From theory to action: applying social determinants of health to public health practice

Mapping health promotion practices across key sectors and its intersectoral approach at the local level: Study protocol

AIMS

This study outlines a protocol aimed at identifying and mapping health promotion practices in need of development from the perspectives of key sectors responsible for it at the local level and from an intersectoral perspective across four Spanish regions.

DESIGN

A complementary multi-method study combining survey methods and qualitative interviews will be adopted.

METHODS

Purposive snowball sampling will be employed to select potentially rich informants from city councils, primary care centres, primary and secondary schools, and public health and civil society organizations in 12 municipalities sensitive to local health. Data on the degree of execution of health promotion activities, the level of intersectorality in their implementation, and their origins will be collected using PromoACTIVA questionnaires, an intersectoral typology model and an interview protocol. A parallel mixed analysis encompassing descriptive statistics and a 'framework analysis' will be performed.

DISCUSSION

This study is expected to yield thorough and reliable insights into health promotion practices and omissions at the local level by focusing on key stakeholders, both individually and collaboratively. This information can enhance health promotion planning and improve its effectiveness, efficiency and contextual relevance. The development and testing of a methodology for the integration and interpretation of these data will ensure sustainable capacity building.

IMPACT

Managers and practitioners interested in health promotion planning in the researched settings can benefit from a comprehensive map of the current state of their practices and insights into the starting points of collaboration. In addition, planners from other local settings will gain access to tools and methodologies to replicate and expand these maps to their own contexts.

STAKEHOLDER ENGAGEMENT

Engaging key stakeholders with experience working in or with primary care centres, public health organizations, primary and secondary schools, civil society organizations, and city councils was vital to ensure the study's relevance and feasibility.

Insights, beliefs, and myths surrounding tuberculosis among pulmonary patients with delayed healthcare access in a high-burden TB state in Nigeria - a qualitative inquiry

Introduction

Nigeria grapples with a substantial burden of tuberculosis (TB), particularly in Oyo State, designated as a high-burden State for TB. Effectively addressing this persistent health challenge necessitates more than just medical interventions; it requires a profound understanding of the diverse insights, beliefs, and myths held by TB patients.

Methods

This qualitative study explores the perspectives of pulmonary TB patients with delayed healthcare access in Oyo State, Nigeria, focusing on their beliefs, and conceptions. In-depth interviews were conducted with 25 TB patients and 20 healthcare providers.

Results

Thematic analysis of patients' responses revealed a complex interplay between cultural, spiritual, and biomedical insights. These challenges questioned the germ theory, associating TB with witchcraft and spiritual attacks. Beliefs in hereditary transmission, links between tobacco use and health outcomes, and uncertainties about infection nature underscored disparities influenced by socio-economic factors. Insights into transmission ideas, preventive measures, and treatment beliefs highlighted a blend of culturally influenced and scientifically supported strategies. Healthcare providers' insights emphasized the necessity for targeted health education.

Discussion

These findings contribute to a nuanced understanding of TB perceptions, emphasizing the importance of culturally sensitive interventions to enhance awareness and promote timely and accurate health-seeking behaviors.

Incorporating an intersectional gender approach to improve access to maternal and child health screening services

BACKGROUND

In the Americas, the Pan American Health Organization (PAHO) has promoted initiatives that aim at the elimination of mother-to-child transmitted diseases for over two decades. Although Guatemala has assumed the commitment to improve access and coverage of reproductive and perinatal services, the goals have not yet been reached. Often, the implementation of these efforts is hampered by complexities rooted in social, cultural, and environmental intersections. The objective of this work is to share our experience applying gender intersectionality as a methodological and analytical tool in a participatory research project that aims to improve access to maternal and child health screening services. The study shows the novel strategy that incorporates intersectionality contributing to evidence on how it can be applied to strengthen public health efforts around the implementation of the EMTCT Plus (Elimination of mother-to-child transmission of HIV, Syphilis, Hepatitis B, and Chagas disease) framework, in the mostly rural municipality of Comapa, in Guatemala.

METHODS

We applied a participatory methodology, integrating theoretical and methodological frameworks to have an intersectional understanding of health services delivered by both, midwives, and the public health institution, for the prevention, diagnosis, treatment, and follow-up of HIV, Syphilis, Hepatitis B, and Chagas. The data was collected by conducting interviews, focus groups, workshops, and reviewing laboratory databases, guided by five strategies from a cultural appropriateness framework.

RESULTS

The intersectional analysis shed light on the synergies and gaps of the current efforts and protocols implemented by both the midwives and the Ministry of Health. The services offered for the four diseases were often delivered independently from each other, and a comprehensive educational and communication material strategy was absent. However, our findings will be used to inform consistent, locally relevant, and culturally appropriate educational content for the local population, also following the national policy guidelines.

