Expenditures for Public Health: Assessing Historical and Prospective Trends

We integrated publicly available fiscal and budgetary data to assess historical and prospective trends in public health system funding at the federal, state, and local levels in relation to the recommended objectives outlined in the Institute of Medicine''s definitive 2002 report. Although historical growth rates for public health expenditures at all levels were competitive with other major funding objects (requested or funded budget items), outlays for health care services and medical research dwarfed public health spending in absolute amounts. Competition for scarce discretionary resources, competing policy priorities, and protracted fiscal pressures will make it difficult for public health systems to achieve the recommended objectives.Public health is often described by policymakers as an important national priority.¹ From an aging population to the growing threat of pandemic influenza and other emerging infectious diseases to the burgeoning health crises of obesity and other chronic illnesses, the most persistent and costly challenges to American health and well-being fall increasingly on the public health system and on public health professionals at all levels.²Since the seminal Future of Public Health was first published in 1988, the National Academy of Sciences and the Institute of Medicine (IOM) have returned repeatedly to discussion of the fragility of the public health system.³ In its 2002 reexamination of the challenges facing public health, the IOM''s definitive The Future of the Public''s Health in the 21st Century emphasized the critical role that public health agencies play in promoting health and mitigating disease burden in a heterogeneous and aging population.⁴ For an expanding and diverse range of social and public health challenges, the first responder is increasingly the emergency room physician, the community-based nurse, or the epidemiologist at the local public health department.⁵Although it is likely that components of the public health system have strengthened over time, the IOM and other analysts emphasize the urgent need to confront significant gaps that threaten the public''s health and security. According to the IOM, “the public health system that was in disarray in 1988 remains in disarray today.”⁶ Additional resources have become available since the IOM completed its report in 2002, principally related to biohazard and pandemic flu preparedness, but as the US Government Accountability Office and others have concluded in subsequent analyses, “much remains to be accomplished.”⁷Recent assessments of the functionality and performance of the public health system identified serious deficiencies and suggested that progress has not been uniform.⁸ Improvements in disease surveillance, laboratory capacity, communication, and public health workforce have strengthened federal, state, and local public health agencies and improved all-hazard preparedness, but observers have identified serious challenges and areas of continuing and unresolved concern.⁹ The public health workforce is aging rapidly; projected retirement rates among public health professionals as high as 45% over the next 5 years and high vacancy and turnover rates will strain state and local public health systems for years to come.¹⁰ Gaps also remain in essential public health functions at the state and local level. Regional interstate planning, planning for mass vaccination and the distribution of medical supplies, and development of adequate surge capacity are incomplete or insufficient. The Government Accountability Office concluded in 2004 that “no State is fully prepared to respond to a major public health threat,” an assessment that the Centers for Disease Control and Prevention (CDC) reiterated in 2008.¹¹In its recommendations to policymakers, the IOM emphasized the need to strengthen funding and support for public health agencies at all levels.¹² Of its 34 recommendations, 12 dealt explicitly with increased funding for public health system infrastructure and workforce components, and roughly another third could require additional funding support, at least indirectly, to achieve their objectives.¹³ Hundreds of medical, nursing, public health, and patient advocacy organizations have reinforced the IOM''s conclusion that further resource investments are needed to strengthen public health infrastructure and improve preparedness.¹⁴Broad consensus among public health stakeholders supports the argument that further investments are needed to ensure a functional, resilient public health system at all levels. It is therefore worth considering carefully the extent to which legislative and administrative policymakers whose decisions shape the federal budget and influence the legislative process for appropriations have actually increased (or plan to increase) resource commitments to public health funding objects (requested or funded budget items). Public budgeting is ultimately an attempt by policymakers to coordinate and balance individual policy preferences and public goods against the limited availability of scarce public resources. How has public health fared in resource competition with other funding objects? What are the expectations for public health funding growth in the foreseeable future?     

How is health-related “deservingness” reckoned? Perspectives from unauthorized im/migrants in Tel Aviv

Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care “make sense”? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related “deservingness.” In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, this article further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to – and, furthermore, from the perspectives of – unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must consider the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other.     

