Promoting health equity in cities through evidence-based action

The impact of the urban setting on health and, in particular, health inequities has been widely documented. However, only a few countries have examined their inter- or intra-city health inequalities, and few do so regularly. Information that shows the gaps between cities or within the same city is a crucial requirement to trigger appropriate local actions to promote health equity. To generate relevant evidence and take appropriate actions to tackle health inequities, local authorities need a variety of tools. In order to facilitate a comprehensive understanding of health systems performance, these tools should: (1) adopt a multi-sectorial approach; (2) link evidence to actions; (3) be simple and user-friendly; and (4) be operationally feasible and sustainable. In this paper we have illustrated the use of one such tool, The World Health Organization's Urban HEART, which guides users through a process to identify health inequities, focusing on health determinants and then developing actions based on the evidence generated. In a time of increasing financial constraints, there is a pressing need to allocate scarce resources more efficiently. Tools are needed to guide policy makers in their planning process to identify best-practice interventions that promote health equity in their cities.

[Variability in the measurement of the pharmaceutical prescription quality by autonomous communities]

AIM

To examine how the different Spanish health regions are evaluating pharmaceutical prescription quality and the type of prescribing indicators used.

DESIGN

Cross-sectional study.

SETTING

The 17 Spanish Autonomous Communities during the period from January to December 2007.

MEASUREMENTS

Definition and type of prescribing indicators, measurement units.

RESULTS

We obtained information from 16 of the 17 CCAA through their health services. All health services had developed quality indicators of drug prescription. The number of indicators varied from 3 to 22 between regions. Most of the regions are using indicators based on adequate selection of drugs. Nine of the 16 CCAA are also including prevalence indicators and only the Basque Country and Cantabria are using indicators based on the quality of the therapeutic process. Nine CCAA use the number of packs as measurement unit and the other seven CCAA measure prescriptions in defined daily doses (ddd). The indicators most frequently used are: percentage of new drugs in 15 CCAA (93%), omeprazole in total IBP drugs in 13 (81.2%), percentage of generic drugs in 11 (68.7%) and selection of NSAID in 10 (62%).

CONCLUSION

Each regional health service has developed its own set of drug prescription quality indicators. Consequently, there is great variability between regions in the assessment of the quality of drug prescription. Common indicators are needed in order to establish a benchmarking process between regional health services.

Monitoring integrated care with a clinical logic model

Introduction

The Dutch Healthcare Inspectorate is in search for a better insight into how to measure the quality of integrated care. The central purpose of this study was to identify indicators that provide insight into the performance of the chain as a whole, by means of a clinical logic model.

Theory and methods

Chain care makes high demands on communication and transfer of information between caregivers. The extent to which such requirements are met constitutes an indicator of the quality of care delivered. In order to be able to identify suitable indicators, chain care is charted in the form of a schematic model, a so-called ‘clinical logic’.

A clinical logic captures the elements of the disease process and the care chain to which it gives rise. The components of the model and the factors that determine the quality of care are described in an analytical manner, based on scientific evidence. Measures are selected that capture the following questions: ‘What are the key elements of care at each step in the process?’, ‘How does the patient flow through the care system?’, ‘Where are the major decision points in treatment related to the goal?’

Results and conclusions

Clinical logics were applied on three patient groups: dementia, heart failure and depression. On the basis of the clinical logic for heart failure patients 15 indicators were proposed, for dementia 9 indicators and for depression 12 indicators.

Clinical logics have proven to be a sound method to chart chain/integrated care, but it is mainly focused on the process of care. It is more concrete than the chronic care model. Next, the identified indicators will be tested into practice.

Environmental health indicators of climate change for the United States: findings from the State Environmental Health Indicator Collaborative

OBJECTIVE

To develop public health adaptation strategies and to project the impacts of climate change on human health, indicators of vulnerability and preparedness along with accurate surveillance data on climate-sensitive health outcomes are needed. We researched and developed environmental health indicators for inputs into human health vulnerability assessments for climate change and to propose public health preventative actions.