CONCLUSIONS

Using intersectionality as a method and as an analytical tool allowed us to understand the (1) interrelation of diverse social, cultural, and environmental determinants which influence the delivery of health services, as well as (2) the dynamics between the traditional and institutional health systems. (3) Community engagement and the participation of different stakeholders in a consultative process have been fundamental for the conceptual and methodological tenets of this research. (4) Finally, giving a more prominent role to midwives can strengthen sustainability and cultural appropriateness, which is complementary to the delivery of institutional health services.

Family Neglect and Perspectives on Patients Living with Mental Health Disorders on the Street

In Ghana, some persons living with mental illness end up on the street. Whereas most instances have resulted from family neglect, the paucity of effective social services to cater for neglected persons with mental health disorder persons is disturbing. The present study explored family caregivers' perspectives on reasons why families neglect persons living with mental illness to be homeless and their suggestions on how families and society could prevent such occurrences. Using a qualitative approach, individual interviews were conducted with twenty family caregivers of persons living with a mental health disorder. Results revealed multifactorial causation to family neglect and provide directions for future research. Findings highlight the need for mental health rehabilitation programmes to consider family caregivers' perspectives on the causes of neglect and ways to improve mental health rehabilitation, which must be factored into policies for effectiveness. Suggestions on family and society's role to prevent such occurrences are discussed.

The economic burden of individuals living with generalized myasthenia gravis and facing social determinants of health challenges

Objective

Better understanding the impact of social determinants of health (SDOH) barriers from the patient perspective is crucial to improve holistic patient support in generalized myasthenia gravis (gMG), a rare autoimmune disorder with high disease and treatment burden. The objective of this study was to identify economic challenges experienced by individuals living with gMG and SDOH barriers to better address current unmet needs.

Methods

Adults (18-75 years) living with gMG and experiencing SDOH barriers in the United States were recruited to a mixed-methods study including qualitative interviews and a web-based quantitative survey. Quotas were implemented to include a balanced spread of baseline demographic categories including insurance type, living environment, and employment status among the study sample. Direct and indirect economic challenges were identified by degree of concern.

Results

The survey was completed by 38 individuals living with gMG, the majority of whom were enrolled in public insurance and not employed. The most commonly reported major economic concerns were managing funds for emergency care (66%), loss of income (61%), and non-medical expenses (58%), highlighting the diversity of economic challenges. Individuals who were using public insurance plans, living in non-urban environments, and unemployed experienced pronounced challenges around managing non-medical costs and accessing government assistance.

Conclusion

Both direct and indirect costs were emphasized as major concerns among individuals living with gMG and SDOH barriers. Increasing access to relevant, personalized, and holistic resources, including care management, should be prioritized to improve disease management and outcomes for individuals living with gMG.

Editors in Chief of Public Health Reports, 1878-2022: Men and Women Who Shaped the Discussion of Public Health Practice From 1918 Influenza to COVID-19

OBJECTIVES

Public Health Reports (PHR), the official journal of the Office of the US Surgeon General and US Public Health Service, is the oldest public health journal in the United States. Considering its heritage through the eyes of its past editors in chief (EICs), many of whom have been influential public health figures, can provide a fresh point of view on US public health history, of which the journal has been an integral part. Here, we reconstruct the timeline of past PHR EICs and identify women among them.

METHODS

We reconstructed the PHR EIC timeline by reviewing the journal's previous mastheads and its articles describing leadership transitions. For each EIC, we identified dates in office, concurrent job titles, key contributions, and other important developments.

RESULTS

PHR had 25 EIC transitions in 109 years of its history, during which a single individual in charge of the journal could be identified. Only 5 identifiable EICs were women, who served as EIC for approximately one-quarter of the journal's traceable history (28 of 109 years). PHR's longest-serving EIC was a woman named Marian P. Tebben (1974-1994).

CONCLUSIONS

PHR history revealed frequent EIC transitions and a low representation of women among its EICs. Mapping the timeline of past EICs of a historic public health journal can yield valuable insights into the workings of US public health, especially in the area of building a research evidence base.

Impact of social determinants of health on individuals living with generalized myasthenia gravis and implications for patient support programs

Introduction

Social determinants of health (SDOH) are important contributors to health outcomes, and better understanding their impact on individuals diagnosed with rare, chronic diseases with high burden and unmet need is critical. Characterizing SDOH burden can help improve the design of patient support programs (PSPs), using targeted approaches to remove barriers to access.

Methods

This study used a mixed-methods strategy employing a quantitative survey, which was designed based on qualitative interviews, to understand the unmet needs and awareness/utilization of PSPs among individuals living with generalized myasthenia gravis (gMG) and experiencing SDOH barriers. The survey was completed by 38 individuals living with gMG, of which the majority were non-White/Caucasian, unemployed, low income, and enrolled in public insurance. Common SDOH challenges, awareness/utilization of available PSPs, and unmet needs were identified.