Practice paper of the American Dietetic Association: addressing racial and ethnic health disparities

Minority populations have remained in relatively poor health compared to the majority population and continue to be underserved by the health care system. Racial and ethnic health disparities are not new phenomena. Understanding the causes of these disparities continues to evolve. Within the past decade researchers have looked more toward social determinants of health to explain the differences. The Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care provided documentation to shift the discussion from patient behaviors to the contributions of health care systems, including health care providers, that contribute to health disparities. The report was the first comprehensive study that documented racial and ethnic inequities within the US health care delivery system (ie, differential treatment on the basis of race and ethnicity). The authors of the IOM report indicated that they found some evidence to suggest that bias, prejudice, and stereotyping by providers may contribute to differences in care. It is possible that food and nutrition practitioners have the same biases and are presented with the same systems challenges as the health care providers referenced in the IOM report. It is, therefore, also possible that food and nutrition practitioners may be at risk of contributing to health disparities. This article provides an in-depth look at the recommendations put forth by the IOM, offers discipline-specific recommendations consistent with those outlined in the IOM model, and introduces other models that may be of use as food and nutrition practitioners move forward with developing strategies to eliminate racial and ethnic health disparities.     

Service-learning: an integral part of undergraduate public health

In 2003, the Institute of Medicine (IOM) described public health as "an essential part of the training of citizens," a body of knowledge needed to achieve a public health literate citizenry. To achieve that end, the IOM recommended that "all undergraduates should have access to education in public health." Service-learning, a type of experiential learning, is an effective and appropriate vehicle for teaching public health and developing public health literacy. While relatively new to public health, service-learning has its historical roots in undergraduate education and has been shown to enhance students' understanding of course relevance, change student and faculty attitudes, encourage support for community initiatives, and increase student and faculty volunteerism. Grounded in collaborative relationships, service-learning grows from authentic partnerships between communities and educational institutions. Through emphasizing reciprocal learning and reflective practice, service-learning helps students develop skills needed to be effective in working with communities and ultimately achieve social change. With public health's enduring focus on social justice, introducing undergraduate students to public health through the vehicle of service-learning as part of introductory public health core courses or public health electives will help ensure that our young people are able to contribute to developing healthy communities, thus achieving the IOM's vision.     

Association of Prenatal Physical Activity and Gestational Weight Gain: Results from the First Baby Study

BackgroundIn response to increasing rates of excessive gestational weight gain (GWG) and evidence of postpartum weight retention and long-term overweight and obesity, the Institute of Medicine (IOM) revised their guidelines for GWG in 2009. Prenatal physical activity is recommended, although its role in preventing excessive GWG is unclear. We sought to understand the association between prenatal physical activity and GWG in a longitudinal cohort.MethodsDuring a baseline survey at 34 weeks, women (n = 3,006) reported their height, prepregnancy weight, and physical activity during pregnancy. GWG was self-reported at 1-month postpartum. Multivariable logistic regression adjusting for age, race/ethnicity, education, poverty status, marital status, gestational age at the time of delivery, and smoking was used to model the association between adequate physical activity during pregnancy and exceeding the IOM recommendations for GWG.FindingsOverweight women were most likely to exceed the IOM recommendations for GWG (78.7%), followed by obese women and normal weight women (65.0% and 42.4%, respectively). The majority of women participated in some physical activity during pregnancy, with 41.2% engaging in 60 to 149 minutes and 32.1% engaging in at least 150 minutes of physical activity per week. In adjusted analysis, meeting the physical activity guidelines was associated with a 29% (confidence interval, 0.57–0.88) lower odds of exceeding the IOM recommendations for GWG compared with inactive women.ConclusionsFindings of high rates of excessive GWG, especially among women with overweight and obesity, are concerning given the associated health burdens. The association of guideline-concordant physical activity with appropriate GWG suggests this is an important target for future interventions.     

以全健康理论提升我国应对突发公共卫生事件的能力

随着全球化进程和交通技术发展,突发公共卫生事件的影响范围可以在短时间内从发生地突破国家界限,并对其他国家形成健康威胁。突发公共卫生事件不仅累及人类-动植物-环境健康,对于社会发展也有长远影响,因此其应对方法已经超越了一般卫生问题,需要以整体和综合的策略进行应对。本文以全健康视角剖析了我国目前突发公共卫生事件应对体系存在的问题和短板,应用全健康相关理念,从整体、联动、发展、可持续的角度提出了相关建议,为我国进一步优化突发公共卫生事件应对体系提供参考依据。     

LESBIAN HEALTH RESEARCH: A REVIEW AND RECOMMENDATIONS FOR FUTURE RESEARCH

Prior to 1990 lesbians were "invisible" in health care research. Researchers who asked questions specifically about lesbian health concerns were rare, and the burgeoning research on women's health seldom included variables that measured sexual orientation or behavior. In the last decade, however, lesbian health has emerged as a major area of study. A 1999 Institute of Medicine (IOM) report on Lesbian Health has outlined the challenges and gaps in this area of research and has called for focus and funding on specific areas of need. In this article I review research on lesbian health, discuss methodological issues specific to this area of research, and summarize the recommendations of the IOM report.     

