Upending the social ecological model to guide health promotion efforts toward policy and environmental change

Designing Health Recommender Systems to Promote Health Equity: A Socioecological Perspective

Health recommender systems (HRS) have the capability to improve human-centered care and prevention by personalizing content, such as health interventions or health information. HRS, an emerging and developing field, can play a unique role in the digital health field as they can offer relevant recommendations, not only based on what users themselves prefer and may be receptive to, but also using data about wider spheres of influence over human behavior, including peers, families, communities, and societies. We identify and discuss how HRS could play a unique role in decreasing health inequities. We use the socioecological model, which provides representations of how multiple, nested levels of influence (eg, community, institutional, and policy factors) interact to shape individual health. This perspective helps illustrate how HRS could address not just individual health factors but also the structural barriers-such as access to health care, social support, and access to healthy food-that shape health outcomes at various levels. Based on this analysis, we then discuss the challenges and future research priorities. We find that despite the potential for targeting more complex systemic challenges to obtaining good health, current HRS are still focused on individual health behaviors, often do not integrate the lived experiences of users in the design, and have had limited reach and effectiveness for individuals from low socioeconomic status and racial or ethnic minoritized backgrounds. In this viewpoint, we argue that a new design paradigm is necessary in which HRS focus on incorporating structural barriers to good health in addition to user preferences. HRS should be designed with an emphasis on health systems, which also includes incorporating decolonial perspectives of well-being that challenge prevailing medical models. Furthermore, potential lies in evaluating the health equity effects of HRS and leveraging collected data to influence policy. With changes in practices and with an intentional equity focus, HRS could play a crucial role in health promotion and decreasing health inequities.

Physical activity promotion in French cystic fibrosis centers: capitalizing on experience

BACKGROUND

Physical activity (PA) provides physical and psychosocial benefits for people with cystic fibrosis (pwCF). However, practice levels remain below recommendations and strategies for promoting PA in specialist centers need to be better identified. The socio-ecological model of health emphasizes the central role of policies and environment in influencing individuals' health behaviors. This model provides a basis for understanding how health professionals perceive the promotion of PA in their centers.

OBJECTIVE

The aim of this study was to explore intervention components of PA promotion in specialized CF centers in France that are "experienced" in PA promotion, to identify elements that can be transferable to other centers.

METHODS

A descriptive qualitative study was conducted with 16 healthcare professionals and pwCF. Semi-structured interviews were conducted and analyzed using inductive and deductive methods classically used in psychology.

RESULTS

Five themes were extracted: the action and its context, the partnerships established around this action to promote physical activity, the evaluation of the action, its reproducibility, and the changes induced by COVID-19.

CONCLUSIONS

Some factors emerged as essential for promoting PA among pwCF, notably the dialogue between the health professionals and patients, the presence of adapted PA instructors, and the involvement of partners.

Consensus in Action: Context-Specific Physical Activity Guidelines for Undergraduate Students at a South African University

Physical inactivity among undergraduate university students has been considered a public health concern. To address this, researchers have utilized consensus workshop approaches to develop effective physical activity (PA) recommendations. However, the existing research has limitations: it is outdated, not context-specific to young adults, and does not account for psychosocial factors (such as mental health, motivation, and social support) that hinder or promote PA behavior, particularly in South Africa. Therefore, the purpose of this study was to engage with stakeholders to achieve a consensus on a set of context-specific guidelines to enhance the physical activities of undergraduate university students. Utilizing the Social Ecological Model, this study employed two online consensus workshops with 25 purposively selected stakeholders (Round 1 = 8 and Round 2 = 17). Stakeholders were divided into breakout rooms via the Google Meets feature, to discuss and brainstorm the guidelines, expressing their agreement or disagreement with the proposed names and descriptions. The consensus was considered achieved when the majority of stakeholder responses fell into the 'Agree with the guideline' category. An inductive thematic analysis approach was used to generate common themes, which were then coded via Atlas Ti. V8. Stakeholders reached a consensus on four categories and 32 guidelines, namely, PA (9 guidelines), mental health (7 guidelines), motivation (9 guidelines), and social support (7 guidelines). Each category, along with its respective set of guidelines, provides insights into the type of information undergraduate students require to enhance their PA participation. Using a consensus workshop facilitated the co-creation of context-specific guidelines to enhance the physical activities of undergraduate university students. This approach proved to be a valuable tool for fostering collaboration between academic staff and students.

Community-Driven Health Promotion: Evaluation of a Rural Microgrant Program

INTRODUCTION

Microgrants for health promotion have the potential to engage communities in designing and implementing place-based interventions to improve health and social outcomes. However, the evidence base around microgrants for health promotion is limited. This study presents the evaluation of a health service-funded microgrant program for health promotion in rural Australia.

METHODS

The evaluation framework was developed through a participatory approach and involved collaborative logic model building and co-prioritized evaluation questions with health service staff and grant recipients. Evaluation questions focused on participation, short-term outcomes, and the perceived value of program activities. Qualitative methods (reflexive thematic analysis) were used to answer the evaluation questions. Data sources included semi-structured interviews with grantees (n = 11) and the health service's health promotion team (n = 4), electronic field notes kept by the health promotion team (n = 50 documents), electronic progress reports completed by grantees (n = 6) and information and feedback forums (n = 2).

RESULTS

Since the program's inception in 2019, the health service has received 22 grant applications of which 15 were approved and 14 disbursed. Evaluation results show that grantees were community members with multiple roles, often with previous experience in applying for grants. Expected outcomes have been partially met, especially with regard to the program's aim of community empowerment. The most notable impact was the enhancement of participants' perception of and relationship with the health promotion team, as well as the creation of opportunities for community members such as exposure to art and bridging of social groups.

CONCLUSION

Microgrants represent a feasible way to increase health opportunities and foster community participation in the planning and delivery of health promotion programs. The key program activities identified and suggested improvements can help guide program replication and adaptation by other small organizations.

PUBLIC CONTRIBUTION

Community members who had previously received a health service grant were invited to participate in collaborative workshops and follow-up surveys to codesign the grant program evaluation framework, co-prioritize evaluation questions and guide the results' dissemination plan.

Work-related impacts on doctors' mental health: a qualitative study exploring organisational and systems-level risk factors

BACKGROUND

Protecting doctors' mental health has typically focused on individuals, rather than addressing organisational and structural-level factors in the work environment.

OBJECTIVES

This study uses the socioecological model (SEM) to illuminate and explore how these broader factors inform the mental health of individual doctors.

DESIGN

Semi-structured interviews (20-25 hours) and ethnographic observations (90 hours) involving work shadowing doctors (n=14).

PARTICIPANTS

Doctors representing various career stages, specialty areas, genders and cultural backgrounds.

SETTING

Three specialties in a public South Australian hospital. Thematic analysis revealed work-related risk factors for poor mental health.

RESULTS

The SEM framework was used to analyse the work environment's impact on doctors' mental health. The analysis identified how the layers interconnect to influence risk factors for individual doctors. Microsystem: lack of control over career advancement, disenfranchisement due to understaffing and concerns about handling complex cases relative to experience. Mesosystem: negative impacts of shift work and fragmented teams, leading doctors to absorb pressure despite exhaustion to maintain professional credibility. Exosystem: high patient loads with time constraints and geographical limitations hindering care delivery, compounded by administrative burdens. Macrosystem: the commercialisation of medicine emphasising corporatisation and bureaucratic processes, which devalues professional autonomy.

CONCLUSIONS

This study highlights how doctors experience layers of interconnected factors that compromise their mental health but over which they have very little control. Interventions must therefore address these issues at organisational and systemic levels, for which starting points evident within our data are identified.

Ask Your Relative: A mixed method analysis of the Sexual Health and Healthy Relationship Q&As submitted by American Indian Alaska Native young adults

BACKGROUND

Disparities in sexual health outcomes persist among American Indian and Alaska Native (AIAN) youth due to intersectional challenges accessing youth-friendly health services. AIAN youth have an increased prevalence of STIs and teen pregnancy. To address disparities in sexual health outcomes, the Ask Auntie/Ask Your Relative (AYR) Q&A service has been used by AIAN youth and young adults for over seven years as a trusted resource for information on sensitive health topics. There is a continued need to better understand the health-seeking behaviors of AIAN youth, especially those related to healthy relationships and sexual health, to improve the alignment of health resources to their needs.

