional features of democracy determining the distribution of power, nor by aspects of political representation. The effect of quality of government on health policy warrants more study.     

The effects of social support on health, well-being and management of diabetes mellitus: a black South African perspective

Objectives To determine the underlying dimensions of a social support measure and investigate the effects of social support on health, well-being and management of diabetes mellitus (metabolic control and blood pressure (BP) control).

Design A cross-sectional, analytical design was used with a structured questionnaire, comprising demographic characteristics, the MOS Social Support Survey scale and the health perceptions and mental health sub-scales from the SF-20.

Setting Two outpatient diabetes mellitus clinics in Pretoria, South Africa.

Participants Over a three-month period, the questionnaire was administered to 263 black diabetes mellitus outpatients (174 women and 89 men), aged between 16 and 89 years. The majority of patients (91%) were diagnosed as type 2 diabetes mellitus. Only 22% of the patients had acceptable metabolic control (HbA₁c<8.0%), in comparison with 46% who had good BP control (130/85 mmHg). There were significant differences between the clinics on BP control: participants from clinic 1 had better BP control than participants from clinic 2.

Results Principal components analysis, followed by an orthogonal (VARIMAX) rotational solution, resulted in two social support factors accounting for 78.9% of the variance. The first factor was labelled socio-emotional support, due to the emphasis on close caring relationships. The second factor was concerned with the more tangible aspects of social support, such as the provision of assistance. Coefficient alpha was 0.97 (socio-emotional support), 0.95 (tangible support) and 0.97 (overall social support). Patients with lower levels of social support had poorer general health and well-being than patients with higher levels of social support. Controlling for clinic, patients with controlled BP had significantly more socio-emotional and tangible support than patients with poor BP control.

Conclusions The study demonstrated that: (1) socio-emotional and tangible support were the underlying dimensions of social support; (2) socio-emotional support is an important determinant of health and well-being; and (3) social support is beneficial for one aspect of diabetes mellitus management, namely, BP control.     

Mutuality at the center: health promotion with Cape Verdean immigrant women

Objective. Public health care researchers, policy makers, and providers are increasingly interested in developing more effective and culturally responsive health promotion theories and interventions for diverse immigrant populations. The purpose of this study was to develop health promotion theory that validates the local knowledge and experiences of Cape Verdean women health promoters who work with immigrant women in their community.

Design. In-depth, semi-structured interviews were conducted with nine culturally savvy, community-based Cape Verdean women health promoters about their perspectives and daily experiences of health promotion practice with Cape Verdean immigrant women. This study used Glaserian grounded theory to analyze the interviews. This approach identified concepts and developed an integrated process through which to theorize about the practice of health promoters.

Results. For Cape Verdean women health promoters, a process of creating relationships was a key to promoting women's health. The relational theory of health promotion practice reflects these dynamic processes, properties, and stages through which Cape Verdean women health promoters develop mutually engaging relationships with immigrant women.

Conclusion. These findings challenge health care professionals to broaden the repertoire of health promotion strategies to include relationship-building between health promoters and community women. Through these relationships health promoters can understand the complex structural, cultural, and community factors that influence immigrant women's health and incorporate that knowledge into more effective health promotion practices.     

The determinants of self-rated health among ethnic minorities in Hungary

Background . The health status of a population is largely determined by the mutually interrelated factors of social and financial conditions, and by lifestyle, including health-related behaviour. The aim of the study was to investigate the factors influencing self-rated health among different ethnic minorities living in closed communities in the South-East Hungarian region.

Methods . The cross-sectional survey was based on interviewer-administered questionnaires on socio-demographic variables, lifestyle and health status. In the study 100–120 persons were recruited from Serbian, Croatian, Romanian, German minorities and the Hungarian population. Univariate and multivariate logistic regression models were used.

Results . In the univariate analyses, poor self-rated health correlated with all the factors examined except marital status. In the multivariate logistic regression model, poor health was found to be significantly associated with age, educational level, ethnicity, body mass index and chronic diseases. Poor self-rated health was observed in the Croatians and in the Hungarian control group.

Conclusion . In South-East Hungary, demographic parameters, especially being a member of a minority, and objective health status are highly important determinants of self-rated health. Several of the parameters studied in our survey indicated no effect or no special differences within the population of the region as concerns of self-rated health; certain other factors, however, proved to be special features for the studied ethnic minority, justifying the launching of target group-oriented health intervention programmes.