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The Emerging Case for the The Emerging Case for the Effectiveness of Health Effectiveness of Health
PromotionPromotion
David V. McQueenDavid V. McQueenAssociate Director for Global Associate Director for Global
Health PromotionHealth PromotionWorld Bank, September 14, 2004World Bank, September 14, 2004
The accepted triangular relationship
Policies & ProgramsPolicies & Programs(Health or Non-health)(Health or Non-health)
DeterminantsDeterminantsof Healthof Health
Health ImpactHealth Impact(Outcomes)(Outcomes)
An old-old (tedious) storyAn old-old (tedious) story
The health of populations is affected The health of populations is affected by and is a product of the social by and is a product of the social determinants in the populationdeterminants in the population
Early Insights orEarly Insights orwe knew it thenwe knew it then
Graunt (London, 1662)Graunt (London, 1662)• Analysis of social distribution of Analysis of social distribution of
mortality rates mortality rates Virchow and Engels (mid-19Virchow and Engels (mid-19thth
century) century) • Effects of social class and work Effects of social class and work
conditions on illness ratesconditions on illness rates Durkheim (Paris, 1897)Durkheim (Paris, 1897)
• Social integration and suicideSocial integration and suicide
History and Theory of Public Health:History and Theory of Public Health:
Slowly Changing ParadigmsSlowly Changing Paradigms Sanitary Era (when we knew it)Sanitary Era (when we knew it)
Germ TheoryGerm Theory
Infectious & Chronic Disease Infectious & Chronic Disease Epidemiology Epidemiology (individual risk factor (individual risk factor epidemiology--“social” Epidemiology)epidemiology--“social” Epidemiology)
* * Health Promotion (finding it again)Health Promotion (finding it again)
Health Promotion Perspective: Health Promotion Perspective: The Components of The Components of ContextContext
LIFELIFESTYLESTYLE: Collective pattern of life conduct: Collective pattern of life conduct LIFE LIFE CONDUCTCONDUCT: Pattern of behavior of an : Pattern of behavior of an
individual in their day-to-day livesindividual in their day-to-day lives LIFE LIFE CONDITIONSCONDITIONS: Patterns of resources of an : Patterns of resources of an
individual or group (including health status)individual or group (including health status) LIFE LIFE SITUATIONSITUATION: Collective pattern of life : Collective pattern of life
conditions conditions LIFE LIFE CHANCESCHANCES: Structural-based probability of : Structural-based probability of
correspondence of lifestyle and life situationcorrespondence of lifestyle and life situation
Adapted from Rutten, A. (1995). The implementation of health Adapted from Rutten, A. (1995). The implementation of health promotion: a new structural perspective. promotion: a new structural perspective. Social Science & MedicineSocial Science & Medicine, , 41(2), 1627-1637.41(2), 1627-1637.
SOCIOCULTURAL ENVIRONMENT FRAMEWORK
Determinants
SOCIALRESOURCES
Standard of livingCulture and historySocial institutionsBuilt environmentsPolitical structuresEconomic systems Technology
Neighborhood Living Conditions
Community Development and Employment Opportunities
Opportunities for Learning and
Developing Capacity
Community Customs, Norms and Processes
Civic Engagement & Participation
in Decision-Making
Intermediate Outcomes
Health Outcome
Health Promotion, Prevention
and Care Opportunities
PHYSICALENVIRONMENT
Natural Resources
EQUITY ANDSOCIALJUSTICE
.