METHODS

This mixed-method study began with two phases. Phase 1 involved an analysis of all AYR data using Google Analytics and basic frequency counts. Phase 2 reviewed all questions and answers related to sexual health and healthy relationships (N = 240) using thematic analysis, NVivo 12.0, and intersectionality, guided by the social determinants of health. All AYR answers were coded based on type, name/location, number of times viewed, and examples. The final step of the analytic process was to utilize an intersectional approach and socioecological model (Individual, Community, Tribe/Nation, and World) to create a visual model with results.

RESULTS

Phase 1-Since We R Native began tracking AYR data, the service has been utilized by 2.37 M users, with 1.16 M unique pageviews. The average time on the page was 4 min and 46 s. The number of AYR questions submitted varied by year, and were most frequent in 2016, then decreased in subsequent years. In Phase 2, the main themes identified in AYR questions were (1) Reaching Out for Help, (2) Identity and Physical Development, and (3) Healthy Relationships. Analysis of the Q&A answers identified 244 resources, and of these, 100 were Native-specific. The context-specific resources represented 21 uniquely coded health topics, ranging from women's health to behavioral health.

CONCLUSIONS

The broad range of healthy relationship and sexual health questions submitted to the AYR service reflects the types of health information that AIAN young adults want to know about. Resources provided in response to their questions connected Q&A viewers to a wide variety of organizations and programs designed to support AIAN young adults in their health and wellness journey. Findings from this study may be useful for creating additional culturally tailored resources.

Expansion and evaluation of level II and III recovery residences for people taking medications for an opioid use disorder: project HOMES (Housing for MAR Expanded Services) study protocol

INTRODUCTION

As the US continues to battle the opioid epidemic, recovery residences remain valuable services for people in recovery. While there is a growing body of literature describing positive outcomes experienced by people who live in recovery residences, little is known about the experience of people who live in these residences while taking medications for an opioid use disorder (MOUD) as part of their recovery. Thus, this study has three aims: (1) expand the availability of recovery residences that meet the National Alliance for Recovery Residences standards in Texas and serve individuals taking medications for an opioid use disorder as part of their recovery; (2) evaluate recovery residences for people taking MOUD as part of their recovery; and (3) compare the cost-effectiveness of recovery residences to treatment-as-usual.

METHODS AND ANALYSIS

In collaboration with community partners, we opened 15 recovery residences in the State of Texas to house people taking MOUD as part of their recovery. We are collecting quantitative and qualitative data to evaluate outcomes at the intrapersonal, interpersonal, organisational and community levels. At the intrapersonal level, we are assessing changes in behavioural and psychosocial constructs using a longitudinal survey, objectively measuring current substance use with a point-of-interview breathalyser and urinalysis, and examining changes in healthcare utilisation using data obtained from a healthcare information exchange. We are collecting interpersonal data using in-depth individual interviews with residents and staff. We are collecting organisational data using field observation and a cost-effectiveness study, and we are collecting community data using neighbourhood mapping.

ETHICS AND DISSEMINATION

The UTHealth institutional review board approved all protocols. We will disseminate study findings via conference presentations, peer-reviewed publications and brief community reports.

Protocol for a cluster randomised controlled trial to evaluate effectiveness of a self-help group intervention to encourage smoke-free homes in slums of Kochi(Kochi Intervention for tobacco smoke free homes-KIFT)

Background

Exposure to second hand smoke (SHS) is a cause for heart disease and lung cancer among non- smokers. This cluster randomized control trial will evaluate the effectiveness of a tobacco smoke free home intervention in reducing exposure to second hand smoke.

Protocol

The intervention will be conducted among 30 clusters in urban and peri-urban areas of Kochi, India. The sample size is 300 per arm and 15 clusters to detect a minimal difference of 0.03ng/ml in cotinine levels between groups, at 80% power with a two-sided alfa of 0.05 considering variable cluster size. A baseline survey will be undertaken to identify smokers. Data related to smoking, indoor smoking, nicotine dependence, blood pressure (BP) of smokers, morbidity experienced, and lung volume Fev1/Fev6 of smokers will be measured. Urine cotinine, morbidity, BP of spouse and child will be assessed. Air quality monitors measuring PM2.5 will be placed in homes. Trained self-help group women and frontline health workers will implement the intervention. The intervention will consist of monthly home visits to educate the smoker on the harms of second-hand smoke using 3 A's. The circle of influencers around the smoking men will also be contacted by the members of self-help group to provide support to stop smoking within homes and to quit. They will then organize two-three meetings of community leaders and heads of women's groups, present data on harms of SHS, and explain the rationale for establishing smoke free homes in their community for a duration of six months. After the intervention a post assessment will be conducted and this will be repeated after six months.

Ethics and dissemination

The trial protocol was approved by the Institutional Ethical Committee of Amrita Institute of Medical Sciences. Results will be submitted to open access peer reviewed journals and shared with other stakeholders.

Trial registration

CTRI/2021/06/034478.

Identifying Factors That Influence Physical Activity and Healthy Aging Among Older Latino Adults

BACKGROUND

For older Latinos, some benefits of leisure-time physical activity (LTPA) include enhanced cognitive functioning, decreased loneliness, and reduced premature mortality. Despite LTPA benefits, adults ≥50 years are one of the most inactive age groups in the United States.

METHODS

This qualitative study aimed to add to the limited evidence of LTPA in older Latino adults by exploring the barriers and facilitators for fitness class uptake and park use. Guided by a Social-Ecological Model of Health and Social Determinants of Health theoretical and a phenomenological research design, qualitative research data were collected via 27 personal interviews with Latino adults using a semistructured interview guide. Participants were recruited using purposive sampling strategies in collaboration with community partners. Bicultural data collectors conducted the semistructured interviews over Zoom. Thematic analysis was performed using Dedoose, following an inductive and deductive approach.

RESULTS

The main barriers to fitness class attendance and park use were family and/or work commitments, perceived safety, and perceived discrimination. Conversely, the critical facilitators for participation were socialization into a group, social connectedness with group members, fitness instructor characteristics, and exercise history.

CONCLUSIONS

Findings from this study hold important implications for the design of fitness programming and park-based recreation, including the need to increase the cultural diversity of recreation staff and culturally relevant programming. Future research is needed on time poverty related to family/work commitments and whether discriminatory practices at fitness centers, like ageism and race/ethnicity, influence physical activity behavior.

Global school plate waste estimates highlight the need for building a sustainable food education system

Food waste reduction is essential for supporting the sustainability of food systems. Wasteful behaviours are difficult to change after they have been formed, highlighting the importance of early interventions. Here we present an assessment of school plate food waste from 29 countries, and examine the environmental implications, causes, and interventions. School plate waste ranged from 4% to 46% per capita per meal and was positively correlated with country income levels. On a global scale, this waste embodies ∼150 Mha of cropland and ∼770 MtCO2e of greenhouse gas emissions; hence, reducing school plate food waste offers potentially large environmental gains. We propose a comprehensive, multistakeholder framework centred around sustainable food education that cultivates food systems knowledge and skills, and an appreciation for nature and food labour to reduce the psychological distance between youth and their food waste. To effectively implement the framework requires the support and engagement of families, communities and the broader society beyond the confines of schools.

Leveraging local knowledge to contextualize the opioid epidemic within HEALing Communities Study communities: A Photovoice protocol

Since its inception 30 years ago, Photovoice has gained increasing popularity as a research method and more recently has been incorporated within randomized controlled trial (RCT) designs. Photovoice is a participatory action research method that pairs photography with focus group discussions to record community strengths and concerns, build critical consciousness, and reach policymakers. Adherence of Photovoice implementation to these original tenets of Photovoice varies. This article provides the Photovoice protocol developed by the authors to improve the methodological rigor of Photovoice integration into RCTs and help contextualize the landscape for the HEALing Communities Study (HCS: NCT04111939), a greater than $350 million investment by the National Institute on Drug Abuse along with the Substance Abuse and Mental Health Services Administration to reduce opioid overdose deaths in 67 of the hardest-hit communities in four states (Kentucky, Massachusetts, New York, and Ohio). The product of a cross-state collaboration, this HCS Photovoice protocol provides ethical and methodological tools for incorporating Photovoice into RCT designs to enhance community engagement, communication campaigns, and data-driven decision-making about evidence-based practice selection and implementation.