Considerations for increasing the competences and capacities of the public health workforce: assessing the training needs of public health workers in Texas

Background  

Over the last two decades, concern has been expressed about the readiness of the public health workforce to adequately address the scientific, technological, social, political and economic challenges facing the field. A 1988 report from the Institute of Medicine (IOM) served as a catalyst for the re-examination of the public health workforce. The IOM's call to increase the relevance of public health education and training prompted a renewed effort to identify competences needed by public health personnel and the organizations that employ them.     

Interprofessional Leadership Training in MCH Social Work

The need to train health social workers to practice interprofessionally is an essential goal of social work education. Although most health social workers have exposure to multidisciplinary practice within their field work, few social work education programs incorporate interprofessional learning as an integrated component of both course work and field experiences (McPherson, Headrick, & Moss, 2001; Reeves, Lewin, Espin, & Zwaranstein, 2010; Weinstein, Whittington, & Leiba, 2003). In addition, little is written about the kinds of curricula that would effectively promote interdisciplinary training for social work students. These findings are particularly puzzling since there is increasing and compelling evidence that interdisciplinary training improves health outcomes (IOM, 2001). This article describes a social work education program that incorporates an Interprofessional education and leadership curriculum for Maternal and Child Health Social Work (MCHSW) at the University of Maryland's School of Social Work. The University of Maryland's Interprofesisonal Training Model is described along with the components needed to formulate an interdisciplinary learning experience. Various outcomes and lessons learned are discussed.     

Do panel surveys really make people sick? A commentary on Wilson and Howell (60:11, 2005, 2623–2627)

In a recent article in this journal, Wilson and Howell [2005. Do panel surveys make people sick? US arthritis trends in the Health and Retirement Survey. Social Science &; Medicine, 60(11), 2623–2627.] argue that the sharp trend of rising age-specific arthritis prevalence from 1992 to 2000 in the USA among those in their 50s based on the original Health and Retirement Study (HRS) cohort of respondents is “almost surely spurious.” Their reasons are that no such trend is found in the National Health Interview Study (NHIS) over this same time period, and that an introduction of a new birth cohort into HRS in 1998 also indicates no trend. They also claim that there may be an inherent bias in panel surveys leading respondents to report greater levels of disease as the duration of their participation in the panel increases. This bias, which they call “panel conditioning,” suggests a tendency for participants in a longitudinal survey to seek out medical care and diagnosis of symptoms asked about in previous waves.     

Emerging infections: getting ahead of the curve.

The early history of infectious diseases was characterized by sudden, unpredictable outbreaks, frequently of epidemic proportion. Scientific advances in the late 19th and early 20th centuries resulted in the prevention and control of many infectious diseases, particularly in industrialized nations. Despite these improvements in health, outbreaks of infectious disease continue to occur, and new infections emerge. Since 1987, the National Academy of Science''s Institute of Medicine (IOM) has published three reports that have identified erosion of the public health infrastructure among the factors contributing to new and reemerging infectious diseases. In partnership with many public and private organizations in the United States and abroad, the Centers for Disease Control and Prevention (CDC) has developed a strategic plan that addresses the priorities set forth in the IOM reports and serves as a guide for CDC and its partners to combat emerging microbial threats to health. Laboratory-based surveillance, better communication networks, and improvements in the public health infrastructure are the cornerstones of the strategy. Emerging Infectious Diseases, a new periodical produced by CDC, will serve as a forum for exchange of information about incipient trends in infectious diseases, analysis of factors contributing to disease emergence, and development and implementation of prevention measures.     

Children's Health and Environment Education and Training for Health Care Professionals in Canada: Assessing Gaps,Barriers, and Needs

Abstract

Scientific evidence suggests that children may be especially vulnerable to environmental hazards. However, medical professionals are often unable to effectively diagnose and treat environment-related illness in patients. To rectify this, many have called for improved post-secondary education and training opportunities in this field in Canada. This study aims to assess the state of education and training for healthcare professionals in children's environment and health, identify related gaps and barriers, and develop recommendations for improvement. Survey participants indicated three primary barriers to the integration of children's health and environment topics in current curricula: a lack of available expertise in the discipline in Canada, a lack of perceived importance of the topic, and a lack of financial and institutional support. A concerted effort must be undertaken to overcome the identified barriers to produce a cadre of healthcare professionals skilled in children's health and environment.     