Results

Financial and mental health concerns were the most common among individuals living with gMG and experiencing SDOH barriers throughout diagnosis, accessing treatment, initiating treatment, and continuing treatment. Awareness and utilization of existing support services were low, especially when accessing treatment. Educational, financial, and personalized support with high "human touch" were commonly perceived as the most valuable resources.

Implications

To better serve the needs of individuals with gMG experiencing SDOH barriers, PSPs should use a targeted approach to offer services tailored to harder-to-reach populations. Further, providers, advocacy groups, manufacturers, and public organizations in the gMG ecosystem should strengthen collaborations with PSPs to enable individuals living with gMG to access the services they need to improve their health outcomes.

The Effect of Income Disparities on Influenza Vaccination Coverage in the United States

OBJECTIVES

Although influenza vaccinations are widely accessible, many people in the United States do not receive them as recommended by the Centers for Disease Control and Prevention. This study examined the relationship between income and receiving the influenza vaccination among US adults.

METHODS

We used 2014-2018 National Health Interview Survey data (N = 138 697). Adults self-reported whether they received a shot or nasal spray vaccine within the previous 12 months and their total family income. We used multivariable logistic regression to obtain odds ratios and 95% CIs.

RESULTS

Approximately 43% of adults reported receiving the influenza vaccine in the previous 12 months. After adjustment, adults in lower-income-level categories had decreased odds of influenza vaccine receipt compared with adults with a total family income ≥$100 000. Specifically, adults with a total family income <$35 000 had 21% decreased odds of receiving the influenza vaccine (adjusted odds ratio = 0.79; 95% CI, 0.75-0.83).

CONCLUSIONS

In this population of US adults, lower income levels were associated with decreased odds of influenza vaccine receipt. The relationship between income and receipt of the influenza vaccine may have important implications for future influenza vaccination efforts. Increasing influenza vaccination coverage among lower-income adults should be considered a public health priority.

Race/ethnic differences in prevalence and correlates of posttraumatic stress disorder in World Trade Center responders: Results from a population-based, health monitoring cohort

OBJECTIVE

This study evaluated race/ethnic differences in the prevalence and correlates of World Trade Center (WTC) related posttraumatic stress disorder (PTSD) in WTC responders.

METHOD

Data were analyzed from a population-based, health monitoring cohort of 15,440 nontraditional (i.e., construction workers) and 13,403 police WTC responders.

RESULTS

Among nontraditional responders, the prevalence of WTC-related PTSD was highest in Latino/a (40.4%) versus Black (27.3%) and White (26.5%) responders; among police responders, Latino/a (10.4%) responders also had higher prevalence of PTSD relative to Black (9.8%) and White (8.7%) responders. However, multivariable analyses revealed that prior psychiatric diagnosis, greater severity of WTC-related exposures, post-9/11 stressful life events, (in police responders only) older age, and (in nontraditional responders only) lower income and education levels accounted for substantially higher prevalence of WTC-related PTSD across ethnic/racial groups. Additionally, among nontraditional responders, subgroups with added risk included responders who were: Latino/a or White had high post-911 stressful events; Latino/a or Black and had pre-9/11 psychiatric history; and Latinas. Among police responders, subgroups with added risk were Latino/a or Black police with a low annual income.

CONCLUSIONS

Collectively, results of this study underscore the burden of differential vulnerability that can contribute to higher prevalence of PTSD in certain cultural subgroups following large magnitude traumatic events. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Cervical cancer risk and screening among women seeking assistance with basic needs

BACKGROUND

In the United States, more than half of cervical cancers occur in women who are inadequately screened. Interventions to improve access to cervical cancer preventive care is critical to reduce health inequities.

OBJECTIVE

This study aimed to evaluate the need for cervical cancer screening among women seeking assistance with basic needs and to assess best approaches to facilitate Papanicolaou test referral.

STUDY DESIGN

This study is a secondary analysis of a randomized controlled trial of low-income female callers to 2-1-1 Missouri, a helpline for local health and social services. The need for cervical cancer screening was assessed. Callers were randomized to 1 of 3 arms, each providing a Papanicolaou test referral: verbal referral only, verbal referral and tailored print reminder, or verbal referral and navigator. The primary outcome was contacting a Papanicolaou test referral 1 month following intervention. Student t tests or Mann-Whitney U tests were used to analyze significant differences in continuous variables, whereas Fisher exact or χ² tests were used for categorical variables. We stratified by number of unmet basic needs (0-1 vs ≥2) and compared success of contacting a Papanicolaou test referral among study groups (verbal referral vs tailored reminder vs navigator) using the Fisher exact test and χ² test, respectively. Multivariate logistic regression was used to assess risk factors for nonadherence for Papanicolaou test at baseline and at 1 month follow-up, adjusting for race and ethnicity, age, insurance status, self-rated health, smoking, and study group.