Association between the perceived built environment and health behaviors in older adults: a cross-sectional study from Beijing, China

BACKGROUND

Under the background of the increasing trend of population aging, the health and quality of life of older adults have become the focus of social concern. As an important part of older adults' daily life, the design and configuration of the built environment may positively or negatively affect older adults' health behaviors. Therefore, this study aims to explore the relationship between older adults' perceived built environments and health behaviors, which is the association between perceived built environments and older adults' physical activity (PA) and social interactions. This is important for optimizing the community built environment and improving the quality of life of older adults.

METHODS

In this study, a questionnaire was surveyed on 916 Chinese older adults aged 60 and above. The questionnaire was used to collect demographic information and social interaction from the participants, and the Physical Activity Neighborhood Environment Scale (PANES) and the Physical Activity Scale for the Elderly (PASE) were used to assess older adults' subjective perceptions of the built environment in their neighborhoods and their levels of PA, respectively. In data analysis, ANOVA and chi-square tests were used to compare the significance of differences between groups, and multiple linear regression model were used to estimate the association between older adults' perceived characteristics of the built environment and their PA and social interaction.

RESULTS

After controlling for confounders such as gender, age, BMI, and education level, the multiple linear regression model showed that perceived destination accessibility, neighborhood infrastructure, aesthetic qualities, and neighborhood environment indices were significantly correlated with PA (β = 0.083 ~ 0.095, P < 0.05) and social interaction (β = 0.087 ~ 0.144, P < 0.05) among older adults. In addition, neighborhood safety (β = -0.084, P < 0.05), social environment (β = 0.091, P < 0.01), and street connectivity (β = 0.112, P < 0.001) were also strongly associated with older adults' social interaction.

CONCLUSIONS

Different perceived built environment attributes are correlated with the health behaviors of Chinese older adults to different degrees. This finding helps to guide community planning and construction, provides an empirical basis for improving health behaviors of older adults, and provides an important reference for building healthy communities for older adults and realizing comprehensive healthy development of older adults.

TRIAL REGISTRATION

There was no trial registration for this study, but the study was approved by the Institutional Review Board of Tsinghua University (No. THU0120230196).

The factors related to depressive symptoms in urban older adults in South Korea: a study based on the Seoul Aging Survey

PURPOSE

This study aims to comprehensively examine the determinants of depression among urban older adults in Seoul, utilizing the social-ecological model to address multifaceted influences.

METHODS

A comprehensive analysis was conducted using data from the 2022 Seoul Aging Survey, which surveyed 2,914 individuals aged 65 and above. A multiple logistic regression analysis was performed to identify factors contributing to depressive symptoms, including socio-demographic characteristics, health behaviors and status, research accessibility, social support, and environmental influences.

RESULTS

This study revealed that poor subjective health (OR = 1.47) and the presence of multiple chronic diseases (OR = 1.59) significantly increased the risk of depressive symptoms among urban older adults. From a social support standpoint, living alone was associated with a higher risk of depression (OR = 1.66), low food security (OR = 2.56), and low digital competency (OR = 2.70) were all significant predictors of depressive symptoms. Additionally, a lack of engagement with cultural facilities (OR = 2.15) was identified as a critical environmental factor contributing to depression.

CONCLUSIONS

The findings underscore the need for comprehensive policy and practical interventions aimed at preventing chronic disease, enhancing social support networks, improving digital literacy, ensuring food security, and expanding access to healthcare and cultural facilities. Such measures are crucial in mitigating depression among urban older adults, thereby enhancing their overall well-being and quality of life.

Examining and mitigating racism in nursing using the socio-ecological model

Racism in nursing is multifaceted, ranging from internalized racism and interpersonal racism to institutional and systemic (or structural) elements that perpetuate inequities in the nursing profession. Employing the socio-ecological model, this study dissects the underlying challenges across various levels and proposes targeted mitigation strategies to foster an inclusive and equitable environment for nursing education. It advances clear, context-specific mitigation strategies to cultivate inclusivity and equity within nursing education. Effectively addressing racism within this context necessitates a tailored, multistakeholder approach, impacting nursing students, faculty, administration, professional organizations, and licensing and accrediting bodies. This all-encompassing strategy recognizes that the interplay of interpersonal dynamics, community culture, institutional policies, and broader societal structures intricately shapes individual experiences. Nurses, nurse leaders, educators, organizations, and policymakers can work together to create a more equitable and inclusive nursing profession by targeting each of these levels. This transformational process can yield positive outcomes across various environments where nurses learn, work, and serve people and enable the demographic composition of nurses to better match the populations served.

Challenges in the distribution of antimicrobial medications in community dispensaries in Accra, Ghana

INTRODUCTION

The dispensation of medicines in some low- and middle-income countries is often carried out by private vendors operating under constrained conditions. The aim of this study was to understand the challenges reported by employees of dispensaries, specifically, chemical and herbal shops and pharmacies in Accra, Ghana. Our objectives were twofold: (1) to assess challenges faced by medicine vendors related to dispensing antimicrobials (antibiotic and antimalarial medications), and (2) to identify opportunities for improving their stewardship of antimicrobials.

METHODS

Data were collected in 79 dispensaries throughout Accra, in 2021, using a survey questionnaire. We used open-ended questions, grounded on an adapted socioecological model of public health, to analyze these data and determine challenges faced by respondents.

RESULTS

We identified multiple, interlocking challenges faced by medicine vendors. Many of these relate to challenges of antimicrobial stewardship (following evidence-based practices when dispensing medicines). Overall, medicine vendors frequently reported challenges at the Customer and Community levels. These included strained interactions with customers and the prohibitive costs of medications. The consequences of these challenges reverberated and manifested through all levels of the socioecological model of public health (Entity, Customer, Community, Global).

DISCUSSION

The safe and effective distribution of medications was truncated by strained interactions, often related to the cost of medicines and gaps in knowledge. While addressing these challenges requires multifaceted approaches, we identified several areas that, if intervened upon, could unlock the great potential of antimicrobal stewardship. The effective and efficient implementation of key interventions could facilitate efforts spearheaded by medicine vendors and leverage the benefits of their role as health educators and service providers.

CONCLUSION

Addressing barriers faced by medicine vendors would provide an opportunity to significantly improve the provision of medications, and ultimately population health. Such efforts will likely expand access to populations who may otherwise be unable to access medications and treatment in formal institutions of care such as hospitals. Our findings also highlight the broad range of care provided by shopkeepers and vendors at dispensaries. These findings suggest that the meaningful engagement of dispensaries as valued conduits of community health is a promising pathway for interventions aiming to improve antimicrobial stewardship.

Barriers to Adopting Healthy Lifestyle and Health Promotion among Ethnic Minority Bedouin Women in Southern Israel: A Qualitative Study

BACKGROUND

A healthy lifestyle is a crucial step in disease prevention and management, as well as a significant predictor of health promotion. Yet, despite an increase in chronic morbidity among Bedouin women in southern Israel, little research has been conducted on their health behaviors. Therefore, the aim of this study is to examine barriers to adopting a healthy lifestyle and health promotion among ethnic minority Bedouin women in southern Israel.

METHODS

This qualitative study was based on data collected through focus groups during June and July 2021. Participants included 44 Bedouin women aged 18-55. Focus groups were recorded and transcribed. Transcriptions were thematically analyzed and coded using the ecological model.

RESULTS

We found multiple barriers at various levels that prevent Bedouin women from adopting a healthy lifestyle and health promotion. At the individual level, such factors included the impact of financial limitations on healthful nutrition, as well as a lack of awareness or knowledge regarding healthy lifestyle and health promotion. At the organizational level, barriers include a lack of clinics, accessibility, and availability of health services and cultural incompatibility of the health services. At the community level, impediments to a healthy lifestyle include inaccessibility to sports facilities and suppression of physical activity. At the public policy level, participants, especially those living in unrecognized villages, described difficult living conditions related to environmental and social neglect as affecting their health status and ability to maintain a healthy lifestyle.

CONCLUSION

Study findings emphasize the need for policymaking and a systemic approach to address health disparities and ensure equal health promotion for the Bedouin population.