HEALTHIER COMMUNITIES
“The process of enabling people to increase control over, and to improve, their health” WHO, 1984, 1986 and Epp, 1986
“Any activity or program designed to improve social and environmental living conditions such that people’s experience of well-being is increased” Labonté & Little, 1992
HP definitionsHP definitions(there are many)(there are many)
The Historical Development of Health The Historical Development of Health Promotion in the 20Promotion in the 20thth Century: Two Traditions, Century: Two Traditions,
Two OriginsTwo Origins
The continentThe continent North AmericaNorth America
Framed by concernswith the social,economic and political roots of health
Focus on the sociopolitical
Framed by the enlargementof the traditional scope ofhealth education
Focus on the individual
The Historical Development of Epidemiology The Historical Development of Epidemiology in the 20in the 20thth Century: Two Traditions, One Old, Century: Two Traditions, One Old,
One RecentOne Recent
EpidemiologyEpidemiology Social EpidemiologySocial Epidemiology
Framed by concerns with etiology, traditional bio-medical model and a developed disciplinary base in scientific method
Framed by the enlargementof the traditional scope ofepidemiology
Focus on the individual plusfocus on the sociopolitical
Dominant Patterns of WorkDominant Patterns of Work
MethodsMethods ActionAction TheoryTheory Concerned Concerned
with CAUSEwith CAUSE
ActionAction Concepts and Concepts and
PrinciplesPrinciples MethodsMethods Concerned Concerned
with with CHANGECHANGE
Epidemiology Health Promotion
Health Promotion and EffectivenessHealth Promotion and Effectiveness
Effectiveness is a broad, loosely defined Effectiveness is a broad, loosely defined term, generally linked to the notion of term, generally linked to the notion of “outcomes”“outcomes”
Notion that effective health promotion Notion that effective health promotion leads to changes in the determinants of leads to changes in the determinants of health is a little differenthealth is a little different
Underlying epistemology of “outcomes” Underlying epistemology of “outcomes” remains complicatedremains complicated
Complexity and Methodology areComplexity and Methodology areIntertwined in Health PromotionIntertwined in Health Promotion
Most community-based health promotion Most community-based health promotion interventions include a complex mixture of interventions include a complex mixture of many disciplines, many variables of varying many disciplines, many variables of varying degrees of measurement difficulty, and degrees of measurement difficulty, and dynamic changing settingsdynamic changing settings
Understanding multi variate fields of action Understanding multi variate fields of action may require a mixture of complex may require a mixture of complex methodologies and considerable time to methodologies and considerable time to unravel causal relationshipsunravel causal relationships
Identifying appropriate change processes
HighCertainty about what works
Low
High
Low
Agreement about how to do it
Standards Guidance
Political compromise
Experiment
Innovation
Creativity
“Zone of Complexity”
Trial & Error
• Focus on areas with high certainty and high agreement• Understand and utilze effective change processes
StrategyStrategyHealth DisparitiesHealth Disparities
Focus on the closing the gap in Focus on the closing the gap in both the rates and risks for poor both the rates and risks for poor
healthhealth
Tackle DeterminantsTackle Determinants
The root causes of socioeconomic The root causes of socioeconomic inequitiesinequities
Social Resources Social Resources Mediate Exposure to Health RisksMediate Exposure to Health Risks
Social ResourcesStandard of livingCulture and historySocial institutionsBuilt environmentsPolitical structuresEconomic systems Technology
PhysicalEnvironment
COMMUNITYHEALTH
Part IIPart II
EFFECTIVE INTERVENTIONS IN THE SOCIAL ENVIRONMENT TO IMPROVE COMMUNITY HEALTH
Efforts of the CPSTF**Community Preventive Services Task Force – an HHS task force
Priority Interventions for Health Priority Interventions for Health Enhancing Social EnvironmentsEnhancing Social Environments
RANKED BY POTENTIAL IMPACT ON IMPROVING COMMUNITY HEALTHRANKED BY POTENTIAL IMPACT ON IMPROVING COMMUNITY HEALTH
11 Child development programs (Head Start, etc.).Child development programs (Head Start, etc.).
22 Adequate public investment in education.Adequate public investment in education.
33 ““Living wages” to move working families above poverty.Living wages” to move working families above poverty.
44 Access to quality health care for all ages.Access to quality health care for all ages.
55 Mixed income housing to decrease segregation by Mixed income housing to decrease segregation by socioeconomic status.socioeconomic status.
