For debate: a new wave in public health improvement

Exploring the rise and diversity of health and societal issues that use a public health approach: A scoping review and narrative synthesis

There is an increase in calls across diverse issues for a "public health approach" however, it is not clear whether there is any shared understanding in approach in its conceptualisation or implementation. Our aims were to (1) identify and categorise the issues which discuss a public health approach within published literature since 2010, (2) chart the descriptions and applications of public health approaches across and within four purposively sampled categories of issues, and (3) capture any evaluations conducted. A scoping review of published literature was undertaken; Seven leading databases were searched: AMED, APA PsycInfo, ASSIA, CINAHL complete, Cochrane Library (Review), Embase, and MEDLINE for articles published between 2010 and 2022 which have applied, described or called for a "public health approach" to address any issue. 3,573 studies were identified through our initial searches, of these 1,635 articles were recognised for possible inclusion from analysis of titles and abstract. The final number of included studies was 1,314. We identified 28 categories, 26 of which were societal issues, where a public health approach is being advocated. We purposively selected four of these categories; adverse childhood experiences; end of life care; gambling addiction and violence reduction/ knife crime for further analysis of the approach including how it was conceptualised and operationalised; less than 13% of the studies described the implementation of a public health approach and there was considerable heterogeneity across and within categories as to how this was done. Since 2010 there have been increasing calls for a public health approach to be taken to address health and societal challenges. However, the operationalisation of a public health approach varied extensively and there were few evaluations of the approach. This has implications for policy makers and those involved in commissioning related approaches in the future as the evidence-base is limited.

Challenges and opportunities for improvement in the management and financing system of Health Promotion Offices in Hungary

Background

One hundred ten Health Promotion Offices (HPOs) have started operating in Hungary in response to public health challenges. Many of them have been active for almost 10 years, yet their operational experience has not been evaluated. The specific objectives of our study were: (1) to describe the current operational and funding system of HPOs, (2) to identify challenges related to the current management and funding practices, and (3) to formulate recommendations for improvement based on gathered experience and international experience.

Design

In order to gain a deeper insight into the operational experience of HPOs, an online survey was conducted with the professional or economic managers of HPOs. A scoping review was carried out to gather international experiences about best practices to formulate recommendations for improvement in developing the operational and financing scheme for HPOs.

Results

We found that current HPO network in Hungary faces three main challenges: a deficient management system, inflexible financing scheme, and unequal ability to purchase or provide services for the population.

Conclusions

Based on the survey complemented by international experiences, we propose the overhaul of the professional management system and switching toa combination of fixed and performance-based financing scheme for the HPOs in Hungary.

A complexity-informed in-depth case study into the sustainability and impact of a culture of health: The TR14ers community youth dance group

There are calls for researchers to study existing community assets and activities that appear to improve health and have achieved longevity. The TR14ers Community Dance Charity Limited is a community youth dance group that has been running since 2005 providing free weekly sessions for children and adolescents in an economically disadvantaged town in the UK. An in-depth case study employing qualitative, quantitative and participatory methods was undertaken with the TR14ers (current participants and those who have left, co-ordinators and families) over 6 months with the aim of understanding the sustainable processes and impact of the Group. The 12 complex systems' leverage points described by Meadows and the five domains of adolescent wellbeing developed by the United Nations H6+ Technical Working Group on Adolescent Health and Well-Being were used as frameworks to recognise the complexity of community assets like the TR14ers. The quantitative and qualitative data indicated that being part of the TR14ers contributed to multiple health and wellbeing outcomes. The positive experiences of being a TR14er led members to actively recruit others through word of mouth and public performances. Central to the TR14ers is a commitment to children's rights, which is communicated formally and informally throughout the membership informing how and what the Group does, leading to the structure and delivery of the Group evolving over time. Members sought to ensure the sustainability of the Group after they had left and were keen to mentor younger members to develop and become the leaders. Based on the insights from this case study we suggest that efforts to develop cultures of health, like the TR14ers, should focus on the core values of the activity or intervention that underpin what it does and how within the local context.

Self-control and unhealthy body weight: The role of impulsivity and restraint

We examine the relationship between trait self-control and body weight. Data from a population representative household survey reveal that limited self-control is strongly associated with both unhealthy body weight and poorer subjective weight-related well-being. Those with limited self-control are characterized by reduced exercising, repeated dieting, unhealthier eating habits, and poorer nutrition. We propose an empirical method to isolate two facets of self-control limitations-high impulsivity and low restraint. Each has differential predictive power. Physical activity, dieting, and overall body weight are more strongly associated with restraint; impulsivity is relatively more predictive of when, where, and what people eat.

Enacting care by being experts and managing relationships: A discourse analysis of chief medical officer of health media briefings during the COVID-19 pandemic

In Canada, Chief Medical Officers of Health (CMOHs) are responsible for protecting and promoting the health of their respective populations, but few studies have examined this role and its connections with the practice of medicine. In Canada and elsewhere, CMOHs and other public health physicians have articulated their actions as caring for their populations as patients. In order to understand the components of enacted care, this study is a functional discourse analysis of transcribed CMOH media briefings at three time points in five Canadian jurisdictions during the first full year of the COVID-19 pandemic (2020). Transcripts were coded and analysed in an iterative, comparative process to understand the content, actions and purpose of CMOH communication during media briefings. CMOHs used their public communications to enact their care of populations by "being experts" and "managing relationships". "Being experts" involved describing disease characteristics, assessing risk and evidence, framing risk and evidence, and making judgments about intervention and exemption. "Managing relationships" involved self-regulating emotions, acknowledging the emotions of others, seeking adherence and collaboration, and setting expectations and boundaries. The findings suggest that traditional biomedical roles were performed by CMOHs in media briefings, implying the existence of a patient (or multiple patient-like relationships) and supporting further research into the processes by which public health physicians care for populations as patients.