RESULTS

Among 932 female callers, 250 (26.8%) needed cervical cancer screening. The frequency of unmet basic needs was high, the most common being lack of money for unexpected expenses (91.2%) and necessities, such as food, shelter, and clothing (73.2%). Among those needing a Papanicolaou test, 211 women received screening referrals. Women in the navigator group (21 of 71, 29.6%) reported higher rates of contacting a Papanicolaou test referral than those exposed to verbal referral only (11/73, 15.1%) or verbal referral and tailored print reminder (9/67, 13.4%) (P=.03). Among 176 women with ≥2 unmet needs who received a Papanicolaou test referral, the provision of a navigator remained associated with contacting the referral (navigator [33.9%] vs verbal referral [17.2%] vs tailored reminder [10.2%]; P=.005). Assignment to the navigator group (adjusted odds ratio, 3.4; 95% confidence interval, 1.4-8.5) and nonwhite race (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.8) were independent predictors of contacting a Papanicolaou test referral.

CONCLUSION

Low-income women seeking assistance with basic needs often lack cervical cancer screening. Health navigators triple the likelihood that women will make contact with Papanicolaou test services, but most 2-1-1 callers still fail to schedule Papanicolaou testing despite assistance from navigators. Interventions beyond health navigators are needed to reduce cervical cancer disparities.

Cost-effectiveness of Leveraging Social Determinants of Health to Improve Breast, Cervical, and Colorectal Cancer Screening: A Systematic Review

Importance

Screening for breast, cervical, and colorectal cancers in the United States has remained below the Healthy People 2020 goals, with evidence indicating that persistent screening disparities still exist. The US Department of Health and Human Services has emphasized cross-sectoral collaboration in aligning social determinants of health with public health and medical services. Examining the economics of intervening through these novel methods in the realm of cancer screening can inform program planners, health care providers, implementers, and policy makers.

Objective

To conduct a systematic review of economic evaluations of interventions leveraging social determinants of health to improve screening for breast, cervical, and colorectal cancer to guide implementation.

Evidence Review

A systematic literature search for economic evidence was performed in MEDLINE, Embase, PsycINFO, Cochrane Library, Global Health, Scopus, Academic Search Complete, Business Source Complete, EconLit, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ERIC (Education Resources Information Center), and Sociological Abstracts from January 1, 2004, to November 25, 2019. Included studies intervened on social determinants of health to improve breast, cervical, and colorectal cancer screening in the United States and reported intervention cost, incremental cost per additional person screened, and/or incremental cost per quality-adjusted life-year (QALY). Risk of bias was assessed along with qualitative assessment of quality to ensure complete reporting of economic measures, data sources, and analytic methods. In addition, included studies with modeled outcomes had to define structural elements and sources for input parameters, distinguish between programmatic and literature-derived data, and assess uncertainty.

Findings

Thirty unique articles with 94 706 real and 4.21 million simulated participants satisfied our inclusion criteria and were included in the analysis. The median intervention cost per participant was $123.87 (interquartile interval [IQI], $24.44-$313.19; 34 estimates). The median incremental cost per additional person screened was $250.37 (IQI, $44.67-$609.38; 17 estimates). Studies that modeled final economic outcomes had a median incremental cost per person of $122.96 (IQI, $46.96-$124.80; 5 estimates), a median incremental screening rate of 15% (IQI, 14%-20%; 5 estimates), and a median incremental QALY per person of 0.04 years (IQI, 0.006-0.06 year; 5 estimates). The median incremental cost per QALY gained of $3120.00 (IQI, $782.59-$33 600.00; 5 estimates) was lower than $50 000, an established, conservative threshold of cost-effectiveness.

Conclusions and Relevance

Interventions focused on social determinants of health to improve breast, cervical, and colorectal cancer screening appear to be cost-effective for underserved, vulnerable populations in the United States. The increased screening rates were associated with earlier diagnosis and treatment and in improved health outcomes with significant gains in QALYs. These findings represent the latest economic evidence to guide implementation of these interventions, which serve the dual purpose of enhancing health equity and economic efficiency.

Process, Practice and Progress: A Case Study of the Health Impact Assessment (HIA) of Brexit in Wales

Health impact assessment (HIA) is a systematic and flexible tool, which is advocated by the World Health Organisation as a method through which to consider the impact of policies on the health and well-being of a population, and the inequalities that may arise because of it. In 2018, the HIA support unit in Wales carried out a comprehensive and unique HIA on the impact of Brexit in Wales. The aims were to understand the differential impacts that Brexit would have on the health and well-being of the population and to provide evidence to inform decision makers across a range of public bodies. It followed a five-step process for HIA and utilised a wide range of evidence sources and health intelligence including both quantitative and qualitative evidence. This paper reflects on the process of carrying out the HIA and the methods used. It discusses the stages of the HIA, and shares the findings and reflections of implementation which will be beneficial to other HIA practitioners and policy makers. It does not concentrate on the findings of the HIA in detail, but focusses on what worked and any challenges encountered. It has been used to progress the practice of HIA in Wales and demonstrates the value of HIA as a method to inform and influence complex decisions.