US Public Health Agency involvement in youth-focused illicit drug policy, planning, and prevention at the local level, 1999-2003

Objectives. We examined local public health agencies’ involvement in community illicit drug policy advocacy and provision related to youths to determine the extent to which public health agencies were involved in local drug policy activities and could potentially provide an infrastructure for policy alternatives.Methods. We conducted telephone interviews from 1999 to 2003 with 1793 US public health agencies in 804 communities surrounding schools participating in the Monitoring the Future study. Respondents reported public health agency planning, priorities, and involvement in alternative drug policy advocacy and prevention activities. We examined results for variance by site sociodemographic characteristics.Results. Most students lived where public health agencies provided resources for community- and school-based drug use prevention. More than one third resided where public health agencies advocated for drug policy alternatives and more than one quarter where public health agencies were involved in juvenile drug court programs. Such activities were significantly higher in urban communities, in the West, and in sites where the proportion of African Americans was above the national average.Conclusions. Although local public health agencies could increase participation levels in drug policy alternatives, current involvement suggests that agencies may provide a base for supporting the development of public health alternatives to deterrence-based drug policies. Such a base may be more likely in communities with the highest need for such policies and services.US illicit drug policy varies significantly by state and substance.1 However, deterrence approaches predominate. Health researchers have called for a public health policy focus that uses prevention and treatment in lieu of incarceration.2^–4 Whether a public health approach would better address US drug use than would deterrence is the subject of other articles. However, when considering policy approaches involving public health–related components, it would be helpful to know what role US public health agencies already play in drug policy and practice.A 1988 Institute of Medicine (IOM) report seriously questioned the ability of state and local health agencies to address immediate crises and enduring public health problems, including substance abuse.5 The IOM found that public health system capabilities were inadequate and called for public health “to serve as leader and catalyst of private efforts as well as performing those health functions that only government can perform.”5^(p31) Twelve years later, in a 2000 editorial in the Journal, Des Jarlais6 called for a public health approach to drug policy, including prevention, treatment alternatives to incarceration, and programs to reduce health consequences of drug abuse. Des Jarlais concluded that a major challenge for public health would be to incorporate scientific drug use research into public policies to reduce harms associated with use.Recent research has shown that state public health agencies are increasing participation in health policy formation and development7 and are helping to bridge gaps between adolescent drug treatment service need and provision.8 However, little is known about public health agency involvement in local-level alternative drug policy advocacy. Most drug arrests and policy applications occur at state and local levels.1^,9 Furthermore, federal drug control spending recently has moved away from treatment and prevention and toward supply reduction. From 2001 to 2007, federal drug control spending for treatment and prevention steadily decreased from 47% of the total budget to 37%, whereas proportional spending on supply reduction increased from 53% to 63%.10 Thus, the understanding of local public health agency activity relative to drug policy and related local-level services would help provide greater knowledge of the ability to meet the public’s need for substance abuse services.The ideal—but highly costly—method of investigating public health agency drug policy–related activity participation would involve conducting a random sample of all state and local public health agencies. We were positioned to survey public health agencies surrounding a nationally representative sample of middle and high schools. Substance use etiology indicates that drug use initiation occurs primarily during the middle and high school years; thus, it may be important to examine public health agency policies in communities surrounding such schools.11^,12 secondary-school youths are affected by public health agency advocacy for alternative public health drug policies and prevention activities? (2) What percentage of youths are affected by actual public health agency involvement in such alternatives? (3) Is there evidence for site sociodemographic variance in reported advocacy and involvement?     

Effect of Modifiable Risk Factors on Preterm Birth: A Population Based-Cohort

Objectives The purpose of this study is to evaluate the prevalence, impact, and interaction of short interpregnancy interval (IPI), pre-pregnancy body mass index (BMI) category, and pregnancy weight gain (PWG) on the rate of preterm birth. Methods This is a population-based retrospective cohort study using vital statistics birth records from 2006 to 2011 in OH, US, analyzing singleton live births to multiparous mothers with recorded IPI (n?=?393,441). Preterm birth rate at <37 weeks gestational age was compared between the referent pregnancy (defined as normal pre-pregnancy maternal BMI, IPI of 12–24 months, and Institute of Medicine (IOM) recommended PWG) and those with short or long IPI, abnormal BMI (underweight, overweight, and obese), and high or low PWG (under or exceeding IOM recommendations). Results Only 6?% of the women in this study had a referent pregnancy, with a preterm birth rate of 7.6?% for this group. Short IPIs of <6 and 6–12 months were associated with increased rates of preterm birth rate to 12.9 and 10.4?%, respectively. Low PWG compared to IOM recommendations for pre-pregnancy BMI class was also associated with increased preterm birth rate of 13.2?% for all BMI classes combined. However, the highest rate of preterm birth of 25.2?% occurred in underweight women with short IPI and inadequate weight gain with _adjOR 3.44 (95?% CI 2.80, 4.23). The fraction of preterm births observed in this cohort that can be attributed to short IPIs is 5.9?%, long IPIs is 8.3?%, inadequate PWG is 7.5?%, and low pre-pregnancy BMI is 2.2?%. Conclusions Our analysis indicates that a significant proportion of preterm births in Ohio are associated with potentially modifiable risk factors. These data suggest public health initiatives focused on preterm birth prevention could include counseling and interventions to optimize preconception health and prenatal nutrition.     