A New Tool for Determining and Monitoring Public Healthcare Systems

The challenge of maintaining a standard of treatment has become a core issue due to the COVID-19 outbreak, and many countries are currently addressing this issue. Since public health policymaking is a multidimensional issue, including different aspects, measures, features, and scales, and so forth, multidimensional definitions of reasonable medical treatments may improve planning and performance standards for public health systems. This study emphasizes the need to settle all of the dimensions in policymaking to aim to elicit reasonable medical treatment definitions and adequacy assessments from diverse healthcare stakeholders and offer a universally applicable reasonable medical treatment formula. Interviews of thirty-two stakeholders were qualitatively analyzed and mapped onto an innovative quadrilateral model. The findings showed that most interviewees viewed the system positively. However, they identified various lacunas-clinical/service, social/ethical, legal, and economically reasonable medical treatment aspects. A generic formula for the medical sub-services' activity accounted for these, given any specific time period and technological development. The stakeholders' positive assessment reflects an acquiescence for resource allocation and policy enforcement, rather than optimal healthcare. Nationally, this should be addressed. The quadrilateral mapping of the stakeholders enhances the translatability and generalizability of the systemic data. A comprehensive reasonable medical treatment formula will help the policymakers to optimize services, and it will render healthcare planning/implementation transparent, effective, and responsible.

Actions Speak Louder Than Words: Health Behaviours and the Literacy of Future Healthcare Professionals

Our everyday behaviours in life can positively and negatively impact our health, thus cumulatively shaping our lifestyles as more or less healthy. These behaviours are often determined by our knowledge, literacy, motivations and socioeconomic backgrounds. The authors aimed to assess health behaviours and explore variables that may affect persons studying to become future healthcare professionals in Poland. This study was conducted with a group of 275 undergraduate students attending the Poznan University of Medical Sciences representing six different majors of study. We used self-reported, cross-sectional survey conducted through the use of a questionnaire that consisted of one standardised scale (Juczyński’s Health Behaviour Inventory) as well as a self-developed health literacy measure. The students showed average to high levels of health-promoting behaviours (mean HBI = 82.04 ± 11.26). Medium to strong associations were found between these behaviours and high scores on the health literacy scale (p = 0.001, r = 0.45 between total scores of the two scales). Dietetics students and female respondents scored significantly better on both scales, which suggests that their self-reported behaviours and health literacy were higher than those of other participants. Exhibiting health-protective behaviours and high health literacy is likely to result in the better individual health of our respondents, but, more importantly, will also influence their future professions. As members of the healthcare workforce they will be responsible for the health of the population and it is crucial for them not only to provide care, education, and guidance, but also to act as role-models for their patients and society.

Actions Speak Louder Than Words: Health Behaviours and the Literacy of Future Healthcare Professionals

Our everyday behaviours in life can positively and negatively impact our health, thus cumulatively shaping our lifestyles as more or less healthy. These behaviours are often determined by our knowledge, literacy, motivations and socioeconomic backgrounds. The authors aimed to assess health behaviours and explore variables that may affect persons studying to become future healthcare professionals in Poland. This study was conducted with a group of 275 undergraduate students attending the Poznan University of Medical Sciences representing six different majors of study. We used self-reported, cross-sectional survey conducted through the use of a questionnaire that consisted of one standardised scale (Juczyński’s Health Behaviour Inventory) as well as a self-developed health literacy measure. The students showed average to high levels of health-promoting behaviours (mean HBI = 82.04 ± 11.26). Medium to strong associations were found between these behaviours and high scores on the health literacy scale (p = 0.001, r = 0.45 between total scores of the two scales). Dietetics students and female respondents scored significantly better on both scales, which suggests that their self-reported behaviours and health literacy were higher than those of other participants. Exhibiting health-protective behaviours and high health literacy is likely to result in the better individual health of our respondents, but, more importantly, will also influence their future professions. As members of the healthcare workforce they will be responsible for the health of the population and it is crucial for them not only to provide care, education, and guidance, but also to act as role-models for their patients and society.

Tackling Root Causes Upstream of Unhealthy Urban Development (TRUUD): Protocol of a five-year prevention research consortium

Poor quality urban environments substantially increase non-communicable disease. Responsibility for associated decision-making is dispersed across multiple agents and systems: fast growing urban authorities are the primary gatekeepers of new development and change in the UK, yet the driving forces are remote private sector interests supported by a political economy focused on short-termism and consumption-based growth. Economic valuation of externalities is widely thought to be fundamental, yet evidence on how to value and integrate it into urban development decision-making is limited, and it forms only a part of the decision-making landscape. Researchers must find new ways of integrating socio-environmental costs at numerous key leverage points across multiple complex systems. This mixed-methods study comprises of six highly integrated work packages. It aims to develop and test a multi-action intervention in two urban areas: one on large-scale mixed-use development, the other on major transport. The core intervention is the co-production with key stakeholders through interviews, workshops, and participatory action research, of three areas of evidence: economic valuations of changed health outcomes; community-led media on health inequalities; and routes to potential impact mapped through co-production with key decision-makers, advisors and the lay public. This will be achieved by: mapping system of actors and processes involved in each case study; developing, testing and refining the combined intervention; evaluating the extent to which policy and practice changes amongst our target users, and the likelihood of impact on non-communicable diseases (NCDs) downstream. The integration of such diverse disciplines and sectors presents multiple practical/operational issues. The programme is testing new approaches to research, notably with regards practitioner-researcher integration and transdisciplinary research co-leadership. Other critical risks relate to urban development timescales, uncertainties in upstream-downstream causality, and the demonstration of impact.