Perceptions of barriers and levers of health-enhancing physical activity policies in mid-size French municipalities

Background

Policy is one of the levers for initiating structural change to foster the promotion of health-enhancing physical activity (HEPA). To this end, policy-makers have to deal with complex ecosystems embedded in specific contexts. However, limited research has been conducted on this topic at the local level. The purpose of this study was to identify the perceived barriers and levers of HEPA policies according to department heads and elected officials across various sectors in mid-size French municipalities.

Methods

This study used a mixed method primarily based on an adaptation of the concept mapping approach. A list of statements completing the sentence: ‘In a mid-size municipal context, to develop HEPA policies, it is necessary to …’ was submitted to key informants of 17 mid-sized French cities. Key informants in each municipality first rated the importance of each statement without considering their local context; they then rated the feasibility of each statement given their local context. In both cases, they used a Likert scale ranging from 1 to 6.

Results

A total of 23 municipal department heads and 10 elected officials from the sport (n = 14), health (n = 10) and social (n = 9) sectors in 11 mid-size French cities participated in this study. A list of 84 statements, sorted into 16 categories, was rated by participants according to their importance (M = 4.52, SD = 0.86) and their feasibility (M = 3.77, SD = 0.74). Potential barriers to (n = 10) and levers of (n = 38) HEPA policy development were identified. These results varied according to the position and sector of the participants.

Conclusions

The results suggest that local contextual factors can affect the development of HEPA policies in mid-size French municipalities. The different perceptions of the potential levers and barriers according to sector might affect intersectoral collaboration. This study contributes by enhancing understanding of how local HEPA policies are developed in the French context.

Applying a health equity tool to assess a public health nursing guideline for practice in sexually transmitted infection assessment in British Columbia

SETTING

There is a multitude of health equity tools but little guidance on how to effectively use these tools in public health nursing practice. In BC, public health nurses who are certified in sexually transmitted infection care utilize guidelines authorized by the nursing regulatory body.

INTERVENTION

As part of the Equity Lens in Public Health (ELPH) research project, an assessment of the nursing guideline, Sexually Transmitted Infection (STI) Assessment Decision Support Tool, was undertaken using the Assessing Equity in Clinical Practice Guidelines health equity assessment tool. The chosen tool is intended for use by health care providers, is broadly applicable to clinical practice guidelines, can be used retrospectively, and falls within the category of equity checklists and audits.

OUTCOMES

Overall, the tool was useful in assessing the inclusion and omission of an equity focus in the guideline. However, there were several challenges: the identification of an appropriate health equity tool; the absence of an evaluation of the chosen tool; the tool's focus on chronic disease versus communicable disease; and the difficulty of obtaining client perspectives.

IMPLICATIONS

For an improved equity lens in the STI Assessment Decision Support Tool, future revisions should be equity focused and include perspectives from affected populations, an emphasis on the determinants of health that perpetuate inequities for populations who experience a disproportionate burden of STI, information on provincially available resources, and service delivery models that improve timely and equitable access to treatment and care.

A County-Level Health Index to Capture Geographic Variation in Health Conditions in North Dakota, South Dakota, and Minnesota

INTRODUCTION

Individual health is influenced by multiple, potentially correlated factors including healthcare availability, community context, and socioeconomic factors. To measure the health changes at county-levels across North Dakota, South Dakota, and Minnesota, a measure of relative health, health index, was developed incorporating multiple indicators from domains of health conditions, health behaviors, and social determinants.

METHODS

We combined data from all 206 counties in the aforementioned three states for the years 2008-2012 from multiple data sources. We performed factor analysis that accounted for a hierarchical structure of the overall health index comprising of 15 indicators.

RESULTS

A hierarchical structure is identified in which three intermediate factors are connecting the health index with 15 health indicators. The grouping results of the 206 counties based on health index values demonstrate the existence of a gradient in health conditions in the Northern Plains.

CONCLUSIONS

The health status of urban areas was generally better than that of rural areas in the Northern Plains during this study period. The developed index adds stability to the estimates of the population characteristics, especially in rural, sparsely populated counties.

Defining and Theorizing About Culture: The Evolution of the Cultural Determinants of Help-Seeking, Revised

BACKGROUND

The recent interest in defining and theorizing about social determinants of health has illuminated the importance of culture as a central phenomenon of interest. However, cultural processes appear in multiple places in social determinants of health models, and their specifics are not delineated or operationalized.