Review of Institute of Medicine and National Research Council Recommendations for One Health Initiative

Human health is inextricably linked to the health of animals and the viability of ecosystems; this is a concept commonly known as One Health. Over the last 2 decades, the Institute of Medicine (IOM) and the National Research Council (NRC) have published consensus reports and workshop summaries addressing a variety of threats to animal, human, and ecosystem health. We reviewed a selection of these publications and identified recommendations from NRC and IOM/NRC consensus reports and from opinions expressed in workshop summaries that are relevant to implementation of the One Health paradigm shift. We grouped these recommendations and opinions into thematic categories to determine if sufficient attention has been given to various aspects of One Health. We conclude that although One Health themes have been included throughout numerous IOM and NRC publications, identified gaps remain that may warrant targeted studies related to the One Health approach.     

Is compulsory overseas medical screening of migrants justifiable?

For more than four decades the international Organization for Migration (IOM) has been providing medical screening of prospective migrants according to the admission requirements of resettlement countries. The main reason resettlement countries impose mandatory medical screening is to prevent the entrance of migrants with certain health problems in the belief that they pose a potential public health risk or financial burden to the nation. High rates of communicable diseases among foreign-born residents of industrial countries have raised concern about the impact of international migration on transmission of such diseases and the role and efficacy of medical screening. IOM''s experience provides insight into the complex and sensitive problems related to mandatory screening of migrant populations, including: conflicting objectives, epidemiological concerns, uncertain economic benefit, and ethical dilemmas. Medically sound screening mechanisms must be formulated that meet the needs of receiving countries while responding to the epidemiology of disease, the rights of individuals, and the public health concerns of the community.     

Undergraduate public health at 4-year institutions: it's here to stay

Undergraduate public health education at 4-year institutions, those with and without graduate public health education, has grown rapidly during the first decade of the 21st century since the IOM recommended that "all undergraduates have access to education in public health." Much of this growth has been guided by the Educated Citizen and Public Health initiative, a collaboration of arts and sciences and public health educators that encourages introductory course work in public health, epidemiology, and global health plus undergraduate minors and majors in public health. The Educated Citizen and Public Health model, as opposed to existing professional models, envisions core public health education based on the Association of American Colleges and Universities' Liberal Education and America's Promise essential learning outcomes that encourage experiential learning, evidence-based thinking, a global and community focus, plus integration and synthesis. Public health education in this model provides solid generalist grounding for graduate education in public health as well as a range of graduate disciplines from the health professions to international affairs and from law to business. In addition, it helps ensure a broad range of college graduates who understand and support public health approaches. The Healthy People 2020 objective to increase the proportion of 4-year colleges and universities that offer minor or major in public health should help propel additional growth, especially in 4-year colleges without graduate public health education. Integrative curricula designed as part of the reform of undergraduate education provide opportunities to make evidence-based public health approaches available to a large number of undergraduates.     

Evaluating NRC’s Recommendations for Educating Children with Autism a Decade Later

Background

Over a decade ago, the National Research Council (NRC) published the influential book, Educating Children with Autism.

Objective

To survey parents and state-level special education administrators to evaluate how NRC’s recommendations, as published in Educating Children with Autism, have impacted educational practices for children with autism in the US.

Methods

149 parents of children with autism and 35 state-level special education administrators from 35 states were surveyed on the degree to which they agreed with NRC’s recommendations and the degree to which they believed NRC’s recommendations have been implemented.

Results

Parents and administrators agreed with most NRC recommendations; however, disagreements between parents and administrators were evident regarding labeling of students with autism, intensity of services, and training of staff. Conversely, parents and administrators concurred that the recommendations had been poorly to modestly implemented, overall. Lowest levels of implementation were found for training of qualified staff, research-based curricula, and mental health supports for families. Qualitative analysis of parents’ comments highlighted that vigorous advocacy was necessary for their children to receive appropriate services consistent with NRC’s recommendations.

Conclusions

Over a decade following publication of Educating Children with Autism, most of NRC’s recommendations have not been fully implemented. Policy makers should focus particular attention on improving professional training, disseminating research-based practices, and providing mental health supports for families.