DATA SOURCES

We conducted a review of the scientific literature to identify outcomes and actions that were related to climate change. Data sources included governmental and nongovernmental agencies and the published literature.

DATA EXTRACTION

Sources were identified and assessed for completeness, usability, and accuracy. Priority was then given to identifying longitudinal data sets that were applicable at the state and community level.

DATA SYNTHESIS

We present a list of surveillance indicators for practitioners and policy makers that include climate-sensitive health outcomes and environmental and vulnerability indicators, as well as mitigation, adaptation, and policy indicators of climate change.

CONCLUSIONS

A review of environmental health indicators for climate change shows that data exist for many of these measures, but more evaluation of their sensitivity and usefulness is needed. Further attention is necessary to increase data quality and availability and to develop new surveillance databases, especially for climate-sensitive morbidity.

Use of city-archival data to inform dimensional structure of neighborhoods

A growing body of research has explored the impact of neighborhood residence on child and adolescent health and well-being. Most previous research has used the US Census variables as the measures of neighborhood ecology, although informative census data are not designed to represent the sociological and structural features that characterize neighborhoods. Alternatively, this study explored the use of large-city administrative data and geographical information systems to develop more uniquely informative empirical dimensions of neighborhood context. Exploratory and confirmatory structural analyses of geographically referenced administrative data aggregated to the census-block group identified three latent dimensions: social stress, structural decline, and neighborhood crime. Resultant dimensions were compared through canonical regression to those derived from US Census data. The relative explanatory capacity of the city-archival and census dimensions was assessed through multilevel linear modeling to predict standardized reading and mathematics achievement of 31,742 fifth- and 28,922 eight-grade children. Results indicated that the city-archival dimensions uniquely augmented predictions, and the combination of city and census dimensions explained significantly more neighborhood effects on achievement than did either source of neighborhood information independently.

Article Commentary: Indicators to Measure Success of Smoke-free Policies

The health consequences of involuntary exposure to tobacco smoke are well documented. The past decade provides several examples of successful smoke-free policies that are directly related to improving public health. The objective of this communication is to identify indicators that demonstrate the success of smoke-free policies. Indicators are identified from smoke-free policy evaluations conducted by countries such as the United States, New Zealand, and Israel. Indicators were identified that demonstrate the success of smoke-free policies in the areas of compliance, indoor air quality, bio-monitoring, medical tests, and health behaviors. As smoke-free policies continue to be implemented, indicator evaluation activities should be considered from the start.

Overlooking undernutrition? Using a composite index of anthropometric failure to assess how underweight misses and misleads the assessment of undernutrition in young children

In light of current international interest in the Millennium Development Goals, this short report examines the suitability of one of the primary indicators being used to assess progress. Using anthropometric data on 46,784 children aged 0-35 months in seven developing countries, we show how the weight for age (underweight) indicator is problematic but not for the reasons conventionally cited. We show that the information it provides about the degree and direction of change in undernutrition over time sometimes contradicts that provided by other conventional indicators. We demonstrate the potential of an alternative indicator, the composite index of anthropometric failure (CIAF), which can be used to show the overall extent of undernutrition among children, and which provides an unequivocal statement on the direction and degree of change in undernutrition over time. Given the fundamental importance of undernutrition to child survival and health, the issues raised will be of interest to and have implications for policy makers and planners alike.

Butterflies as indicators of climate change

In Britain, most butterfly species reach the limit of their range due to climate. Such species are the ones most likely to show rapid adaptations to climate change. There are indications that several butterfly species are adapting and that these insects make good indicators of the likely effects of climate change on other animals.