The Use of the Bolk Model for Positive Health and Living Environment in the Development of an Integrated Health Promotion Approach: A Case Study in a Socioeconomically Deprived Neighborhood in The Netherlands

Background. Despite considerable efforts, health disparities between people with high and low socioeconomic status (SES) have not changed over the past decades in The Netherlands. To create a culture of health and an environment in which all people can flourish, a shift in focus is needed from disease management towards health promotion. The Bolk model for Positive Health and Living Environment was used as a tool to guide this shift. This study aimed to describe how this model was used and perceived by stakeholders in a case study on an integrated health promotion approach for residents with low SES. Methods. An instrumental case study was undertaken in Venserpolder, a neighborhood in Amsterdam South East of approximately 8500 residents. A participatory action approach was used that allowed continuous interaction between the residents, health care professionals, researchers, and other stakeholders. The Bolk model is a tool, based on the conceptual framework of positive health, that was developed to guide health promotion practice. Its use in the case study was evaluated by means of semistructured interviews with stakeholders, using qualitative directed content analyses. Results. The Bolk model was found to be a useful tool to identify and map the needs and strengths of residents with low SES. The model facilitated the development and implementation of eight health promotion pilots by transforming the needs and strengths of residents into concrete actions carried out by responsible actors in the neighborhood. Although the Bolk model seemed to be accepted by all stakeholders, the shift towards positive health thinking appeared to be more embodied by local professionals than by residents. Adjustments were proposed to enhance the applicability of the model in a multicultural setting, to increase its cultural sensitivity and to use language more familiar to residents. Conclusions. The Bolk model for positive health and living environment seems to be promising in the guidance of health promotion practices in Amsterdam South East. Further research and development are needed to improve its cultural sensitivity and to investigate its applicability in a broader range of public health settings.

The Welleye: A Conceptual Framework for Understanding and Promoting Wellbeing

We present the Welleye – a novel and conceptually clear framework that shows how attention links the objective circumstances of people’s lives and selves to how they spend their time and feel day to day. While existing wellbeing frameworks in policy contain many of the factors included in the Welleye, they all lack attention as the “lens” that determines the impact of these factors on how people feel. Policymakers and organizations can use the Welleye to better understand how people are faring and design and evaluate interventions aimed at making people better off.

Enablers and barriers English secondary schools face in promoting healthy diet and physical activity behaviours

This study sought to understand the current challenges mainstream secondary schools in England face in creating a health promoting school culture for diet and physical activity behaviours. An in-depth qualitative case study of two purposely selected state-funded schools, including interviews with teachers, observations of school activities including meal breaks and a qualitative survey with parents was done. Inductive thematic analysis was used to explore emerging themes. Additional interviews with the leadership team from four further schools were used to develop and refine emerging themes. Four main themes emerged from the data: competing pressures, school environment, personnel and policy. Results demonstrate that schools recognize they have role to play in promoting healthy lifestyle behaviours to pupils; however, several significant barriers were identified such as lack of government support and regulation, school structures and organization, focus on core subjects, business-run canteens and lack of family and community engagement. Given the importance of maintaining a healthy weight throughout the life course, schools have an important role to play in creating healthy environments in which students can easily make a healthy choice. Future school promotion initiatives need to consider addressing the barriers that schools face by working with them and the communities in which they are embedded.

There has been little research done in secondary schools to understand how to promote healthy lifestyle behaviours to adolescents (secondary schools provide secondary education for students aged 11–18 years). COVID-19 has brought the importance of maintaining a healthy weight back into sharp focus and schools are an ideal setting to educate and support young people in making healthy diet and activity choices. This research sought to understand how important school staff thought creating a health-promoting culture in schools was, how they could create such a culture and what support they had or needed to do so. From interviews with school staff, observing school activities and a questionnaire to parents, we found that schools and parents believe that schools have a role to play in supporting healthy diet and physical activity behaviours although they identified many pressures that prevent making health promotion a priority; these include time and resources as well as a lack of government policy. The importance of having a head teacher with a belief in the benefits of a healthy lifestyle was recognized. The way secondary schools are structured in England makes a joined-up approach difficult and requires central planning and coordination. More support, including resources and policy commitments, are needed to support secondary schools to create a healthy school environment.

Healthy Leadership and Workplace Health Promotion as a Pre-Requisite for Organizational Health

(1) Background: Increasing stress levels at the workplace constitute a concerning organizational trend, challenging not only employees but also organizations alike, as it is in most instances associated with increasing workloads. In consequence, employees have started to demand that organizations begin to accept responsibility for their health and well-being. The present contribution seeks to investigate, to which extent individuals are able to deal with stress and whether their employers and respective supervisors (leaders) accept responsibility for their health, for instance, by leading by example. In addition, the existence and support generated by the organization in form of Workplace Health Promotion (WPHP) is inquired. (2) Methods: Semi-structured qualitative interviews with 40 (full and part-time) employees from two European countries were conducted. (3) Results: The study with employees from Austria and Germany (n = 40) confirmed that employees have started to recognize the potential of the workplace as an environment, where individual health can be enhanced. Yet, the results showed that only a few companies have already put some WPHP measures into practice. Likewise, the implementation of healthy leadership is rather limited to date. (4) Conclusions: At present, companies are still more likely to delegate responsibility for employee health and well-being to their staff, having not fully realized the potential of healthy leadership and organizational health promotion. There is great potential to increase WPHP measures on the employer side, through both healthy leadership and supporting WPHP measures.