OBJECTIVES

This theory development article describes the complexity of defining cultural variables and uses medical anthropology to show how cultural domains, constructs, and variables can be defined.

METHODS

Using cultural anthropology theory, empirical work, and a literature synthesis as a starting point, the evolution of the cultural determinants of help-seeking theory is explored and the revision of the theory is highlighted.

RESULTS

The expanded theory include structural concepts as control variables, reframes illness as "suffering," and adds concepts of course, cure, manageability, meaning in life, functioning, social negativity, and perceived need.

DISCUSSION

Strategies for and benefits of isolating and operationalizing cultural variables for middle-range theory development and testing are discussed.

Testing the influence of cultural determinants on help-seeking theory

Despite increased risks for mental health problems, East Asian immigrant women have the lowest overall service-utilization rates of any cultural group in the United States. Although the influence of cultural processes as the cause of low service use is widely speculated, no empirical study has tested cultural determinants (including culturally specific idioms of distress, culture-based illness interpretations, or concerns about social consequences), social contextual factors, perceived need (PN), and help-seeking (HS) behaviors. In the present study, we examined how cultural determinants, such as symptom experience, beliefs and interpretations, and perceptions about the social environment, affect PN and HS type for Japanese women living in the United States. Increasing physical symptom severity increased the predicted probability of endorsing PN. For those participants with PN, 48.6% of them used medical HS (χ2 = 11.27, p = .00), and 12.5% of them used the psychological HS (χ2 = 7.43, p = .01). Multivariate logistic regression revealed that, when PN is considered with the other cultural variables while controlling for structural variables, PN increases the odds of medical HS (OR = 2.78, 95% CI [1.0-5.8], p < .01). The odds of medical HS are also increased with higher social support (OR = 1.07, 95% CI [1.0-1.1], p < .01). Finally, the presence of interpersonal stigma beliefs decreased the odds of medical HS (OR = 2.4, 95% CI [1.1-5.3], p < .03). Clinical and research implications are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Do Mothers with Lower Socioeconomic Status Contribute to the Rate of All-Cause Child Mortality in Kazakhstan?

Background

This study aimed to explore whether or not mothers with higher educational and wealth status report lower rate of child mortality compared to those with less advantageous socioeconomic situation.

Methods

Data used were cross-sectional and collected from Multiple Indicator Cluster Survey in Kazakhstan conducted in 2015. Subjects experiencing childbirth were 9278 women aging between 15 and 49 years. The associations between maternal education and household wealth status with child mortality were examined by multivariate analytical methods.

Results

The overall prevalence of child mortality was 6.7%, with noticeable variations across the different regions. Compared with women who had the highest educational status, those with upper and lower secondary were 1.47 and 1.89 times more likely to experience child death. Women in the lowest and second lowest wealth quintile had 2.74 and 2.68 times higher odds of experiencing child death compared with those in the richest wealth status households.

Conclusions

Policy makers pay special attention to improving socioeconomic status of the mothers in an effort to reduce child mortality in the country. Women living in the disadvantaged regions with poor access to quality health care services should be regarded as a top priority.

Implications of male circumcision for women in Papua New Guinea: a transformational grounded theory study

Background

Male circumcision reduces the risk of female-to-male transmission of human immunodeficiency virus (HIV) and is being explored for HIV prevention in Papua New Guinea (PNG). PNG has a concentrated HIV epidemic which is largely heterosexually transmitted. There are a diverse range of male circumcision and penile modification practices across PNG. Exploring the implications of male circumcision for women in PNG is important to inform evidence-based health policy that will result in positive, intended consequences.

Methods

The transformational grounded theory study incorporated participatory action research and decolonizing methodologies. In Phase One, an existing data set from a male circumcision study of 861 male and 519 female participants was theoretically sampled and analyzed for women’s understanding and experience of male circumcision. In Phase Two of the study, primary data were co-generated with 64 women in seven interpretive focus group discussions and 11 semi-structured interviews to develop a theoretical model of the processes used by women to manage the outcomes of male circumcision. In Phase Three participants assisted to refine the developing transformational grounded theory and identify actions required to improve health.

Results

Many women know a lot about male circumcision and penile modification and the consequences for themselves, their families and communities. Their ability to act on this knowledge is determined by numerous social, cultural and economic factors. A transformational grounded theory was developed with connecting categories of: Women Know a Lot, Increasing Knowledge; Increasing Options; and Acting on Choices. Properties and dimensions of each category are represented in the model, along with the intervening condition of Safety. The condition of Safety contextualises the overarching lived realty for women in PNG, enables the inclusion of men in the transformational grounded theory model, and helps to explain relationships between men and women. The theory presents the core category as Power of Choice.