Workgroup report: developing environmental health indicators for European children: World Health Organization Working Group

A working group coordinated by the World Health Organization developed a set of indicators to protect children's health from environmental risks and to support current and future European policy needs. On the basis of identified policy needs, the group developed a core set of 29 indicators for implementation plus an extended set of eight additional indicators for future development, focusing on exposure, health effects, and action. As far as possible, the indicators were designed to use existing information and are flexible enough to be developed further to meet the needs of policy makers and changing health priorities. These indicators cover most of the priority topic areas specified in the Children's Environment and Health Action Plan for Europe (CEHAPE) as adopted in the Fourth Ministerial Conference on Health and Environment in 2004, and will be used to monitor the implementation of CEHAPE. This effort can be viewed as an integral part of the Global Initiative on Children's Environmental Health Indicators, launched at the World Summit on Sustainable Development in 2002.

Indicators of socioeconomic position (part 1)

This glossary presents a comprehensive list of indicators of socioeconomic position used in health research. A description of what they intend to measure is given together with how data are elicited and the advantages and limitation of the indicators. The glossary is divided into two parts for journal publication but the intention is that it should be used as one piece. The second part highlights a life course approach and will be published in the next issue of the journal.

Using Red List Indices to measure progress towards the 2010 target and beyond

The World Conservation Union (IUCN) Red List is widely recognized as the most authoritative and objective system for classifying species by their risk of extinction. Red List Indices (RLIs) illustrate the relative rate at which a particular set of species change in overall threat status (i.e. projected relative extinction-risk), based on population and range size and trends as quantified by Red List categories. RLIs can be calculated for any representative set of species that has been fully assessed at least twice. They are based on the number of species in each Red List category, and the number changing categories between assessments as a result of genuine improvement or deterioration in status. RLIs show a fairly coarse level of resolution, but for fully assessed taxonomic groups they are highly representative, being based on information from a high proportion of species worldwide. The RLI for the world's birds shows that that their overall threat status has deteriorated steadily during the years 1988-2004 in all biogeographic realms and ecosystems. A preliminary RLI for amphibians for 1980-2004 shows similar rates of decline. RLIs are in development for other groups. In addition, a sampled index is being developed, based on a stratified sample of species from all major taxonomic groups, realms and ecosystems. This will provide extinction-risk trends that are more representative of all biodiversity.

Rationale for a new generation of indicators for coastal waters

More than half the world's human population lives within 100 km of the coast, and that number is expected to increase by 25% over the next two decades. Consequently, coastal ecosystems are at serious risk. Larger coastal populations and increasing development have led to increased loading of toxic substances, nutrients and pathogens with subsequent algal blooms, hypoxia, beach closures, and damage to coastal fisheries. Recent climate change has led to the rise in sea level with loss of coastal wetlands and saltwater intrusion into coastal aquifers. Coastal resources have traditionally been monitored on a stressor-by-stressor basis such as for nutrient loading or dissolved oxygen. To fully measure the complexities of coastal systems, we must develop a new set of ecologic indicators that span the realm of biological organization from genetic markers to entire ecosystems and are broadly applicable across geographic regions while integrating stressor types. We briefly review recent developments in ecologic indicators and emphasize the need for improvements in understanding of stress-response relationships, contributions of multiple stressors, assessments over different spatial and temporal scales, and reference conditions. We provide two examples of ecologic indicators that can improve our understanding of these inherent problems: a) the use of photopigments as indicators of the interactive effects of nutrients and hydrology, and b) biological community approaches that use multiple taxa to detect effects on ecosystem structure and function. These indicators are essential to measure the condition of coastal resources, to diagnose stressors, to communicate change to the public, and ultimately to protect human health and the quality of the coastal environment.