Strengthening prevention in communities through systems change: lessons from the evaluation of Healthy Families NZ

This article presents the findings from the first 3 years of the evaluation of Healthy Families NZ, a systems-change intervention to prevent chronic diseases in 10 communities. The initiative, which builds on existing prevention activities, aims to strengthen the health prevention system through evidence-driven action to enable people to make good food choices, be physically active, smoke-free and free from alcohol-related harm. Key investment areas are a dedicated systems thinking and acting health promotion workforce, and activating leaders who can influence transformational change. The evaluation to date has found the initiative is being implemented with integrity. Evidence indicates a shift towards greater action on prevention, and the prevention system being strengthened. Māori ownership has been enabled, and prioritizing equity has led teams to utilize methods that amplify diverse local perspectives. There is progress on developing a flexible workforce through adaptive learning, flexible resources, professional development and a responsive National team. There is also progress in activating local leadership and empowering local teams. The initiative design has explicitly taken into account the context of complexity within which it is being implemented. It has evolved to focus on action that can accelerate sharing information and practices within communities, and between policy and decision-makers. Healthy Families NZ and its evaluation have been refunded to 2022. This provides an important opportunity to gather further insight into effective ways to strengthen the community agency and trust needed to promote and deliver evidence-based action on prevention.

Tackling Root Causes Upstream of Unhealthy Urban Development (TRUUD): Protocol of a five-year prevention research consortium

Poor quality urban environments substantially increase non-communicable disease. Responsibility for associated decision-making is dispersed across multiple agents and systems: fast growing urban authorities are the primary gatekeepers of new development and change in the UK, yet the driving forces are remote private sector interests supported by a political economy focused on short-termism and consumption-based growth. Economic valuation of externalities is widely thought to be fundamental, yet evidence on how to value and integrate it into urban development decision-making is limited, and it forms only a part of the decision-making landscape. Researchers must find new ways of integrating socio-environmental costs at numerous key leverage points across multiple complex systems. This mixed-methods study comprises of six highly integrated work packages. It aims to develop and test a multi-action intervention in two urban areas: one on large-scale mixed-use development, the other on major transport. The core intervention is the co-production with key stakeholders through interviews, workshops, and participatory action research, of three areas of evidence: economic valuations of changed health outcomes; community-led media on health inequalities; and routes to potential impact mapped through co-production with key decision-makers, advisors and the lay public. This will be achieved by: mapping system of actors and processes involved in each case study; developing, testing and refining the combined intervention; evaluating the extent to which policy and practice changes amongst our target users, and the likelihood of impact on non-communicable diseases (NCDs) downstream. The integration of such diverse disciplines and sectors presents multiple practical/operational issues. The programme is testing new approaches to research, notably with regards practitioner-researcher integration and transdisciplinary research co-leadership. Other critical risks relate to urban development timescales, uncertainties in upstream-downstream causality, and the demonstration of impact.

Identification of the multimorbidity training needs of primary care professionals: Protocol of a survey

Current epidemiological situation has prompted the consideration of multimorbility (MM) as a prevalent condition, influenced by age, educational level and social support, related to unfavorable social and health determinants. Primary Care (PC) has a key role in its approach but further training of professionals in MM is required. The evidence on the effectiveness of training interventions in MM is still limited. Knowing the experiences, opinions and training needs of professionals is essential to enhance training interventions.

OBJECTIVES

Identify perceived training needs by PC health professionals (doctors and nurses) in MM and polypharmacy.

METHODS

Design: Cross-sectional study based on an online survey (anonymous-ad hoc questionnaire). Participants and recruitment: 384 doctors and nurses working in healthcare centers and out-of-hospital emergencies of the Spanish National Health System. Non-probabilistic convenience sampling via email addressed to Health Institutions, and social networks.

DATA

Demographic characteristics and professional profile data (close-ended and multiple-choice questions) will be collected. Open-ended questions will be used to identify training needs, difficulties and resources about MM; required skills to care patients with MM will be assessed using a 4-item ordinal scale.

ANALYSIS

Coding of data prior to analysis. Descriptive statistical analysis, participation and completion rates of the questionnaire and estimation of absolute and relative frequencies and 95% confidence intervals in close-ended questions. Content analysis with inductive methodology in open-ended questions. Ethics: Ethical approval, Online informed consent.

CONCLUSIONS

The identification of training needs of health professionals who care for patients with MM will be necessary data for developing highly effective training activities.

Developing principles of social change as a result of a Pasifika Youth Empowerment Program: A qualitative study

ISSUE

Empowerment is a concept over-used in health promotion, yet it is an important process that can used in developing the capacity and capability of young people for creating social change to improve healthier lives.

METHODS

The Youth Empowerment Program (YEP), a pilot study aimed at empowering 15 youth (18-24 years) to lead healthier lives. We present secondary outcomes of the original YEP study, using focus groups and mobile-mentary approaches to capture the impact of the YEP through the youths' understanding of the program. Thematic analyses to examine the pragmatic usefulness of the empowerment program.

RESULTS

We identified three major themes: (aa) Knowledge: education and awareness of healthy living and understanding of the wider social health issues, compound the health complexities of obesity; (b) Youth as catalysts for change: the youth viewed themselves as agents of social change; and (c) Transformation: the youth recognised themselves as catalysts for change that can positively transform communities into action.

CONCLUSION

This study contributes new insights and depth of understanding about how the empowerment program can strengthen the process of individual capacity in an effort to mobilise social change for the betterment of the whole community, particularly among indigenous Pasifika population groups. SO WHAT?: Developing empowerment principles will enable others to consider "how apply" empowerment more practically when working with young people and not use it flippantly with no real action-oriented outcome.

