Ambiguous expectations for intersectoral action for health: a document analysis of the Danish case

Ideas about intersectoral action and policy-making for health (ISA) are prominent among public health professionals. They are often presented as effective ways to address root causes of poor health and health inequality, and as such the best way to promote population health. The implementation of such ideas has proven difficult though. In this paper we argue that neo-institutional theory can help us conceptualize implementation challenges by pointing to implicit expectations and contradictions associated with the ISA idea itself. With Denmark as empirical case, we conducted a document analysis of recommendations for municipal ISA. The analysis shows how the recommendations provide a very abstract conceptualization of ISA that does not give much practical guidance for action. We show how ISA is discursively constructed with buzzword qualities as the natural way to organize health promotion, by being presented as a means to produce better quality services, more cost-effective operations and ensure the future of the welfare state, while at the same time hardly changing much at all. By applying the lens of institutional logics we show how ISA, although being vaguely defined, offer ambiguous normative and symbolic repertoires for action. We discuss the implementation challenges associated with this advocacy rhetoric and suggest that the domination of the corporation logic may appear to reduce the political character of ISA and potentially conflict with the ideals of health as a matter of social justice and human rights.     

Understanding the challenges of intersectoral action in public health through a case study of early childhood programmes and services

After two decades of intersectoral public health action, the literature reports considerable ongoing difficulty in achieving this aim. This article analyses two of the challenges of intersectoral action: (1) ensuring convergence among the interests and resources of sectoral actors, and (2) coordinating the multiplicity of sectoral programmes. A case study employing Actor–Network Theory is used to provide an in-depth understanding of the persistence of these problems. In 2008, the Montreal Directorate of Public Health in the province of Quebec, Canada, implemented a vast consultation and mobilization process to address problems highlighted by the Survey of the School Readiness of Montreal Children. The process mobilized regional and local multi-sectoral actors in order to propose solutions. At the local community level, the process resulted in increased coordination leading to intersectoral innovation, while at the regional level it brought about the deployment of additional resources, albeit in sectoral programmes. This study analyses how intersectoral issues raised by the survey have been addressed so as to produce these results. It discusses how the balance between sectoral interests and the common good, as well as between sector autonomy and interdependence, is central to dealing with these two critical challenges.     

A public health model of the social determinants of health

Summary As we move forward in the new century, epidemiologists and public health practitioners are faced with the challenge of reviewing the current direction of epidemiology and its links with public health. While the history of epidemiology has been a successful and productive one, there is a danger that modern epidemiology is becoming too narrow in its scope, concerned primarily with the analysis of risk factors in individuals, while ignoring sociological and ecological perspectives of health. We argue that a theoretical framework to guide the practice of epidemiology is needed which encompasses a role for social determinants of health while simultaneously also acknowledging the importance of behaviour and biology, and the inter-connectedness of all these factors. This paper presents a public health model of social determinants of health, which provides a framework for testing the causal pathways linking social determinant variables with health care system attributes, disease inducing behaviours and health outcomes. This approach provides an improved opportunity to identify and evaluate evidence-based public health interventions, and facilitates stronger links between modern epidemiology and public health practice.     

The importance of addressing social determinants of health at the local level: the case for social capital

Social determinants are gaining momentum in public health practice. Many proposed solutions for tackling social determinants are outside the scope of local public health professionals. This article reviews the literature to find possible moderating variables which may buffer the effects of the social determinants of health at the local level, and allow social determinants to be addressed within the purview of local health departments. The systematic approach employed for this article entailed searches of electronic academic databases (PubMed, EBSCO and Medline) and additional searches using Internet search engines and relevant websites for articles published between 1,975 and May 2010. The search revealed 2,554 articles, and 36 were determined appropriate for inclusion. The purpose of the search was to identify published articles relating to social determinants of health, social capital and effective approaches for addressing both at the level of the local health department. The search was then expanded to include unpublished material, to include the perspectives of local health departments. This process resulted in the inclusion of content from five sources. In this article, the case is made for focusing on social capital interventions to mitigate health problems associated with social determinants. Examples of successful interventions are provided to aid public health professionals in developing locale-specific solutions for addressing social determinants.     

Developing a tool to assess responsibility in health innovation: Results from an international delphi study

Objectives

The way new health technologies are being developed and brought to market undermines the sustainability of health systems around the world and limits the emergence of innovations that could generate greater system-level benefits. While Responsible Research and Innovation (RRI) offers relevant principles to address this policy problem, there are no tools to assess whether an innovation qualifies as a Responsible Innovation in Health (RIH). Drawing on RRI and health policy research, we developed a RIH Tool that entails a three-step process: screening, assessment and rating.