Exploring the consent process among pregnant and breastfeeding women taking part in a maternal vaccine clinical trial in Kampala, Uganda: a qualitative study

BACKGROUND

The involvement of pregnant women in vaccine clinical trials presents unique challenges for the informed consent process. We explored the expectations and experiences of the pregnant women, spouses/partners, health workers and stakeholders of the consent process during a Group B Streptococcus maternal vaccine trial.

METHODS

We interviewed 56 participants including pregnant women taking part in the trial, women not in the trial, health workers handling the trial procedures, spouses, and community stakeholders. We conducted 13 in-depth interviews and focus group discussions with 23 women in the trial, in-depth interviews with 5 spouses, and 5 women not in the trial, key informant interviews with 5 health workers and 5 other stakeholders were undertaken.

RESULTS

Decision-making by a pregnant woman to join a trial was done in consultation with spouse, parents, siblings, or trusted health workers. Written study information was appreciated by all but they suggested the use of audio and visual presentation to enhance understanding. Women stressed the need to ensure that their male partners received study information before their pregnant partners joined a clinical trial. Confidentiality in research was emphasised differently by individual participants; while some emphasised it for self, others were keen to protect their family members from being exposed, for allowing them to be involved in research. However, others wanted their community participation to be acknowledged.

CONCLUSION

We found that pregnant women make decisions to join a clinical trial after consulting with close family. Our findings suggest the need for an information strategy which informs not only the pregnant woman, but also her family about the research she is invited to engage in.

Using Photovoice to Improve Engagement in Community Health Assessments Addressing Behavioral Health

Behavioral health disorders are well-known to have close links with the social determinants of health, yet little is known about how impacted communities perceive these links. Qualitative participatory methods can not only provide insight into how communities conceptualize these relationships but also empower those with lived experience to contextualize their perspectives and formulate calls to action. This study used Photovoice as a participatory method to supplement the Clark County Health Department Community Health Assessment and determine priority facilitators and barriers contributing to the behavioral health of Clark County, KY, residents. A secondary aim was to gain a greater understanding of how the Photovoice methodology impacts community engagement efforts in Community Health Assessments. Twenty-three Clark County residents participated in four Photovoice groups involving five weekly sessions, which included photograph "show and tell," critical group dialogue, participatory analysis, and planning for dissemination. Secondary analysis of Photovoice focus group discussions revealed behavioral health facilitators and barriers were most influenced by (1) public sector unresponsiveness, (2) strong partnerships formed between community and grassroots organizations, and (3) the siloed division of responsibility between agencies and across sectors. The authors also found the Photovoice method successfully enhanced engagement and empowered those with lived experience to frame their perspectives of the behavioral health landscape. This project has implications for enhancing community engagement and empowerment in behavioral health-focused public health assessments and shaping policy to promote multi-sector collaboration.

Farm to Preschool Programs and Its Impact on Children's Dietary Health: Evaluation Through Bronfenbrenner's Socio-Ecological Model

Children's development is shaped by the world around them. According to Bronfenbrenner's theory, children are influenced by direct interactions and the broader environment, which includes family, community, and society. This concept aligns with initiatives like farm-to-preschool programs. These programs forge connections between communities and local food sources, introducing gardening and nutritional education. This approach aligns seamlessly with Bronfenbrenner's theory, creating a multi-layered learning experience and fostering children's healthier eating habits. This review delves into how farm-to-preschool efforts enhance young children's diets through the ecological model evaluation framework, encompassing health, education, economics, and the environment.

Emergency Nurses' Reasons for Not Recommending Their Hospital to Clinicians as a Good Place to Work

Importance

Half of emergency nurses report high burnout and intend to leave their job in the next year. Whether emergency nurses would recommend their workplace to other clinicians may be an important indicator of a hospital's ability to recruit clinicians.

Objective

To examine why emergency nurses do not recommend their hospital to other clinicians as a good place to work.

Design, Setting, and Participants

This qualitative study used directed content analysis of open-text responses (n = 142) from the RN4CAST-NY/IL survey of registered nurses licensed in New York and Illinois between April 13 and June 22, 2021. Inductive and deductive analytic approaches guided study theme development informed by the Social Ecological Model. The collected data were analyzed from April to June 2023.

Main Outcomes and Measures

Nurses who answered "probably not" or "definitely not" to the survey question, "Would you recommend your place of employment as a good place to work?" were prompted to provide a rationale in an open-text response.

Results

In this qualitative study of 142 emergency nurses (mean [SD] age, 43.5 [12.5] years; 113 [79.6%] female; mean [SD] experience, 14.0 [12.2] years), 94 (66.2%) were licensed to work in New York and the other 48 (33.8%) in Illinois. Five themes and associated subthemes emerged from the data. Themes conveyed understaffing of nurses and ancillary support (theme 1: unlimited patients with limited support); inadequate responsiveness from unit management to work environment safety concerns (theme 2: unanswered calls for help); perceptions that nurses' licenses were in jeopardy given unsafe working conditions and compromised care quality (theme 3: license always on the line); workplace violence on a patient-to-nurse, clinician-to-nurse, and systems level (theme 4: multidimensional workplace violence); and nurse reports of being undervalued by hospital management and unfulfilled at work in delivering suboptimal care to patients in unsafe working conditions (theme 5: undervalued and unfulfilled).

Conclusions and Relevance

This study found that emergency department nurses did not recommend their workplace to other clinicians as a good place to work because of poor nurse and ancillary staffing, nonresponsive hospital leadership, unsafe working conditions, workplace violence, and a lack of feeling valued. These findings inform aspects of the work environment that employers can address to improve nurse recruitment and retention.

Arts Engagement as a Health Behavior: An Opportunity to Address Mental Health Inequities

The significance of mental health inequities globally is illustrated by higher rates of anxiety and depression amongst racial and ethnic minority populations as well as individuals of lower socioeconomic status. The COVID-19 pandemic has further exacerbated these pre-existing mental health inequities. With rising mental health concerns, arts engagement offers an accessible, equitable opportunity to combat mental health inequities and impact upstream determinants of health. As the field of public health continues to shift its focus toward social ecological strategies, the social ecological model of health offers an approach that prioritizes social and structural determinants of health. To capture the impacts of arts engagement, this paper creates an applied social ecological model of health while aiming to advocate that engaging in the arts is a protective and rehabilitative behavior for mental health.

Evolution of Food and Nutrition Policy: A Tasmanian Case Study from 1994 to 2023

Food security is a concept with evolving definitions and meanings, shaped by contested knowledge and changing contexts. The way in which food security is understood by governments impacts how it is addressed in public policy. This research investigates the evolution of discourses and practices in Tasmanian food and nutrition policies from 1994 to 2023. Four foundational documents were analysed using qualitative document analysis, revealing persistent food insecurity issues over three decades. The analysis identified a duality in addressing the persistent policy challenges of nutrition-related health issues and food insecurity: the balancing act between advancing public health improvements and safeguarding Tasmania's economy. The research revealed that from 1994 to 2023, Tasmania's food and nutrition policies and strategies have been characterised by various transitions and tensions. Traditional approaches, predominantly emphasising food availability and, to a limited extent, access, have persisted for over thirty years. The transition towards a more contemporary approach to food security, incorporating dimensions of utilisation, stability, sustainability, and agency, has been markedly slow, indicating systemic inertia. This points to an opportunity for future policy evolution, to move towards a dynamic and comprehensive approach. Such an approach would move beyond the narrow focus of food availability to address the complex multi-dimensional nature of food security.

Experiences of patients with disabilities and sexual or gender minority status during healthcare interactions

Aim

The purpose of this study was to examine the lived experiences of lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) people with disabilities when interacting with healthcare professionals related to their gender identity, sexuality, and disability.

Subject and Methods

Historically marginalized groups face many inequities in health care. However, little is known about the intersectional experiences of LGBTQ+ people with disabilities when receiving health care given their likelihood to encounter multiple marginalizations. Data were collected via the 2019 National Survey on Health and Disability (NSHD) and included a sample of 197 LGBTQ+ respondents with disabilities living in the U.S. Quantitative data and demographics were analyzed using descriptive methods. Qualitative data were analyzed using deductive and inductive methods.

Results

72.2% of LGBTQ+ respondents with disabilities avoided discussing their gender or sexual identity with their healthcare providers, with 9.8% never disclosing their identity. Qualitative analyses revealed themes centered around experiences of negative interactions with healthcare providers, including fear, distrust, and avoidance of care (40.1%), dismissal or denial of treatment (30.5%), and assault or aggressive activity (4.1%), although some reported no problems or need to discuss their LGBTQ+ or disability identities (14.7%).