Defining healthstyles to plan behavior change interventions in representative samples of children and adults

Based on Michie's COM-B model, we developed a survey methodology and segmentation procedure to identify groups of Hungarian school children and adults with distinctive characteristics, named healthstyles. We aimed to find interventions fitting to each healthstyle to generate behavioural change. For the segmentation of data, the latent class analysis method was applied. The analysis resulted in 8 healthstyles for the school children and 13 for the adults. Each healthstyle possess distinctive 'traits' and, therefore, special behavioural change methods and prevention strategies can be fitted for them. For demonstrating the advantages of using healthstyles, we discuss possible approaches for selecting behavioural change interventions, one for school children and one for adults.

Health Inequality as a Large-Scale Outcome of Complex Social Systems: Lessons for Action on the Sustainable Development Goals

Action on the Sustainable Development Goals (SDGs) needs to become real and impactful, taking a “whole systems” perspective on levers for systems change. This article reviews what we have learned over the past century about the large-scale outcome of health inequality, and what we know about the behaviour of complex social systems. This combined knowledge provides lessons on the nature of inequality and what effective action on our big goals, like the SDGs, might look like. It argues that economic theories and positivist social theories which have dominated the last 150 years have largely excluded the nature of human connections to each other, and the environment. This exclusion of intimacy has legitimatised arguments that only value-free economic processes matter for macro human systems, and only abstract measurement constitutes valuable social science. Theories of complex systems provide an alternative perspective. One where health inequality is viewed as emergent, and causes are systemic and compounding. Action therefore needs to be intensely local, with power relationships key to transformation. This requires conscious and difficult intervention on the intolerable accumulation of resources; improved reciprocity between social groups; and reversal of system flows, which at present ebb away from the local and those already disadvantaged.

Global Health with Justice: Controlling the Floodgates of the Upstream Determinants of Health through Evidence-Based Law

This article introduces a special issue on the legal determinants of health, following the publication of the Lancet-O'Neill Institute of Georgetown University Commission's report on the subject. We contextualize legal determinants as a significant and vital aspect of the social determinants of health, explain the work of the Lancet-O'Neill Commission and outline where consequent research will usefully be directed. We also introduce the papers that follow in the special issue, which together set out in greater detail the work of the Commission and critically engage with different aspects of the report and the application of its findings and recommendations.

Advancing Strategies for Agenda Setting by Health Policy Coalitions: A Network Analysis of the Canadian Chronic Disease Prevention Survey

Health in all policies can address chronic disease morbidity and mortality by increasing population-level physical activity and healthy eating, and reducing tobacco and alcohol use. Both governmental and nongovernmental policy influencers are instrumental for health policy that modifies political, economic, and social environments. Policy influencers are informed and persuaded by coalitions that support or oppose changing the status quo. Empirical research examining policy influencers' contact with coalitions, as a social psychological exposure with health policy outcomes, can benefit from application of health communication theories. Accordingly, we analyzed responses to the 2014 Chronic Disease Prevention Survey for 184 Canadian policy influencers employed in provincial governments, municipalities, large workplaces, school boards, and the media. In addition to contact levels with coalitions, respondents' jurisdiction, organization, and ideology were analyzed as potential moderators. Calculating authority score centrality using network analysis, we determined health policy supporters to be more central in policy influencer networks, and theorized their potential to impact health policy public agenda setting via priming and framing processes. We discuss the implications of our results as presenting opportunities to more effectively promote health policy through priming and framing by coordinating coalitions across risk behaviors to advance a societal imperative for chronic disease prevention.

Strengthening complex systems for chronic disease prevention: a systematic review

BACKGROUND

While frameworks exist for strengthening health care systems and public health systems, there are no practical frameworks to describe, assess and strengthen systems for chronic disease prevention (CDP) using complex systems approaches.

METHODS

A systematic and integrative review of peer reviewed literature was conducted to answer the following questions: How can systems for CDP be defined? What are key attributes of effective systems? How are complex systems approaches discussed? Search terms were identified and the Medline, SCOPUS, and Global Health databases were searched December 2017 and January 2018. Reference lists and selected journals were hand searched. A working definition for a system for CDP was developed to provide a guideline for inclusion. Key exclusion criteria were literature did not address the research questions or working definition; was published in a language other than English and before 2000; focused on specific chronic diseases and/or risk factors and not CDP broadly; concentrated on the health care sector and clinical services and/or health status and surveillance data; and described evaluations of setting specific actions such as policies, programs, interventions, approaches, projects, laws, or regulations. Selected literature (n = 141) was coded in terms of the extent to which the research questions and the working definition of systems for CDP were addressed. Data was then analysed and synthesized to determine key themes.

RESULTS

A revised definition of systems for CDP and seven attributes of effective systems for CDP are reported (collaborative capacity, health equity paradigm, leadership and governance, resources, implementation of desired actions, information and complex systems paradigm). A framework was developed to provide a foundation for describing, assessing and strengthening systems for CDP.

CONCLUSIONS

The results of this literature review provide a strong foundation for a framework to help strengthen systems for CDP. The framework consolidates not only well-established attributes of effective CDP but also highlights theoretical and practical insights from complex systems perspectives.

Historical Developments and Paradigm Shifts in Public Health Nutrition Science, Guidance and Policy Actions: A Narrative Review

Public health nutrition (PHN) seeks to protect and promote the nutrition-related health and wellbeing of populations. PHN science is dynamic and has evolved over time, helping to inform our understanding of the changing nature, scope, causes and solutions to PHN problems. This scientific basis has informed nutrition guidance and policy. Using a narrative synthesis method and guided by Kuhn's theory on the structure of scientific revolutions, this paper reviews the historical development of PHN, aiming to understand the emergence of major scientific paradigms, paradigm shifts and evidence-informed guidance and policy. We propose that the development of PHN is characterized by the successive layering of paradigms resulting from interactions between science, social change and policy-making. Four eras of PHN are evident: the foundation, nutrient deficiency, dietary excess and imbalances, and environmental sustainability (ES). Dominant paradigms have been communicated through nutrient reference standards, dietary goals and dietary guidelines. Transitions from one era to the next indicated new ways of thinking about PHN, amounting to a paradigm shift. The bidirectional relationship between nutrition and ES is the latest challenge confronting PHN. Investigating PHN paradigm transitions reveals how we have arrived at current guidance and policies, and how PHN might progress into the future.