66 Programs to reintegrate stigmatized populations.Programs to reintegrate stigmatized populations.
77 Parenting classes in settings: schools, churches, etc.Parenting classes in settings: schools, churches, etc.
88 Neighborhood schools as a setting forprograms.Neighborhood schools as a setting forprograms.
99 Family-focused, 1-stop health and human services centers.Family-focused, 1-stop health and human services centers.
1010 Adequate health benefits with employment.Adequate health benefits with employment.
Completed Systematic ReviewsTT
OO
PP
II
CC
NeighborhoodNeighborhood
LivingLiving
ConditionsConditions
Opportunities for Opportunities for Learning and Learning and Developing Developing
CapacityCapacity
Health Promotion Health Promotion Prevention and Prevention and
Care OpportunitiesCare Opportunities
II
NN
TT
EE
RR
VV
EE
NN
TT
II
OO
NN
Mixed-income Mixed-income housing housing developments.developments.
Rental voucher Rental voucher subsidies which subsidies which allow families allow families choice in choice in residential residential location.location.
Publicly funded, Publicly funded, center-based, center-based, comprehensive comprehensive early childhood early childhood development development programs for low-programs for low-income children, income children,
3-5 years of age.3-5 years of age.
Culturally competent Culturally competent health care systems:health care systems:
-interpreters and-interpreters and
bilingual staffbilingual staff
-cultural diversity -cultural diversity
training for training for providersproviders
-linguistically and-linguistically and
culturally culturally appropriateappropriate
health informationhealth information
-ethnic specific -ethnic specific servicesservices
Center-Based Early Childhood Center-Based Early Childhood Development ProgramsDevelopment Programs
•Publicly funded for low-income children ages 3-5
•Comprehensive focus (e.g. Head Start)
cognitive development
social development
health and dental services
home environment
Search for EvidenceSearch for Evidence
English language research literatureEnglish language research literature
1965 to the present1965 to the present
educational, health and social science educational, health and social science databasesdatabases
2,000 citations were screened2,000 citations were screened
57 studies were the subject of detailed 57 studies were the subject of detailed abstractionabstraction
15 studies constituted the best evidence 15 studies constituted the best evidence based on study design and qualitybased on study design and quality
Key Findings:Key Findings:Preventing Cognitive Preventing Cognitive Developmental DelayDevelopmental Delay
Effect measureEffect measure MedianMedian
Placement in special Placement in special education classeseducation classes
(12 studies)(12 studies)
12% decrease12% decrease
Retained (“held-back”) Retained (“held-back”) in grade levelin grade level
(12 studies)(12 studies)
21% decrease21% decrease
The spatial concentration of poverty has been shown to have an adverse effect on a range life experiences, from isolating families from employment opportunities to limiting youth to inferior education, dangerous neighborhood conditions, and harmful environmental conditions.