Conclusion

LGBTQ+ people with disabilities reported high rates of negative experiences disclosing gender or sexual identity and/or disability with healthcare providers. Further research is needed to determine whether negative interactions with medical providers may be caused by a lack of medical understanding, false assumptions about the de-sexualization of disabled people, or ignorance about LGBTQ+ identities.

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA

The aim was to identify which factors facilitate providing integrated behavioral health care for Iraqi refugees in nationally recognized community health center in Northern USA. The social-ecological model (SEM) framework guided this qualitative case study exploring the experience of 11 professional staff. Data were collected from June through August 2021 through individual interviews. Eight themes emerged based on the SEM levels: Intrapersonal-gender-driven engagement; interpersonal-the need for discretion and trusting relationship; community-collaboration with community resources and integrator from the community; organizational-holistic care, and long-term care; and policy-insufficient educational preparation. The results highlight components for clinical practice and policymakers regarding a population that is a big consumer of mental health care. Future research should explore other vulnerable populations, the effect of social groups, and the incorporation of community resources as part of the integrated care team.

A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings

BACKGROUND

Diabetes prevention programs are intended to reduce progression to type 2 diabetes, but are underutilised. This study aimed to explore people with prediabetes' knowledge and attitudes about prediabetes, and their perceptions about engagement in preventive programs in a rural setting. The findings will inform strategies and recommendations to increase preventive health program engagement.

METHODS

Using a qualitative approach with a critical realist methodology, semi-structured interviews were conducted with 20 rural participants with prediabetes from the Northern New South Wales Local Health District in 2021. Interviews were audio-recorded, transcribed verbatim and thematically analysed. The social-ecological model was used as a framework to interpret and action the study findings.

RESULTS

Factors that empowered participants and facilitated a desire to engage in preventive programs included knowledge about prediabetes, a high level of social support, trusting and supportive relationships with health professionals, and a strong desire not to progress to diabetes. Barriers to program engagement included low health literacy levels, limited support, negative experiences with health services, and social and physical constraints. The factors that influenced engagement with preventive health programs were mapped to an individual, interpersonal, organisational, community and policy level, which highlighted the complex nature of behaviour change and the influence of underlying mechanisms.

CONCLUSIONS

Engagement in diabetes prevention programs was dependent on individual agency factors and structural barriers, each of which related to a level of the social-ecological model. Understanding the perceptions of people with prediabetes will inform strategies to overcome multi-level barriers to preventive health program engagement in rural settings.

Qualitative Methodology in Translational Health Research: Current Practices and Future Directions

Translational health research is an interdisciplinary field aimed at bridging the gap between basic science studies, preventative studies, and clinical practice to improve health-related outcomes. Qualitative research methods provide a unique perspective on the emotional, social, cultural, and contextual factors that influence health and healthcare and thus are recognized as valuable tools for translational health research. This approach can be embedded within a mixed method design which complements the quantitative findings. This methodological paper aims to provide a comprehensive review of the fundamental concepts and methodologies used in qualitative research, emphasizing their utilization and significance in translational health research. Several approaches to qualitative research methodology are discussed in this review, including ethnography, phenomenology, grounded theory, case study, and action research. Theoretical frameworks such as the social-ecological model, intersectionality, and participatory action research are also examined to provide a structure for understanding and interpreting complex health issues. This methodological paper also reviews commonly used sampling techniques such as purposive, snowball, convenience, theoretical, and maximum variation sampling, along with data collection methods such as in-depth interviews, focus groups, observation, document analysis, and participatory methods. Moreover, data analysis techniques such as thematic analysis, grounded theory, content analysis, narrative analysis, and reflexive analysis, are discussed in the context of translational health. Overall, this review highlights the challenges and opportunities of using qualitative methods in current practice, while also discussing future directions and providing valuable guidance and insights to researchers interested in conducting qualitative research in translational health.

Personal determinants of change agents' decision-making behavior in community health promotion: a qualitative study

BACKGROUND

Implementing environmental changes to promote healthier communities requires initial positive decisions by change agents from local politics and government. However, there is little research on what influences the change agents' decisions. This explorative, qualitative study aims to identify the personal determinants of the decision-making behavior of local change agents.

METHODS

We conducted semi-structured interviews to assess the personal determinants of decision-making behavior among 22 change agents from local politics and government. Relevant determinants were identified through a structured content analysis of the interview transcripts using the software MAXQDA 2020.

RESULTS

We found the following seven essential clusters of personal determinants of the decision-making behavior of change agents from local politics and government: Imprinting, socialization, and biography; experiences and involvement; attitudes and outcome expectations towards important issues and aspects; knowledge; emotions; personal benefits; and the perceived influences of others.

CONCLUSIONS

The identified personal determinants might serve as a source of understanding the decision-making behavior of change agents in community decision-making processes. Our findings can contribute to the effective planning and implementation of evidence-based multilevel interventions related to changing environmental conditions in communities and provide important information on which personal determinants should be considered when derive strategies for community health promotion within a systematic approach of developing an intervention program theory.

Increasing physical activity levels in care homes for older people: a quantitative scoping review of intervention studies to guide future research

PURPOSE

Physical activity (PA) levels in older care home residents are low. This has detrimental effects on health. Little is known about the nature of interventions to increase physical activity in this population.

METHODS

A scoping review to: (1) identify and describe interventions to increase PA in older care home residents, and (2) describe the extent to which interventions address care home context, systemised by social-ecological models. We systematically searched databases for peer-reviewed intervention studies to increase PA in older people resident in care homes. Data were extracted using the template for intervention description and replication (TIDieR) and mapped against a social-ecological framework to locate the intervention focus.

RESULTS

The 19 included studies consisted of interventions tested in randomised or quasi-experimental trial designs. Interventions consisted of single or multiple components and predominantly addressed individual resident level factors (such as muscle strength) rather than broader social and environmental aspects of context. Interventions were not all fully described. For most interventions a distinct theoretical foundation was not identified. Interventions were mostly delivered by health professionals and research staff external to care homes.

CONCLUSIONS

Future interventions should address contextual care home factors and should be clearly described according to intervention description guidance.Implications for rehabilitationPhysical activity holds promise as an effective means of improving health and function in older care home residents, but physical activity levels in this population are low.Several reasons beyond the individual resident but related to care home contextual factors may explain low PA in care homesTo date, contextual factors influencing PA in care homes have been poorly addressed in interventions.Wider care home context (social, cultural, and environmental factors) must be considered in future interventions.

Fighting the infodemic: the 4 i Framework for Advancing Communication and Trust

BACKGROUND

The proliferation of false and misleading health claims poses a major threat to public health. This ongoing "infodemic" has prompted numerous organizations to develop tools and approaches to manage the spread of falsehoods and communicate more effectively in an environment of mistrust and misleading information. However, these tools and approaches have not been systematically characterized, limiting their utility. This analysis provides a characterization of the current ecosystem of infodemic management strategies, allowing public health practitioners, communicators, researchers, and policy makers to gain an understanding of the tools at their disposal.

METHODS

A multi-pronged search strategy was used to identify tools and approaches for combatting health-related misinformation and disinformation. The search strategy included a scoping review of academic literature; a review of gray literature from organizations involved in public health communications and misinformation/disinformation management; and a review of policies and infodemic management approaches from all U.S. state health departments and select local health departments. A team of annotators labelled the main feature(s) of each tool or approach using an iteratively developed list of tags.

RESULTS

We identified over 350 infodemic management tools and approaches. We introduce the 4 i Framework for Advancing Communication and Trust (4 i FACT), a modified social-ecological model, to characterize different levels of infodemic intervention: informational, individual, interpersonal, and institutional. Information-level strategies included those designed to amplify factual information, fill information voids, debunk false information, track circulating information, and verify, detect, or rate the credibility of information. Individual-level strategies included those designed to enhance information literacy and prebunking/inoculation tools. Strategies at the interpersonal/community level included resources for public health communicators and community engagement approaches. Institutional and structural approaches included resources for journalists and fact checkers, tools for managing academic/scientific literature, resources for infodemic researchers/research, resources for infodemic managers, social media regulation, and policy/legislation.