La nueva oleada de la investigación en salud pública: de la evidencia a la política

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Healthy publics: enabling cultures and environments for health

Despite extraordinary advances in biomedicine and associated gains in human health and well-being, a growing number of health and well-being related challenges have remained or emerged in recent years. These challenges are often 'more than biomedical' in complexion, being social, cultural and environmental in terms of their key drivers and determinants, and underline the necessity of a concerted policy focus on generating healthy societies. Despite the apparent agreement on this diagnosis, the means to produce change are seldom clear, even when the turn to health and well-being requires sizable shifts in our understandings of public health and research practices. This paper sets out a platform from which research approaches, methods and translational pathways for enabling health and well-being can be built. The term 'healthy publics' allows us to shift the focus of public health away from 'the public' or individuals as targets for intervention, and away from the view that culture acts as a barrier to efficient biomedical intervention, towards a greater recognition of the public struggles that are involved in raising health issues, questioning what counts as healthy and unhealthy and assembling the evidence and experience to change practices and outcomes. Creating the conditions for health and well-being, we argue, requires an engaged research process in which public experiments in building and repairing social and material relations are staged and sustained even if, and especially when, the fates of those publics remain fragile and buffeted by competing and often more powerful public formations.

The Novel Psychoactive Substances in the UK Project: empirical and conceptual review work to produce research recommendations

Background

Although illegal drug use has largely been declining in the UK over the past decade, this period has witnessed the emergence of a range of novel psychoactive substances (NPS) (‘legal highs’). These are new, mostly synthetic, substances that mimic the effects of existing drugs). Despite there being many causes for concern in relation to NPS, there has been little prior study of the burden associated with their use in public health terms. Clarity is lacking on research priorities in this rapidly developing literature.

Objectives

To inform the development of public health intervention research on NPS by reviewing existing data on their use, associated problems and potential responses to such problems.

Design

A scoping review and narrative synthesis of selected bodies of evidence was undertaken to summarise and evaluate what is known about NPS use and the related harms of, and responses to, such use. Relevant literature was identified from electronic databases (covering January 2006 to June 2016 inclusive), Google (Google Inc., Mountain View, CA, USA), relevant websites and online drug forums and by contacting experts. Articles were included if they were primary studies, secondary studies involving the analysis and interpretation of primary research or discussion papers. A conceptual framework postulating an evidence-informed public health approach to NPS use in the UK was developed through a pragmatic literature review, the iterative development of concepts and finalisation in light of the results from the empirical review work. The process also involved feedback from various stakeholders. Research recommendations were developed from both strands of work.

Results

A total of 995 articles were included in the scoping review, the majority of which related to individual-level health-related adverse effects attributable to NPS use. The prevalence of lifetime NPS use varied widely between (e.g. with higher prevalence in young males) and within population subgroups. The most commonly reported adverse effects were psychiatric/other neurological, cardiovascular, renal and gastrointestinal manifestations, and there is limited evidence available on responses. In these and other respects, available evidence is at an early stage of development. Initial evidence challenges the view that NPS should be treated differently from other illicit drugs. The conceptual framework indicated that much of the evidence that would be useful to inform public health responses does not yet exist. We propose a systems-based prevention approach that develops existing responses, is multilevel and life course informed in character, and emphasises commonalities between NPS and other legal and illegal drug use. We make 20 recommendations for research, including nine key recommendations.

Limitations

Scoping reviews do not interrogate evidence in depth, and the disjunction between the scoping review and the conceptual framework findings is worthy of careful attention.

Conclusions

Key research recommendations build on those that have previously been made and offer more evidence-based justification and detail, as previous recommendations have not yet been acted on. The case for decision-making on commissioning new research based on these recommendations is both strong and urgent.

Future work

The validity of recommendations generated through this project could be enhanced via further work with research commissioners, policy-makers, researchers and the public.

Study registration

The systematic review element of this study is registered as PROSPERO CRD42016026415.

Funding

The National Institute for Health Research Public Health Research programme.

Using a descriptive social norm to increase vegetable selection in workplace restaurant settings

Objective: Recent work has shown that exposure to social norm messages may enhance the consumption of vegetables. However, the majority of this work has been conducted in laboratories, often with student populations. Little is known about whether this approach can be successfully used in other contexts. In this study, a poster featuring a message based on social norms was tested to examine whether it could increase and maintain the purchase of meals with vegetables in workplace restaurants. Method: A pretest–posttest design with 3 phases was used in 3 workplace restaurants in the United Kingdom. The first 2 weeks formed the preintervention phase, the second 2 weeks the intervention phase, and the last 2 weeks the postintervention phase. During the intervention phase only, posters containing a social norm message relaying information about vegetable purchases of other diners were placed in each restaurant. The main outcome measure was the percentage of meals purchased with vegetables, which was analyzed using Pearson’s chi-squared test. Results: Participants were judged to be male (57%), not overweight (75%), and under the age of 60 (98%). The intervention was positively associated with the percentage of meals purchased with vegetables: baseline versus intervention (60% vs. 64% of meals purchased with vegetables; p < .01); intervention versus postintervention (64% vs. 67% of meals purchased with vegetables; p < .01); and baseline versus postintervention (60% vs. 67% of meals purchased with vegetables; p < .001). Conclusions: Social norm messages may increase the purchase of vegetables in workplace settings.