Understanding similarities in the local implementation of a healthy environment programme: insights from policy studies

This paper reports findings from an evaluation of the local implementation of a procedural public health programme whose objective is to create healthy environments (HE) for vulnerable families in the province of Quebec (Canada) through the funding of local projects. Considering the potential issue of programme–context interaction, our research question was the following: Does the procedural nature of this HE programme result in variation between local cases in terms of the types of projects and collaborations it subsidizes? Given that the creation of healthy environments requires intersectoral health action to address social determinants of health, the data were analysed with respect to intersectorality and cooperation. Results of this qualitative multiple case study (n = 8), for the period 2004–2009, show that the majority of subsidized projects were in the health and social services sector and focused on parenting, parent–child attachment, nutrition and the social networks of families. Only a few initiatives reached beyond the health and social services sector to address social health determinants such as education, housing and transportation. Membership and mandates of the local groups responsible for programme implementation also showed little intersectorality. The limited variation between these eight cases can be attributed to the configuration of the local networks, as well as to specific issues in urban and rural areas. To explain the overall similarity of results across cases, we turned to the literature on policy instruments which suggests that particular characteristics of a programme may produce effects that are independent of its intended objective. In our study, several programme mechanisms, such as those framing the definition of «healthy environment» and budget management rules, could have encouraged the local development of initiatives that focus on individual skills related to parenting and attachment rather than the development of intersectoral health action to address social determinants of health.     

Cost analysis as a management tool for improving the efficiency of primary care: some examples from Java.

Health programs in developing countries increasingly face limited or even reduced budgets. More and better services might be produced from these resources by improving efficiency through better management and program design. Cost analysis at individual health units can help identify sources of inefficiency, and provide guidance to managers as to where they can achieve important gains in productivity. This paper presents several examples from health centers and sub-centers in rural Java. Indonesia, showing how inefficiencies in staffing patterns, personnel management, and drug management can affect cost-efficiency. Routine analysis of cost data could provide the basis for management incentives to local health units to increase both outputs and quality of care.     

A simple simulation model as a tool to assess alternative health care provider payment reform options in Vietnam

Vietnam is currently considering a revision of its 2008 Health Insurance Law, including the regulation of provider payment methods. This study uses a simple spreadsheet-based, micro-simulation model to analyse the potential impacts of different provider payment reform scenarios on resource allocation across health care providers in three provinces in Vietnam, as well as on the total expenditure of the provincial branches of the public health insurance agency (Provincial Social Security [PSS]). The results show that currently more than 50% of PSS spending is concentrated at the provincial level with less than half at the district level. There is also a high degree of financial risk on district hospitals with the current fund-holding arrangement. Results of the simulation model show that several alternative scenarios for provider payment reform could improve the current payment system by reducing the high financial risk currently borne by district hospitals without dramatically shifting the current level and distribution of PSS expenditure. The results of the simulation analysis provided an empirical basis for health policy-makers in Vietnam to assess different provider payment reform options and make decisions about new models to support health system objectives.     

从妇女保健看京沪健康战略的优先与落实

目的分析京沪两地健康战略发布的优先程度及落实现状,比较其差异,并论证其重要意义。方法系统收集国家和京沪两地健康优先战略及公开发布的妇保相关所有政策文献,量化分析健康发展战略的"优先程度""规范引导程度""职责明确程度""任务落实程度"以及"考核评估程度",探讨两地健康战略的优先与落实的效果。结果两地健康战略的优先程度均为65.0%、规范引导程度分别为59.2%(上海)和64.6%(北京),而职责明确程度、任务落实程度和考核评估程度等均为0.0%。结论适宜公共卫生体系应将健康作为优先发展战略,且形成可操作的政策并落实到位。目前京沪两地健康战略的落实现状总体较低,距离理想水平差距较大。     

Definition of an algorithm for the management of common skin diseases at primary health care level in sub-Saharan Africa

In order to help primary health care (PHC) workers in developing countries in the care of common skin diseases, an algorithm for the management of pyoderma, scabies, superficial mycoses, contact dermatitis and referral of early leprosy cases (based on the identification of diseases through the presence of objective key signs, and on treatments by generic drugs) was elaborated. One thousand patients were seen by trained dermatologists, who established diagnoses and treatments; in addition, there was systematic recording of each key sign, according to the successive algorithm steps. We compared the diagnostics and treatments obtained for several combinations of diagnostic signs, with those of the dermatologists. Sensitivity, specificity, positive predictive value and negative predictive value of defined combinations were high for pyoderma, scabies and superficial mycoses. Values were less exact for dermatitis and leprosy, but were considered sufficient for the level of health care targeted. The apportionment of treatments between the algorithm and the dermatological approaches was considered appropriate in more than 80% of cases; mismanagement was possible in 7% of cases, with few predictable harmful consequences. The algorithm was found satisfactory for the management of the dermatological priorities according to the standards required at the PHC level.     