CONCLUSIONS

The 4 i FACT provides a useful way to characterize the current ecosystem of infodemic management strategies. Recognizing the complex and multifaceted nature of the ongoing infodemic, efforts should be taken to utilize and integrate strategies across all four levels of the modified social-ecological model.

Intersectoral collaboration in a Dutch community health promotion programme: building a coalition and networks

In health promotion programmes (HPP), it is crucial to have intersectoral collaboration within coalitions and to build networks between health and other societal sectors. A health broker role is recognized as being helpful in connecting the coalition with the broader network, and participatory action research (PAR) is deemed supportive because it facilitates evaluation, reflection, learning and action. However, there is a lack of insight into how processes that affect collaboration develop over time. Therefore, this study aimed to provide insights into the coalition's processes that facilitate building and maintaining intersectoral collaboration within a HPP coalition and network and how these processes contribute to the coalition's ambitions. As part of PAR, the coalition members used the coordinated action checklist (CAC) and composed network analysis (CNA) in 2018 and 2019. The CAC and CNA results were linked back into the coalition in five group sessions and used for reflection on pro-gress and future planning. Coalition governance, interaction with the context, network building and brokerage, and generating visibility emerged as the most prominent processes. Important insights concerned the health broker's role and positioning, the programme coordinator's leadership and the importance of visibility and trust leading to investment in continuation. The combined research instruments and group sessions supported discussion and reflection, sharing visions and adjusting working strategies, thereby strengthening the coalition's capacity. Thus, PAR was useful for evaluating and simultaneously facilitating the processes that affect collaboration.

Factors that influence older adults' participation in physical activity: a systematic review of qualitative studies

BACKGROUND

Despite the advantages of physical activity (PA), older adults are often insufficiently active to maximise health. Understanding factors that influence PA engagement will support well-designed interventions for older people. Our aim was to review the qualitative evidence exploring the factors affecting older adults' engagement in PA.

METHODS

We searched six electronic databases for studies of community-dwelling older adults (≥70 years) including qualitative methods. We excluded studies of a single-disease group, individuals with cognitive impairment and care home residents. Methodological rigour was assessed with the Critical Appraisal Skills Programme, and framework synthesis was applied using the Capability Opportunity Motivation-Behaviour (COM-B) model, which hypothesises that behaviour is influenced by three factors: capability, opportunity and motivation.

RESULTS

Twenty-five studies were included in the review (N = 4,978; mean 79 years) and 32 themes were identified. Older adults' capability was influenced by functional capacity (e.g. strength) and perceived risk of injury from PA (e.g. falls). Opportunity was impacted by the environment 'fit' (e.g. neighbourhood safety), the availability of social interaction and socio-cultural ageing stereotypes. PA was motivated by identifying as an 'exerciser', health gains and experiencing positive emotions (e.g. enjoyment), whereas negative sensations (e.g. pain) reduced motivation.

CONCLUSIONS

The qualitative synthesis showcased a complex web of interacting factors influencing PA between the sub-domains of COM-B, pinpointing directions for intervention, including a focus on whole systems approaches. There was a lack of research exploring PA influences in the oldest old and in low-income countries. Future research should seek to involve under-served groups, including a wider diversity of older people.

Assessing the implementation of physical activity-promoting public policies in the Republic of Ireland: a study using the Physical Activity Environment Policy Index (PA-EPI)

BACKGROUND

Government policy can promote physical activity (PA) as part of a multilevel systems-based approach. The Physical Activity Environment Policy Index (PA-EPI) is a monitoring framework which assesses the implementation of government policy by drawing on the experience of national stakeholders. This study is the first to assess the extent of policy implementation in the Republic of Ireland using the PA-EPI tool, and to provide information on how policy implementation can be improved, with the intention of maximizing its impact on population levels of PA.

METHODS

This mixed-methods research study, comprising eight steps, was carried out in 2022. Information documenting the evidence for implementation of PA policy, across all 45 PA-EPI indicators, was collected via systematic document analysis, and validated via survey and interview with government officials. Thirty-two nongovernment stakeholders rated this evidence on a five-point Likert scale. Aggregated scores were reviewed by stakeholders who collectively identified and prioritized critical implementation gaps.

RESULTS

Of the 45 PA-EPI indicators, one received an implementation rating of 'none/very little', 25 received a rating of 'low' and 19 received a 'medium' rating. No indicator was rated as fully implemented. The indicators that received the highest level of implementation related to sustained mass media campaigns promoting PA and PA monitoring. Ten priority recommendations were developed.

CONCLUSIONS

This study reveals substantial implementation gaps for PA policy in the Republic of Ireland. It provides recommendations for policy action to address these gaps. In time, studies utilizing the PA-EPI will enable cross-country comparison and benchmarking of PA policy implementation, incentivizing improved PA policy creation and implementation.

Age-Friendly Ecosystems: Expert Voices from the Field

(1) Background: With the growth of the age-friendly movement, age-friendly ecosystems (AFE) garnered more attention. The successful development of an AFE is contingent on unified efforts across different stakeholders; however, limited efforts were made to help create a common understanding of the necessary components of an AFE. (2) Methodology: In response, The John A. Hartford Foundation and The Age-Friendly Institute hosted a series of convenings of international experts to identify a working definition of the characteristics composing an AFE. The goal of these convenings was to provide a foundation on which to unite cross-sector age-friendly work. (3) Results: This paper discussed the findings of the convenings and provided a framework from which future age-friendly work must draw upon. (4) Conclusions: This paper presented a necessary change in how we conceive AFEs.

"Could Be Even Worse in College": Social Factors, Anxiety, and Depressive Symptoms Among Black Men on a College Campus

Understanding mental health risks among Black men is a step forward in reducing health and educational disparities that are persistent in today's society. Semi-structured focus groups were conducted with 20 Black male undergraduate students from a college campus in the Southeast. The aim was to identify and understand the social and contextual factors impacting their risk of experiencing anxiety and depressive symptoms. A thematic analysis, theoretically grounded in the social-ecological model (SEM), was conducted, revealing three overarching themes: 1) what is known or felt about mental health 2) causes of stressors and 3) signs as symptoms. Discussions with men offered insight into their perspectives and personal experiences related to mental health issues and perceived risk factors. Themes suggest that the college transition, academic workload, perceived financial distress, and their desire and need to conform to ideals of masculinity were significant risk factors and stressors. Men offered descriptions of specific symptoms and health behaviors associated with such stress, including social isolation, anger, irritability, and changes in their own personal behaviors. Key findings paint a picture of college mental health experiences for some Black male college students. Moving forward, more research is needed to expand on this study's findings and improve mental health risk among this underserved population. Future directions are discussed alongside the results presented in this paper.

Psychosocial and environmental factors related to physical activity in middle-aged and older adults

The social ecological model provides a comprehensive framework for understanding the multiple-level determinants of physical activity. This study explores the significant individual, social, and environmental variables and their interactions in relation to physical activity in middle-aged and older adults in Taiwan. A cross-sectional study design was implemented. Healthy middle-aged and older adults were recruited (n = 697) through face-to-face and online surveys. The data collected comprised self-efficacy, social support, neighbourhood environment, and demographic characteristics. Hierarchical regression was used for statistical analysis. Self-rated health (B = 74.74, p < .001; B = 101.45, p = .022) and self-efficacy (B = 17.93, p < .001; B = 14.95, p = .020) were the significant individual variables in both middle-aged and older adults. Neighbourhood environment (B = 6.90, p = .015) and the interaction between self-efficacy and neighbourhood environment (B = 1.56, p = .009) were significant in middle-aged adults. Self-efficacy was the most significant predictor for all participants, with the positive correlations of neighbourhood environment arising only for middle-aged adults with high self-efficacy. Policy making or project design should consider multilevel factors in order to facilitate their physical activity.

What are the barriers to sustaining a safe sleep program for infants within hospital settings: An integrative review of the literature

PROBLEM

Safe sleep programs have been existing since the concept was first defined in 1969. The need for health care providers to model safe sleep practices is essential for successful adherence; however, barriers to promoting safe sleep practices hinder healthcare providers' ability to implement safe sleep in hospital settings.

AIM

To determine the barriers to promoting safe sleep practices amongst healthcare workers in the hospital setting.