Health promotion in school environment in Brazil

OBJECTIVE

Evaluate the school environments to which ninth-year students are exposed in Brazil and in the five regions of the country according to health promotion guidelines.

METHODS

Cross-sectional study from 2012, with a representative sample of Brazil and its macroregions. We interviewed ninth-year schoolchildren and managers of public and private schools. We proposed a score of health promotion in the school environment (EPSAE) and estimated the distribution of school members according to this score. Crude and adjusted odds ratios (OR) were used, by ordinal regression, to determine the schoolchildren and schools with higher scores, according to the independent variables.

RESULTS

A student is more likely to attend a school with a higher EPSAE in the South (OR = 2.80; 95%CI 2.67–2.93) if the school is private (OR = 4.52; 95%CI 4.25–4.81) and located in a state capital, as well as if the student is 15 years of age or older, has a paid job, or has parents with higher education.

CONCLUSIONS

The inequalities among the country’s regions and schools are significant, demonstrating the need for resources and actions that promote greater equity.

Engagement of Sectors Other than Health in Integrated Health Governance, Policy, and Action

Health is created largely outside the health sector. Engagement in health governance, policy, and intervention development and implementation by sectors other than health is therefore important. Recent calls for building and implementing Health in All Policies, and continued arguments for intersectoral action, may strengthen the potential that other sectors have for health. This review clarifies the conceptual foundations for integral health governance, policy, and action, delineates the different sectors and their possible engagement, and provides an overview of a continuum of methods of engagement with other sectors to secure integration. This continuum ranges from institutional (re)design to value-based narratives. Depending on the lens applied, different elements can be identified within the continuum. This review is built on insights from political science, leadership studies, public health, empirical Health in All Policy research, knowledge and evidence nexus approaches, and community perspectives. Successful integration of health governance, policy, and action depends on integration of the elements on the continuum.

Changes in Social Capital and Cigarette Smoking Behavior Over Time: A Population-Based Panel Study of Temporal Relationships

INTRODUCTION

Identifying factors that influence individuals' smoking behavior remains a huge public health concern. This study aimed to investigate changes in individuals' cigarette smoking while considering well-known smoking determinants, including social capital, its presence being postulated to reduce smoking.

METHODS

From British Household Panel Survey data, two baseline smoking cohorts were created ("smoking" and "not smoking"). The same individuals from this nationally representative sample (N_T = 8114, aged 16-91 years) were interviewed on four occasions between years 2000 and 2007 to investigate changes in cigarette smoking behavior. Logistic regression models with random effects compensated for within-individual behavior over time. Temporal pathways were investigated by lagging independent variables (t - 1) in relation to our cigarette-use outcome at time (t).

RESULTS

Active social participation at (t - 1) was positively associated with smoking cessation at (t) (odds ratio [OR] = 1.39; 95% confidence interval [CI] [1.07-1.82]). Separating from one's spouse at (t - 1) increased risk for smoking relapse/initiation at (t) (OR = 6.63; 95% CI [1.70-28.89]). Conversely, being married protected against smoking cigarettes (OR = 1.87; 95% CI [1.15-3.04]). These associations held in our robustness checks.

CONCLUSIONS

Initial marital breakdown predicted a high risk of smoking relapse/initiation. The timing of this life event provides a critical window where adverse smoking behavior might occur. Conversely, the positive effects of active social participation on cigarette cessation remained consistent, its absence further predicting smoking relapse/initiation. Robustness of results confirms the important role that active participation has on cigarette smoking behavior. Group smoking cessation interventions could harness participatory elements to better achieve their goals.

IMPLICATIONS

By investigating temporal relationships between well-known smoking determinants and cigarette smoking outcomes, we identified that being "separated" (not "divorced") at time (t) predicted a higher risk of smoking relapse/initiation at (t). Tailored health messages could be employed to highlight the increased risk of cigarette smoking relapse/initiation during this stressful life event. Conversely, active social participation (a common social capital proxy) consistently predicted smoking cessation over time. Future group smoking cessation interventions could be designed explicitly to harness participatory elements to better achieve their goals.

What Prevents Men Aged 40-64 Years from Prostate Cancer Screening in Namibia?

Objectives. Although a growing body of evidence demonstrates the public health burden of prostate cancer in SSA, relatively little is known about the underlying factors surrounding the low levels of testing for the disease in the context of this region. Using Namibia Demographic Health Survey dataset (NDHS, 2013), we examined the factors that influence men's decision to screen for prostate cancer in Namibia. Methods. We use complementary log-log regression models to explore the determinants of screening for prostate cancer. We also corrected for the effect of unobserved heterogeneity that may affect screening behaviours at the cluster level. Results. The results show that health insurance coverage (OR = 2.95, p = 0.01) is an important predictor of screening for prostate cancer in Namibia. In addition, higher education and discussing reproductive issues with a health worker (OR = 2.02, p = 0.05) were more likely to screening for prostate cancer. Conclusions. A universal health insurance scheme may be necessary to increase uptake of prostate cancer screening. However it needs to be acknowledged that expanded screening can have negative consequences and any allocation of scarce resources towards screening must be guided by evidence obtained from the local context about the costs and benefits of screening.