HOUSING AND HEALTH
Family Housing InterventionsFamily Housing Interventions
Provide affordable housing Provide affordable housing
Decrease residential segregation by Decrease residential segregation by socioeconomic statussocioeconomic status
deconcentration interventions: deconcentration interventions:
mixed-income housing mixed-income housing developmentsdevelopments
dispersion interventions: dispersion interventions:
tenant-based rental voucherstenant-based rental vouchers
Tenant-based Rental VouchersTenant-based Rental Vouchers
Intervention Description
•Rental assistance to low-income families so no more that 30% of household income is required for housing
•Allow families choice in residential location in the private rental market in neighborhoods with adequate goods and services
Search for EvidenceSearch for Evidence
English language research literatureEnglish language research literature
1965 to the present1965 to the present
governmental, architectural, economic, governmental, architectural, economic, health and social science databaseshealth and social science databases
510 citations were screened510 citations were screened
23 studies were the subject of detailed 23 studies were the subject of detailed abstractionabstraction
23 studies constituted the best evidence 23 studies constituted the best evidence based on study design and qualitybased on study design and quality
Key Findings:Key Findings:Intentional injuries, victimization, and Intentional injuries, victimization, and
neighborhood safetyneighborhood safety
Effect measureEffect measure MedianMedian
Household member Household member victimized by crime against victimized by crime against
person or property person or property
(6 studies)(6 studies)
6% 6% decreasedecrease
Neighborhood social disorderNeighborhood social disorder
(6 studies)(6 studies)16% 16%
decreasedecrease
Culturally Competent Health Care Culturally Competent Health Care SystemsSystems
•Recruit, retain, and promote staff to reflect the cultural diversity of the community served
•Diversity training for staff
•Access to bilingual staff or interpreter services
•Culturally and linguistically appropriate health education materials
•Ethnic-specific healthcare settings (e.g. neighborhood clinic for recent immigrant group)
Search for EvidenceSearch for Evidence
English language literatureEnglish language literature
1965 to the present1965 to the present
health, social and behavioral science health, social and behavioral science databasesdatabases
980 citations were screened980 citations were screened
17 studies were the subject of detailed 17 studies were the subject of detailed abstractionabstraction
6 studies constituted the best evidence 6 studies constituted the best evidence based on study design and qualitybased on study design and quality
Recruit and retain diverse staffRecruit and retain diverse staff
0 study0 studyInsufficient EvidenceInsufficient Evidence
Cultural sensitivity trainingCultural sensitivity training
1 study1 studyInsufficient EvidenceInsufficient Evidence
Bilingual providers & interpretersBilingual providers & interpreters
1 study1 studyInsufficient EvidenceInsufficient Evidence
Culturally appropriate Culturally appropriate educational materialseducational materials
4 studies4 studies
Insufficient EvidenceInsufficient Evidence
Ethnic specific care settingsEthnic specific care settings
0 study0 studyInsufficient EvidenceInsufficient Evidence
Summary of Evidence
So what can we conclude? So what can we conclude?
We have initial evidence that health We have initial evidence that health promotion interventions on the promotion interventions on the social determinants of health worksocial determinants of health work
However, comprehensive and/or However, comprehensive and/or systematic reviews have only been systematic reviews have only been conducted on a few interventions conducted on a few interventions and almost entirely on western and almost entirely on western literatureliterature
What we need What we need
Many more health promotion Many more health promotion interventions based on the best interventions based on the best theory of practicetheory of practice
Comprehensive and/or systematic Comprehensive and/or systematic reviews that account for efforts in reviews that account for efforts in less developed countriesless developed countries
Context and HealthContext and Health
Contextual approach uses ecologic Contextual approach uses ecologic and multilevel principles and data to and multilevel principles and data to understand determinants of health understand determinants of health and disease and disease
(Social) environment has (Social) environment has independent and/or modifying independent and/or modifying impact on healthimpact on health
Contextual FactorsContextual FactorsExample: Income InequalityExample: Income Inequality
Reflects distribution of Reflects distribution of income/wealth in a populationincome/wealth in a population
Measures: Gini Coefficient, Robin Measures: Gini Coefficient, Robin Hood IndexHood Index
Policy implicationsPolicy implications: g: growth vs. rowth vs. redistributionredistribution
Income Inequality – Income Inequality – Potential Pathways of EffectPotential Pathways of Effect
Underinvestment in human capitalUnderinvestment in human capital
Erosion of social cohesion / capitalErosion of social cohesion / capital
Direct psychological pathwaysDirect psychological pathways
Deconstructing Social Deconstructing Social CapitalCapital (Morenoff, Sampson, Earls)(Morenoff, Sampson, Earls)
Neighborhood resources (parks, local Neighborhood resources (parks, local media, community groups)media, community groups)
Participation in neighborhood Participation in neighborhood voluntary associationsvoluntary associations
Social cohesion (“close-knit”, “trust”)Social cohesion (“close-knit”, “trust”) Social control (action vs. resource)Social control (action vs. resource) Social exchange (action vs. Social exchange (action vs.
resource)resource)