METHODS

Whittemore & Knafl's framework (2005) guided this integrative review. CINAHL, PubMed, and Academic Search Complete databases were used as a search strategy. Inclusion criteria was limited to studies between 2010 and 2021, were peer-reviewed, in English, and quality improvement projects consisting of barriers to implementing safe sleep practices within hospitals. To assess quality of the included studies, the Mixed Methods Appraisal Tool and Standards for Quality Improvement Reporting Excellence were used. The studies were analyzed by two of the authors with data further categorized using the Social Ecological Model (SEM) to develop themes.

RESULTS

Findings of the 10 included studies were presented in the form of a data display matrix. The authors used the SEM to categorize the findings under three main categories at the organizational, individual, and cultural levels.

CONCLUSIONS

Barriers need to be addressed in hospital settings to reduce the risk of sudden infant death syndrome. Therefore, it is vital to consider those barriers while providing teaching programs in hospital settings.

IMPLICATIONS

Findings from this review provide the core elements to consider for the development of safe sleep programs in the hospital setting.

Climate Change and the Public Health Imperative for Supporting Migration as Adaptation

In an era of accelerating global climate change, human mobility has reached unprecedented levels. While it is acknowledged that many cases of human migration in the context of climate change are forced or involuntary, particularly where adaptation measures have failed to achieve sufficient resiliency of communities against impending slow- and sudden-onset disasters. There are also many cases where migration is, itself, a voluntary adaptive measure to secure otherwise unattainable physical safety and life-sustaining resources. It is in these cases that migration can be viewed as adaptation. Under the right policy conditions, it is possible for such adaptive migration to save countless lives. Moreover, it can achieve remarkable health and well-being gains for otherwise vulnerable communities residing on environmentally degrading lands and disproportionately suffering from the health impacts of climate change. While several activists have spoken loudly on the topic of climate migration, emphasizing the human rights imperative for supportive global policy action, the public health community has not been equally vocal nor unanimous in its stance. This paper, a product of the World Federation of Public Health Associations (WFPHA) Environmental Health Working Group, aims to rectify this gap, by analyzing adaptive climate migration through a public health lens. In doing so, it argues that creating an enabling environment for adaptive climate migration is not just a human rights imperative, but also a public health one. This argument is supported by evidence demonstrating how creating such an enabling environment can synergistically support the fulfillment of key public health services and functions, as outlined under the internationally endorsed Global Charter for the Public's Health of the WFPHA.

Unravelling mechanisms underlying the action principles of a community-based health promotion programme: a realist evaluation

BACKGROUND

Since 1986, WHO has advised that applying action principles such as citizen participation and intersectoral collaboration leads to better health. However, less is known about the workability of these principles and how they trigger specific outcomes in interaction with the context. A critical realist perspective was applied to get a better understanding of what worked, and why it worked, in the context of a Dutch community-based health promotion programme (CBHPP). The aim of the study was to unravel the mechanisms underlying the action principles and find combinations of contextual factors and mechanisms that trigger outcomes in a CBHPP.

METHODS

In this single case study, a critical realist methodology was followed. Qualitative data used in this study originated from multiple sources and methods to ensure validity. They include evaluation sessions with coalition members (n = 6) and individual interviews (n = 6); group sessions with community workers (n = 1), a health broker (n = 1), and citizens (n = 12); and seven semi-annual progress reports and minutes of the coalition meetings. The collected data were then compared with the programme theory through a heuristic process of constructing, exploring, and refining context-mechanism-outcome configurations.

RESULTS

The programme initiated a variety of new activities that differed in content, intensity, duration, and number of participants, organised and implemented together with citizens. The most prominent mechanism underlying both action principles were programme-related, namely, patience, personal contact, contribution of budget, and the programme coordinator's leadership. Another important mechanism was creating visibility, which resulted in the involvement of the municipality and a budget to sustain the programme.

CONCLUSION

In this case study, personal contact, patience, perseverance, participatory action research activities, and visibility were found to be the most notable mechanisms underlying the citizen participation and intersectoral collaboration action principles. As the principle-based approach added value to the existing context and introduced most of the mechanisms that triggered the outcomes, it is recommended to include citizen participation and intersectoral collaboration not only as action principles but explicitly as targets in a CBHPP.

Code poverty: An adaptation of the social-ecological model to inform a more strategic direction toward nursing advocacy

The purpose of this discussion paper is to explore how nurses can be strategically poised to advocate for needed policy change in support of greater income equality and other social determinants of health. We adapted Bronfenbrenner's social-ecological model to highlight how four broad pervasive subsystems shape the opportunities that nurses have to engage in advocacy at the policy level. These subsystems include organizations (the microsystem), professional bodies (the mesosystem), public policies (the exosystem), and societal values (the macrosystem). On the basis of this adapted model, we recommend changes among modifiable elements of the microsystem and mesosystem that can help position nurses (ecologically and collectively) to advocate for public policy change and use examples from a Canadian context to illustrate these points. We believe that the ideas arising from this model can be widely used where policy action on the social determinants of health is needed to inform, guide, and frame change efforts and advocacy work.

Perceived Role of Asian Indian Fathers in Florida During Mealtimes: Factors to Consider for Their Involvement in Childhood Obesity Prevention

Research has shown that fathers play an important role in children's mealtimes and dietary habits; yet, little is known about the factors that affect how fathers perceive this role, especially among Asian Indians. This study aimed to examine how Asian Indian fathers perceive their role during child mealtimes and the factors that are associated with fathers' mealtime perceptions. Eighty Asian Indian fathers of 6- to 11-year-old children completed an online survey including measures of demographics, acculturation, gender roles, nutrition knowledge, parental self-efficacy, perceived child weight, and the role of father at mealtime (ROFM). Data were analyzed using descriptive statistics and linear regression. Participants perceived a moderately high level of responsibility during child mealtimes. Regression analysis showed that fathers who had higher income, perceived child weight as being higher, and had higher self-efficacy in feeding children healthy food had higher ROFM. Higher father nutrition knowledge was correlated with lower perceived ROFM, indicating a lack of confidence in utilizing their nutrition knowledge during child mealtimes. The results indicate potential targets to improve Asian Indian fathers' involvement during child mealtimes. These results could be utilized to enhance their engagement in child mealtime healthy eating practices and for childhood obesity prevention.

"The bucket of gold at the end of the rainbow": personal experiences of hope after acquired brain injury

PURPOSE

To investigate personal experiences of, and factors influencing hope following Acquired Brain Injury (ABI).

METHODS

A qualitative phenomenological approach was adopted consisting of semi-structured interviews with 15 adults with ABI. Interviews were transcribed and analysed using thematic analysis, and the Social Ecological Model (SEM) applied as a guiding framework to discuss findings and implications for policy and practice.

RESULTS

Five themes emerged: the importance of hope, changes in hope over time, the connection between hope and positivity, factors influencing hope and the importance of fostering hope. Participants reported varying experiences, with increased levels of hope influenced by: faith; supportive networks and professionals; goals; experiencing progress; having something to look forward to; and seeing others achieve. Professional attitudes were reported to either foster or negatively impact hope after brain injury.

CONCLUSIONS

These findings suggest that hope can play an important and often essential role in the lives of people with ABI. Factors influencing experiences of hope are organised against a SEM framework, identifying intrapersonal, interpersonal, institutional, community, and state and national implications for policy, professional practice and research.Implications for rehabilitationHope plays a critical role in the lives of people following acquired brain injury.Factors which positively influence hope include faith, supportive networks, goals, experiencing progress, and having something to look forward to.Professionals can impact an individual's experience of hope through person-centred and supportive therapeutic relationships.

Health-related quality of life of young academics: A cross-sectional survey of universities in Wuhan, China

Objective

This study aimed to assess the health-related quality of life (HRQoL) of young academics in Wuhan, China, and its determinants.

Methods

A multistage stratified cluster sampling strategy was employed to recruit study participants (young academics <40 years old) from 12 universities in Wuhan. A total of 301 respondents returned a self-complete questionnaire that contained the EQ-5D-5L. Multivariate linear and Tobit regression models were established to determine the sociodemographic and job predictors of the visual analogue scale (VAS) score and the EQ-5D utility index, respectively.