Health Insecurity and Social Protection: Pathways, Gaps, and Their Implications on Health Outcomes and Poverty

Health insecurity has emerged as a major concern among health policy-makers particularly in low- and middle-income countries (LMICs). It includes the inability to secure adequate healthcare today and the risk of being unable to do so in the future as well as impoverishing healthcare expenditure. The increasing health insecurity among 150 million of the world's poor has moved social protection in health (SPH) to the top of the agenda among health policy-makers globally. This paper aims to provide a debate on the potential of social protection contribution to addressing health insecurity, poverty, and vulnerability brought by healthcare expenditure in low-income countries, to explore the gaps in current and proposed social protection measures in healthcare and provide suggestions on how social protection intervention aimed at addressing health insecurity, poverty, and vulnerability may be effectively implemented.

Inverting the pyramid! Extent and quality of food advertised on Austrian television

BACKGROUND

Research showed that food marketing for children frequently contradicts national dietary guidelines. Children, unlike adults, are not able to understand the persuasiveness of the advertisements with its short- and long-term effects on health, thus the common international tenor is to restrict food marketing. In the European Union, marketing restriction based on self-regulation have been initiated (EU Pledge Nutrition Criteria). The study aims contribute to depict the status quo of television advertisement targeted at children before the pledged initiative came into full effect.

METHODS

In this study we analyze the quality and displaying frequency of a set of advertisements targeted at children broadcasted on Austrian television. Promoted food products targeted at children or adults were identified. Category-based analysis of the displayed food was performed based on the Austrian Nutrition guidelines (number of displayed food per food category). The children's food content was analyzed according to the newly established nutritional quality criteria for advertised food in the EU to assess the nutritional quality of the depicted food.

RESULTS

In total, 360 h of video material was recorded in February and March 2014. A set of 1919 food advertisements, with 15.1 % targeted at children were broadcasted. Of all food advertisements targeted at children, 92.4 % was for fatty, sweet and salty snacks, while no advertisements for vegetables, legumes or fruits were shown. From all food advertisements for children, 65.9 % originated from participating companies of the EU Pledge Nutrition Criteria. Further analysis revealed that 95.9 % of the advertised food for children showed at least one aspect of nonconformity with the EU Pledge Nutrition Criteria; on the contrary 64.7 % of the displayed food advertisement also featured at least one desirable food component (e.g. high fibre content, high protein content).

CONCLUSIONS

The present research suggests that the majority of advertised food for children do not conform with the pledged criteria as defined in the EU Pledge Nutrition Criteria and almost all advertisements would be prohibited. We discuss our findings in the context of public health nutrition and present a perspective for future directions in this important field of research.

'Including health in systems responsible for urban planning': a realist policy analysis research programme

INTRODUCTION

Realist methods are increasingly being used to investigate complex public health problems. Despite the extensive evidence base clarifying the built environment as a determinant of health, there is limited knowledge about how and why land-use planning systems take on health concerns. Further, the body of research related to the wider determinants of health suffers from not using political science knowledge to understand how to influence health policy development and systems. This 4-year funded programme of research investigates how the land-use planning system in New South Wales, Australia, incorporates health and health equity at multiple levels.

METHODS AND ANALYSIS

The programme uses multiple qualitative methods to develop up to 15 case studies of different activities of the New South Wales land-use planning system. Comparison cases from other jurisdictions will be included where possible and useful. Data collection includes publicly available documentation and purposively sampled stakeholder interviews and focus groups of up to 100 participants across the cases. The units of analysis in each case are institutional structures (rules and mandates constraining and enabling actors), actors (the stakeholders, organisations and networks involved, including health-focused agencies), and ideas (policy content, information, and framing). Data analysis will focus on and develop propositions concerning the mechanisms and conditions within and across each case leading to inclusion or non-inclusion of health. Data will be refined using additional political science and sociological theory. Qualitative comparative analysis will compare cases to develop policy-relevant propositions about the necessary and sufficient conditions needed to include health issues.

ETHICS AND DISSEMINATION

Ethics has been approved by Sydney University Human Research Ethics Committee (2014/802 and 2015/178). Given the nature of this research we will incorporate stakeholders, often as collaborators, throughout. We outline our research translation strategies following best practice approaches.

Prevalence of alcohol use disorders in mainland China: a systematic review

AIMS

To identify studies about the prevalence of alcohol use disorder (AUD) in mainland China, evaluate the quality of these studies and conduct a meta-analysis of the prevalence of AUD in China's adult population and in population subgroups defined by sex, age and urban versus rural residency.

METHODS

Relevant studies published prior to January 2014 were identified from the following databases: China Knowledge Resource Integrated (CNKI), Wanfang, Pubmed, EmBase and Web of Science. A 16-item quality assessment inventory for epidemiological studies in mainland China was constructed to evaluate the methodological rigor of the studies. A total of 38 studies including 1 304 354 individuals were identified. Outcomes included current and life-time prevalence of AUD, alcohol dependence and alcohol abuse.

RESULTS

The pooled life-time and current prevalence of alcohol dependence were 1.4% [95% confidence interval (CI) = 1.3, 1.5] and 1.5% (95% CI = 1.2, 1.9). For males, pooled estimates of the current prevalence of alcohol dependence, alcohol abuse and AUD were 4.4 (95% CI = 3.1, 5.7), 4.0 (95% CI = 2.2, 5.7) and 10.1% (95% CI = 4.7, 15.4), respectively; the corresponding values for females were all below 0.2, 0.1, and 0.1%. There was large between-study heterogeneity in the prevalence measures that was associated with sample size, the use of key informants and the use of substitute respondents. The quality of included studies was generally low. Higher-quality studies reported higher prevalence.

CONCLUSIONS

Alcohol use disorder is an urgent public health problem in China, especially among males. When using high-quality studies, current and life-time prevalence estimates of alcohol dependence in China measure 2.2% and 3.7%, respectively, approaching those of the Netherlands, United States and other western countries.