Conclusions

This transformational grounded theory provides a means to explore how women experience male circumcision and penile modification in PNG, including for HIV prevention. Women who have had opportunities for education have a greater range of choices and an increased opportunity to act upon these choices. However, women can only exercise their power of choice in the context of safety. The concept of Peace drawn from the Social Determinants of Health is applied in order to extend the explanatory power of the transformational grounded theory. This study shows that women’s ambivalence about male circumcision is often related to lack of safety, a consequence of gender inequality in PNG.

Outbreaks in the age of syndemics: New insights for improving Indigenous health

Conventional approaches for the prevention and control of communicable diseases within Indigenous contexts may benefit from new insights arising from the growing interest in syndemics. Syndemics is a term used to describe a conceptual framework for understanding diseases or health conditions, and how these are exacerbated by the social, economic, environmental and political milieu in which a population is immersed. The use of conventional approaches for outbreak prevention and control remains the bedrock of intervention in the field of communicable diseases; yet on their own, these strategies are not always successful, especially within contexts of marginalization and disadvantage. A broader approach is needed; one that examines the systemic factors involved, understands how various policies and systems support or hinder effective responses and identifies the structural changes needed to create more supportive environments and increase the resilience of the population. In an Indigenous context, whether the focus is on hepatitis C, tuberculosis, HIV or water-borne diseases, it is important to recognize that a) social determinants contribute to the emergence and persistence of outbreaks, b) conventional approaches to communicable disease control are necessary but not sufficient, and c) using a "syndemics lens" can leverage action at multiple levels to tackle the root causes of poor health and inform more effective strategies for improving Indigenous health and reducing health inequities.

Use of Community Health Workers and Patient Navigators to Improve Cancer Outcomes Among Patients Served by Federally Qualified Health Centers: A Systematic Literature Review

Introduction: In the United States, disparities in cancer screening, morbidity, and mortality are well documented, and often are related to race/ethnicity and socioeconomic indicators including income, education, and healthcare access. Public health approaches that address social determinants of health have the greatest potential public health benefit, and can positively impact health disparities. As public health interventions, community health workers (CHWs), and patient navigators (PNs) work to address disparities and improve cancer outcomes through education, connecting patients to and navigating them through the healthcare system, supporting patient adherence to screening and diagnostic services, and providing social support and linkages to financial and community resources. Clinical settings, such as federally qualified health centers (FQHCs) are mandated to provide care to medically underserved communities, and thus are also valuable in the effort to address health disparities. We conducted a systematic literature review to identify studies of cancer-related CHW/PN interventions in FQHCs, and to describe the components and characteristics of those interventions in order to guide future intervention development and evaluation.

Method: We searched five databases for peer-reviewed CHW/PN intervention studies conducted in partnership with FQHCs with a focus on cancer, carried out in the United States, and published in English between January 1990 and December 2013.

Results: We identified 24 articles, all reporting positive outcomes of CHW/PNs interventions in FQHCs. CHW/PN interventions most commonly promoted breast, cervical, or colorectal cancer screening and/or referral for diagnostic resolution. Studies were supported largely through federal funding. Partnerships with academic institutions and community-based organizations provided support and helped develop capacity among FQHC clinic leadership and community members.

Discussion: Both the FQHC system and CHW/PNs were borne from the need to address persistent, complex health disparities among medically underserved communities. Our findings support the effectiveness of CHW/PN programs to improve completion and timeliness of breast, cervical, and colorectal cancer screening in FQHCs, and highlight intervention components useful to design and sustainability.

The ConNECT Framework: a model for advancing behavioral medicine science and practice to foster health equity

Health disparities persist despite ongoing efforts. Given the United States' rapidly changing demography and socio-cultural diversity, a paradigm shift in behavioral medicine is needed to advance research and interventions focused on health equity. This paper introduces the ConNECT Framework as a model to link the sciences of behavioral medicine and health equity with the goal of achieving equitable health and outcomes in the twenty-first century. We first evaluate the state of health equity efforts in behavioral medicine science and identify key opportunities to advance the field. We then discuss and present actionable recommendations related to ConNECT's five broad and synergistic principles: (1) Integrating Context; (2) Fostering a Norm of Inclusion; (3) Ensuring Equitable Diffusion of Innovations; (4) Harnessing Communication Technology; and (5) Prioritizing Specialized Training. The framework holds significant promise for furthering health equity and ushering in a new and refreshing era of behavioral medicine science and practice.