A tool for enhancing strategic health planning: a modeled use of the International Classification of Functioning,Disability and Health

This article describes use of the International Classification of Functioning, Disability and Health (ICF) as a tool for strategic planning. The ICF is the international classification system for factors that influence health, including Body Structures, Body Functions, Activities and Participation and Environmental Factors. An overview of strategic planning and the ICF are provided. Selected ICF concepts and nomenclature are used to demonstrate its utility in helping develop a classic planning framework, objectives, measures and actions. Some issues and resolutions for applying the ICF are described. Applying the ICF for strategic health planning is an innovative approach that fosters the inclusion of social ecological health determinants and broad populations. If employed from the onset of planning, the ICF can help public health organizations systematically conceptualize, organize and communicate a strategic health plan. This article is a US Government work and is in the public domain in the USA.     

‘Punching above their weight’: a qualitative examination of local governments’ organisational efficacy to improve the social determinants of health

Objective : The World Health Organization calls upon local government worldwide to play a greater role in improving public health by improving the social determinants of health. This research aimed to determine how local governments in Victoria, Australia, conceptualised their organisational efficacy to address public health with reference to their statutory obligations. Methods : Sixteen in‐depth interviews were conducted with Victorian local government health planners. Thematic analysis was used to determine the importance of state health priorities and the perceived organisational efficacy of local government to address health via social determinants. Results : While there were disparities between state and local priorities for health, local government believes it can make an important contribution to improving health through ‘upstream’ approaches. Conclusions : Victorian local government has strongly adopted the socio‐ecological model of health and is aware of the important role that its diverse policy and program areas play in creating healthy communities. The Victorian State Government’s priorities, which adopted a more ‘downstream’ approach, were less influential. Implications for public health : State governments’ priority settings should be responsive to local governments’ unique local knowledge of health priorities. There is value in legislating a social determinants role for local government, provided it is supported by state and national government policies that facilitate public health.     

云南省农村“结合型”村级生育健康服务模式案例研究

云南省姚安县的若干行政村近年出现了将计划生育、妇幼保健及妇联工作相结合的村级“结合型”生育健康服务模式。本研究探索了该服务模式产生的历史背景及过程,并对其利与弊进行了调研和讨论。     

Path analysis of income, coping and health at the local level in a Canadian context

This article explores the relationships between social, physical, and sociodemographic characteristics and the health status of individuals within four contrasting neighbourhoods in Hamilton, Ontario, using a cross-sectional design. Using data from a telephone survey conducted in 2001 and 2002 of a random sample of adults (1504 respondents, response rate = 60%), path analysis was used to estimate direct and indirect effects of neighbourhood location and satisfaction on health; specifically, the effect of income, coping skills, and neighbourhood satisfaction on self-rated health. Coping was found to be an important mediator between several lifestyle and neighbourhood characteristics and health outcomes. Income and other measures of wealth such as housing tenure, employment, money worries, and lack of money/food bank use were found significant in all health outcomes as well as daily coping ability. Since coping ability was found to be more important for health status than income, policy implications include a greater emphasis on social programmes to assist individuals to manage stress, as well as income support.     

A proposed core model of the new public health for a healthier collectivity: how to sustain transdisciplinary and intersectoral partnerships

At present, there is no conceptual model by which public health could be represented as intersectoral governance collaborating with society and the state, and acting as a collective on the determinants of health. In this article, our interdisciplinary group, representing core competencies in public health, suggest two complementary conceptual models as frameworks for a diverse public concerned with public health and its core functions. The first conceptual ‘core model’ roots from the Ottawa Charter for Health Promotion. It represents the interrelationships of the three main poles united at the biopower level: the collectivity (entire population), the contemporary state and public health. In the second conceptual model, we present the various components in the meta-network of public health governance. We also present the roles of heterogeneous actors and how they can collaborate within a prominent process of capacity building and development of practice in public health. Thus, we emphasize the importance of intersectoral partnerships the contemporary state can make with public health without inducing any rupture with the social fabric. Our two complementary models can help actors from all sectors better understand the most frequent questions in public health governance (functions, roles, ingredients) and the challenges that intersectoral actors may very likely encounter in the implementation of these frameworks. The sustainability of well-balanced transdisciplinary and intersectoral partnerships contribute to a successful implementation of public health governance, and most importantly to a good health status for the collectivity.     