Results

The study participants reported a mean VAS value of 79.42 (SD = 10.51) and a mean EQ-5D utility index of 0.915 (SD = 0.090). Anxiety/depression was the most frequently reported problem (65.12%), followed by pain/discomfort (43.52%). Transitioning towards a full professorship in national key universities (p < 0.001), lower income (p < 0.05) and too much pressure for academic promotion (p < 0.001) were significant predictors of lower HRQoL; whereas, maintaining routines in physical activities (p < 0.001), sleep (p < 0.001) and meals (p < 0.001), a good relationship with colleagues and family members (p < 0.001), and social activities (p < 0.01) were significant predictors of higher HRQoL.

Conclusion

Low HRQoL of young academics in China is evident, as indicated by the 7.08 and 0.049 gap in VAS and utility index, respectively, compared to the general population at the same age. Work and career pressures are associated with the low HRQoL of young academics. The findings of this study highlight the importance of work-life balance in promoting HRQoL of young academics in universities in China.

Survey of South Carolina Public School Personnel Perspectives on Barriers and Facilitators to Regular Physical Activity and Healthy Eating Behaviors in Schools

BACKGROUND

In South Carolina (SC), 42% of youth are overweight or obese. Two sets of modifiable behaviors contributing to obesity are physical activity (PA) and dietary habits. School-based interventions have successfully improved these behaviors. The purpose of this study was to identify SC public school personnel perspectives on the most common barriers and facilitators to regular PA and healthy eating behaviors in schools.

METHODS

A needs assessment survey was conducted with school personnel statewide. There were 17 questions on the survey that addressed: (1) demographic information about participants' educational backgrounds, (2) barriers to regular PA and healthy eating behaviors in schools, and (3) facilitators to regular PA and healthy eating behaviors in schools. Univariate and bivariate descriptive statistical analyses were performed using IBM SPSS Statistics 27.

RESULTS

Participants (N = 1311) indicated insufficient time for regular PA (n = 514, 39.2%) and limited access to healthy foods for healthy eating (n = 271, 20.7%) as main barriers. The primary facilitators were support from administrators for regular PA (n = 264, 20.1%) and support from cafeteria staff for healthy eating (n = 234, 17.8%). Further analyses explored how factors compared based on roles in schools, academic levels, and school district classifications.

CONCLUSIONS

Results suggest that overarching barriers and facilitators to school-based interventions addressing childhood obesity exist, so common strategies to mitigate challenges and maximize supports can be used in schools. Future studies are needed to examine how decreasing barriers and enhancing facilitators affect the implementation and outcomes of these school-based interventions.

Healthy Here: A Promising Referral System Model for Community–Clinical Linkages to Prevent Chronic Disease

Linking clinical services to community-based resources is a promising strategy for assisting patients with chronic disease prevention and management. However, there remains a gap in understanding how to effectively develop and implement community–clinical linkages (CCLs), especially in communities of color. The Healthy Here initiative used Stage Theory of organizational change to implement a centralized wellness referral system, linking primary care clinics to community organizations in majority Hispanic/Latinx and Native American communities. Data were collected using a standardized referral form. Facilitators and challenges were identified through semi-structured discussions with partner organizations. Between 2016 and 2021, 43 clinics and 497 health care providers made 7,465 referrals, the majority of which were from the focus populations. The average proportion of patients referred by clinic champions decreased significantly over time, reflecting diffusion of the intervention within clinics. Facilitators to system success included building on existing networked partnerships, utilizing a centralized referral center, leveraging funding, sharing data, addressing challenges collectively, incorporating multilevel leadership, and co-developing and testing a standardized referral form and process with a single clinic and provider before scaling up. Challenges included funding restrictions, decreasing referrals within clinics over time, changing availability of resources and programs, and the COVID-19 pandemic. This innovative initiative demonstrates that CCLs can be developed and implemented to successfully reach Hispanic/Latinx and Native American communities and provides strategies for overcoming challenges.

Community–Clinical Linkages: The Effects of the Healthy Here Wellness Referral Center on Chronic Disease Indicators Among Underserved Populations in New Mexico

The majority of U.S. adults are living with at least one chronic condition, and people of color bear a disproportionate burden of chronic disease. Prior research identifies community–clinical linkages (CCLs) as a strategy for improving health. CCLs traditionally use health care providers to connect patients to community-based self-management programs. The purpose of this study was to examine the effectiveness of a centralized CCL system on health indicators and health disparities. Administrative health data were merged with referral system data to conduct a quasi-experimental comparative time series study with a comparison group of nonreferred patients. Interrupted time-series comparisons within referred patients were also conducted. Of the 2,920 patients meeting inclusion criteria, 972 (33.3%) received a referral during the study period (January 2019—September 2021). Hemoglobin A1c levels, used to diagnose diabetes, declined significantly among referred patients, as did disparities among Hispanic/Latinx participants compared with non-Hispanic White participants. No changes were observed in body mass index (BMI). Blood pressure increased among both referred and nonreferred patients. CCLs with a centralized referral system can effectively reduce markers of diabetes and may contribute to the maintenance of BMI. The observed increase in blood pressure may have been affected by the COVID-19 pandemic and warrants further study. Practitioners can work with community partners to implement a centralized CCL model, either on its own or to enhance existing clinician or community health worker-based models.

Higher Rates of Cesarean Sections Found in Somali Immigrant Women in Minnesota

OBJECTIVE

The purpose of this study was to compare prenatal characteristics and postpartum outcomes among Somali and non-Somali women residing in Olmsted County.

METHODS

We reviewed the medical records for a cohort of Somali women (≥18 years old; N= 298) who had singleton births between January 2009 and December 2014 and for an age-matched non-Somali cohort (N= 298) of women residing in Olmsted County, Minnesota. Logistic regression models which accounted for repeated measures were used to assess differences in prenatal and postpartum outcomes between Somali and non-Somali women.

RESULTS

Somali women had a significantly higher odds of cesarean section (adjusted OR=1.81; 95% CI=1.15, 2.84). Additionally, Somali women had a significantly lower odds of postpartum depression (adjusted OR=0.27; 95% CI=0.12, 0.63).

CONCLUSION

The reported adverse postpartum outcomes have implications for interventions aimed at addressing perinatal care disparity gaps for Somali women immigrant and refugee populations.

The clusters of health-risk behaviours and mental wellbeing and their sociodemographic correlates: a study of 15,366 ASEAN university students

Background

This study investigated, through cluster analysis, the associations between behavioural characteristics, mental wellbeing, demographic characteristics, and health among university students in the Association of Southeast Asian Nations (ASEAN) University Network – Health Promotion Network (AUN-HPN) member universities.

Methods

Data were retrieved from a cross-sectional self-administered online survey among undergraduate students in seven ASEAN countries. A two-step cluster analysis was employed, with cluster labels based on the predominant characteristics identified within the clusters. The ‘healthy’ cluster was assigned as the reference group for comparisons using multinomial logistic regression analysis.

Results

The analytic sample size comprised 15,366 university students. Five clusters of student-types were identified: (i) ‘Healthy’ (n = 1957; 12.7%); (ii) ‘High sugary beverage consumption’ (n = 8482; 55.2%); (iii) ‘Poor mental wellbeing’ (n = 2009; 13.1%); (iv) ‘Smoker’ (n = 1364; 8.9%); and (v) ‘Alcohol drinker’ (n = 1554; 10.1%). Being female (OR 1.28, 95%CI 1.14, 1.45) and being physically inactive (OR 1.20, 95%CI 1.04, 1.39) increased the odds of belonging to the ‘High sugary beverage consumption’ cluster. Being female (OR 1.21, 95%CI 1.04, 1.41), non-membership in a sports club (OR 1.83, 95%CI 1.43, 2.34) were associated with ‘Poor mental wellbeing’. Obesity (OR 2.03, 95%CI 1.47, 2.80), inactively commuting to campus (OR 1.34, 95%CI 1.09, 1.66), and living in high-rise accommodation (OR 2.94, 95%CI 1.07, 8.07) were associated with membership in the ‘Smoker’ cluster. Students living in The Philippines, Singapore, Thailand, and Vietnam had a higher likelihood of being alcohol drinkers, compared with those who lived in Brunei.

Conclusions

ASEAN university students exhibited health-risk behaviours that typically clustered around a specific health behaviour and mental wellbeing. The results provided support for focusing interventions on one dominant health-risk behaviour, with associated health-risk behaviours within clusters being potential mediators for consideration.