Nuestra Casa: An advocacy initiative to reduce inequalities and tuberculosis along the US-Mexico border

The US-Mexico border provides a rich learning environment for professional social workers and at the same time poses some challenges. This article explores some of the unique demographics and social and cultural characteristics in the border region. These characteristics have implications for social work teaching, research, policy and practice. The study of borders includes exploring social disparities and inequalities. Health risks and diseases travel fluidly between borders and kill indiscriminately. The US-Mexico border is at high-risk of elevated tuberculosis (TB) and HIV incidence due to socio-economic stress, rapid and dynamic population growth, mobility and migration, and the hybridization of cultures. Every minute, four people die from TB, and 15 more become infected worldwide. The number of deaths due to tuberculosis is unacceptable given that most cases of TB are preventable. Cross-border cooperation and collaboration among social workers, health professionals and public officials between communities and countries can reduce social injustices to move towards a healthier borderland, as demonstrated in the collaborative prevention of TB. Rather than limiting our work to define social inequalities, we seek to further the conversation and suggest social action to address TB. This article contributes ideas and examples of experiences to encourage innovative, community-academic engaged inter- and multidisciplinary interventions like the Nuestra Casa (Our House) initiative. Nuestra Casa is an advocacy, communication and social mobilization strategy to address TB and HIV health disparities and inequalities in underserved communities, which we argue provides a useful model for combating TB and other inequalities plaguing the US-Mexico borderland.

Environmental Influences on HIV Medication Adherence: The Role of Neighborhood Disorder

OBJECTIVES

We hypothesized that highly disordered neighborhoods would expose residents to environmental pressures, leading to reduced antiretroviral (ARV) medication adherence.

METHODS

Using targeted sampling, we enrolled 503 socioeconomically disadvantaged HIV-positive substance users in urban South Florida between 2010 and 2012. Participants completed a 1-time standardized interview that took approximately 1 hour. We tested a multiple mediation model to examine the direct and indirect effects of neighborhood disorder on diversion-related nonadherence to ARVs; risky social networks and housing instability were examined as mediators of the disordered neighborhood environment.

RESULTS

The total indirect effect in the model was statistically significant (P = .001), and the proportion of the total effect mediated was 53%. The model indicated substantial influence of neighborhood disorder on nonadherence to ARVs, operating through recent homelessness and diverter network size.

CONCLUSIONS

Long-term improvements in diversion-related ARV adherence will require initiatives to reduce demand for illicit ARV medications, as well as measures to reduce patient vulnerability to diversion, including increased resources for accessible housing, intensive treatment, and support services.

EXAMINING SOCIOECONOMIC HEALTH DISPARITIES USING A RANK-DEPENDENT RÉNYI INDEX

The Rényi index (RI) is a one-parameter class of indices that summarize health disparities among population groups by measuring divergence between the distributions of disease burden and population shares of these groups. The rank-dependent RI introduced in this paper is a two-parameter class of health disparity indices that also accounts for the association between socioeconomic rank and health; it may be derived from a rank-dependent social welfare function. Two competing classes are discussed and the rank-dependent RI is shown to be more robust to changes in the distribution of either socioeconomic rank or health. The standard error and sampling distribution of the rank-dependent RI are evaluated using linearization and re-sampling techniques, and the methodology is illustrated using health survey data from the U.S. National Health and Nutrition Examination Survey and registry data from the U.S. Surveillance, Epidemiology and End Results Program. Such data underlie many population-based objectives within the U.S. Healthy People 2020 initiative. The rank-dependent RI provides a unified mathematical framework for eliciting various societal positions with regards to the policies that are tied to such wide-reaching public health initiatives. For example, if population groups with lower socioeconomic position were ascertained to be more likely to utilize costly public programs, then the parameters of the RI could be selected to reflect prioritizing those population groups for intervention or treatment.

Macroeconomic policies and increasing social-health inequality in Iran

BACKGROUND

Health is a complex phenomenon that can be studied from different approaches. Despite a growing research in the areas of Social Determinants of Health (SDH) and health equity, effects of macroeconomic policies on the social aspect of health are unknown in developing countries. This study aimed to determine the effect of macroeconomic policies on increasing of the social-health inequality in Iran.

METHODS

This study was a mixed method research. The study population consisted of experts dealing with social determinants of health. A purposive, stratified and non-random sampling method was used. Semi-structured interviews were conducted to collect the data along with a multiple attribute decision-making method for the quantitative phase of the research in which the Technique for Order Preference by Similarity to Ideal Solution (TOPSIS) was employed for prioritization. The NVivo and MATLAB softwares were used for data analysis.

RESULTS

Seven main themes for the effect of macroeconomic policies on increasing the social-health inequality were identified. The result of TOPSIS approved that the inflation and economic instability exert the greatest impact on social-health inequality, with an index of 0.710 and the government policy in paying the subsidies with a 0.291 index has the lowest impact on social-health inequality in the country.

DISCUSSION

It is required to invest on the social determinants of health as a priority to reduce health inequality. Also, evaluating the extent to which the future macroeconomic policies impact the health of population is necessary.