The social determinants of health as predictors of adherence to public health preventive measures among parents and young children during the COVID-19 pandemic: a longitudinal cohort study

ObjectivesTo investigate whether social determinants of health (SDOH) are predictive of adherence to public health preventive measures and to describe changes in adherence over time among parents and children.MethodsA longitudinal study was conducted in children aged 0–10 years and their parents through the TARGet Kids! COVID-19 Study in the Greater Toronto Area, Canada (April–July 2020). This study included 335 parents (2108 observations) and 416 children (2632 observations). Parents completed weekly questionnaires on health, family functioning, socio-demographics, and public health practices. The outcome was adherence to public health preventive measures measured separately for parents and children. Marginal log-binomial models were fitted using repeated measures of the outcome and predictors.ResultsUnemployment (RR 0.67, 95% CI: 0.47, 0.97), apartment living (RR 0.72, 95% CI: 0.53, 0.99), and essential worker in the household (RR 0.74, 95% CI: 0.55, 1.00) were associated with decreased likelihood of adherence among parents; however, no associations were observed for other SDOH, including family income and ethnicity. Furthermore, there was no strong evidence that SDOH were associated with child adherence. The mean number of days/week that parents and children adhered at the start of the study was 6.45 (SD = 0.93) and 6.59 (SD = 0.86), respectively, and this decreased to 5.80 (SD = 1.12) and 5.84 (SD = 1.23) by study end. Children consistently had greater adherence than parents.ConclusionSDOH were predictive of adherence to public health preventive measures among parents but less so in children among our sample of relatively affluent urban families. Adherence was high among parents and children but decreased over time. Equitable approaches to support the implementation of public health guidelines may improve adherence.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00540-5.     

Seeing the forest and the trees: using network analysis to develop an organizational blueprint of state tobacco control systems

In the United States, tobacco control activities are organized primarily in state tobacco control programs. These programs are comprised of public and private agencies working together to reduce tobacco use. The human, financial, and informational resources that go into state tobacco control programs are documented, and the outcomes of these programs have been studied in terms of health and health behavior. However, little is known about the organizational infrastructure that transforms the human, financial, and informational resources into positive health outcomes. This study examined the inter-organizational relationships among key partner agencies in eight state tobacco control programs. The state programs varied in terms of funding level, funding stability, and region of the country. Using a network analytic approach we asked an average of 14 agencies in each state program about their contacts and partnerships with the other key tobacco control agencies in their state program. Using network visualization and statistics we determined that the state networks shared some common features such as a highly central lead agency, but also had differences in network structure in terms of density and centralization. Using blockmodeling we found that, despite differences in state and program characteristics, there was a common organizational structure among the eight state programs. Understanding the inter-organizational relationships and the common organizational structures of state programs can aid researchers and practitioners in enhancing program capacity and in developing strategies for organizing effective public health systems.     

Interventions for physical activity promotion applied to the primary healthcare settings for people living in regions of low socioeconomic level: study protocol for a non-randomized controlled trial

Background

Regular physical activity practice has been widely recommended for promoting health, but the physical activity levels remain low in the population. Therefore, the study of interventions to promote physical activity is essential. Objective: To present the methodology of two physical activity interventions from the “Ambiente Ativo” (“Active Environment”) project.

Methods

12-month non-randomized controlled intervention trial. 157 healthy and physically inactive individuals were selected: health education (n = 54) supervised exercise (n = 54) and control (n = 49). Intervention based on health education: a multidisciplinary team of health professionals organized the intervention in group discussions, phone calls, SMS and educational material. Intervention based on supervised exercise program: consisted of offering an exercise program in groups supervised by physical education professionals involving strength, endurance and flexibility exercises. The physical activity level was assessed by the International Physical Activity Questionnaire (long version), physical activities recalls, pedometers and accelerometers over a seven-day period.

Result

This study described two different proposals for promoting physical activity that were applied to adults attended through the public healthcare settings. The participants were living in a region of low socioeconomic level, while respecting the characteristics and organization of the system and its professionals, and also adapting the interventions to the realities of the individuals attended.

Conclusion

Both interventions are applicable in regions of low socioeconomic level, while respecting the social and economic characteristics of each region.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01852981","term_id":"NCT01852981"}}NCT01852981     

安徽省2004-2010年县级妇幼保健机构发展状况分析

目的:了解安徽省县级妇幼保健机构的发展状况,为妇幼保健机构建设与发展提供依据。方法:开展连续多年监测,对全省县级妇幼保健机构2004-2010年度的资源、服务提供及运营情况等进行分析。结果:安徽省县级妇幼保健机构呈现良好的发展态势,但仍存在政府投入不足、人员编制不够、结构不合理、队伍整体素质不高、妇幼保健机构基础建设缺乏规范、机构之间发展不平衡等问题。结论:应进一步强化政府发展妇幼保健事业的责任,增加投入,加强妇幼保健人才队伍建设,制定妇幼保健机构设置标准,加强对妇幼保健机构的考核评估。