Diversity, biodiversity, conservation, and sustainability

The concepts of diversity and biodiversity are analysed regarding their historical emergence, and their intrinsic meaning and differences are discussed. Through a brief synopsis, difficulties usually experienced by statisticians in capturing the dynamics of diversity are analysed and main problems identified. The shift from diversity to the more holistic biodiversity as a working concept is appraised in terms of the novelty involved. Through a number of examples, the way the two concepts capture natural cyclic changes is analysed, and their reciprocal and complementary relations are approached theoretically. The way diversity could develop from the stores of biodiversity as its active expression through selective and evolutionary processes is described. Through the use of a very simple dynamic model, the concepts of diversity and biodiversity are analysed in extremely opposite hypothetical scenarios. Comparisons with natural situations are made and the theoretical implications from the conservation point of view are discussed. These support the opinion that conservation undertaken in restricted and protected areas is not self-sustainable, needing permanent external intervention to regulate internal processes, and in the long run will most probably lead in the direction of obsolescence and extinction. Finally, the relations between diversity, biodiversity, and sustainability are approached. The vagueness of the sustainability concept is discussed. Preservation of biodiversity is then defended as one of the best available indicators to assist us in fixing boundaries which may help to provide a more precise definition of sustainability.

Indicators for drug and therapeutics committees

AIMS

This study describes development and field testing of a set of indicators for drug and therapeutics committees (DTCs) in hospitals. It was intended that these indicators should be accessible, useful and relevant in the Australian setting.

METHODS

Candidate indicators were written following consultation and data collection. A framework of outcome, impact and process indicators was based on DTC goals, objectives and strategies. The candidate indicators were field tested over a 2 month period in teaching, city non-teaching, rural and private hospitals. The field tests provided response data for each indicator and evaluation of the indicators against criteria for accessibility, relevance, usefulness, clarity and resource utilisation. Consensus on which indicators to accept, modify or reject was reached at a workshop of stakeholders and experts, taking account of the field test results.

RESULTS

Thirty-five candidate indicators were tested in 16 hospitals. Twenty-two had a response from >80% of sites, 23 had a mean relevance rating >3.5, 19 had a mean usefulness rating >3.5, 27 were correctly interpreted by > 90% of sites and 25 could be collected in an acceptable time. The most acceptable indicators required least data collection or provided data deemed useful for purposes other than the field test. At the consensus workshop 13 indicators were accepted with no or minor change, nine were accepted after major modification and eight were discarded. It was recommended that a further five indicators should be merged or subsumed into one indicator.

CONCLUSIONS

This study has developed and field tested a set of indicators for DTCs in Australia. The indicators have been taken up enthusiastically as a first attempt to monitor DTC performance but require ongoing validation and development to ensure continuing relevance and usefulness.

Improved Recovery of Stressed Bifidobacterium from Water and Frozen Yogurt

A roll-tube repair-detection procedure was developed to enumerate injured and noninjured cells of Bifidobacterium species from water and food samples. This procedure combined the Virginia Polytechnic Institute and State University's anaerobic roll-tube procedure and the repair-detection technique for detecting stressed cells. Mara and Oragui's human bifid sorbitol agar medium was modified for use in the roll-tube procedure by replacing the indicator bromocresol purple with phenyl red (0.027 g/l), adding 0.0006 g of methylene blue per 1, increasing the agar content to 25 g/l and adjusting the pH of the medium to 7.1 ± 0.1. The repair-detection roll-tube technique was shown to recover Bifidobacterium cells significantly (P < 0.01) better than pour plates, using the same medium incubated in anaerobe jars, even when a repair-detection system was used. Most repair in the roll tubes occurred in the first hour. B. adolescentis had a poor survival rate after 96 hours in water. Glucose was substituted for sorbitol in the medium used for enumeration of B. longum added to frozen yogurt, because this organism cannot utilize sorbitol. This medium, when used as part of a repair detection system, significantly (P < 0.01) recovered more cells than anaerobic pour plate techniques and was able to separate Bifidobacterium species and Lactobacillus acidophilus by colony morphology. Bifidobacterium cells were 1mm or larger, round and yellow, while the L. acidophilus colonies were so small (< 1/4 mm) their detection and enumeration was difficult.