Allocating municipal services to individuals with complex rehabilitation needs - a discourse analysis of individual administrative decision letters

BACKGROUND

Rehabilitation is considered paramount for enhancing quality of life and reducing healthcare costs. As a result of healthcare reforms, Norwegian municipalities have been given greater responsibility for allocating rehabilitation services following discharge from hospital. Individual decision letters serve as the basis for implementing services and they have been described as information labels on the services provided by the municipality. They play an important role in planning and implementing the services in collaboration with the individual applicants. Research indicates that the implementation of policies may lead to unintended consequences, as individuals receiving municipal services perceive them as fragmented. This perception is characterised by limited user involvement and a high focus on body functions. The aim of this study was to examine how municipal decision letters about service allocation incorporate the recommendations made in the official national guideline and reflect a holistic approach to rehabilitation, coordination and user involvement for individuals with comprehensive needs.

METHODS

The decision letters of ten individuals with moderate to severe brain injury allocating rehabilitation services in two municipalities were examined. It was assessed whether the content was in accordance with the authorities' recommendations, and a discourse analysis was conducted using four tools adapted from an established integrated approach.

RESULTS

The letters primarily contained standard texts concerning legal and administrative regulations. They were predominantly in line with the official guideline to municipal service allocation. From a rehabilitation perspective, the focus was mainly on medically oriented care, scarcely referring to psychosocial needs, activity, and participation. The intended user involvement seemed to vary between active and passive status, while the coordination of services was given limited attention.

CONCLUSIONS

The written decision letters did fulfil legal and administrative recommendations for service allocation. However, they did not fulfil their potential to serve as a means of conveying rehabilitation issues, such as specification of the allocated services, a holistic approach to health, coordination, or the involvement of users in decision processes. These elements must be incorporated throughout the allocation process if the policies are to be implemented as intended. Findings can have international relevance for discussions between clinicians and policy makers.

Solid waste composition and its management: A case study of Kirtipur Municipality-10

The world population is expanding in line with the general trend. The demand for goods is currently higher than it has ever been before. This has resulted in the production of more waste than ever before. The problem of waste management is not new for humans but the complexity of the issue has increased more in present days. The research was focused on composition of solid waste and its management in Kirtipur-10. The research was conducted in ward 10 of Kirtipur municipality to know the ground reality of solid waste in households. The research aimed to understand the solid waste situation, its composition, problems and finding possible solutions to the problems. Household survey, Focused group discussion were conducted during November month of 2022 to collect data. 75 household were taken as sample for research. Wastes, collected from all of the groups of households, were segregated and weighed. Household solid waste (HSW) was comprised of seven categories of waste with organic waste being the largest component (44 %), plastic (13 %), paper (11 %), Glass (10 %), rubber (9 %), others (7 %) and Hazardous waste (6 %). Municipal authorities are usually the responsible agencies for solid waste collection and disposal, but the magnitude of the problem is well beyond the ability of any municipal government to tackle. There is strong dissatisfaction among municipal resident on waste management by local government. Looking at the composition of waste produced, composting of waste at home level can bring a sustainable solution to the problem. The solid waste management system in Kirtipur has low efficiency and needs to be improved.

Strategies to promote construction and demolition waste management in the context of local dynamics

Achieving a broad analysis of construction and demolition waste (CDW) management without considering local scale dynamics, and its detailed characteristics, is a constraint that has made it challenging to optimally engage in an integrated assessment of the circular economy principles in the construction sector. In this sense, this research demonstrates that investing in local strategies is important, involving municipalities and micro and small construction companies. Firstly, the results reveal the importance of having controlled sites, under local responsibility, for the preliminary storage of CDW, creating in waste producers the habit of separating waste onsite, reducing costs and limitations for municipalities. Secondly, frequent supervision actions at construction sites are also important at this scale, as they facilitate progress in terms of encouraging compliance with mandatory legal procedures and good practices for CDW management. But it is easier to improve practice through direct onsite procedures than it is with bureaucratic legal requirements alone. Thirdly, procedural control, implemented by municipal technicians in conjunction with other strategies, also helps to promote CDW management, this being associated with processes of public and private construction works subjected to license or prior control, in opposition to what has been accomplished so far. But the research also demonstrated that regular awareness, training, and supervision actions might increase the likelihood of improvements in behaviour on the local scale, in the sense that stakeholders acquire new habits, which, over time, might lead to better results locally and, as a consequence, influence other scales of intervention.

Environmental and socio-economic determinants of the occurrence of malaria clusters in Colombia

This study identifies the environmental and socio-economic determinants of clusters of high malaria incidence in Colombia during the period of 2008-2019. The malaria cases were obtained from the National System of Surveillance in Public Health, with 798,897 cases reported in the 986 Colombian municipalities evaluated during the study period. Spatial autocorrelation of incidence was examined with global and local indices. Clusters were identified in the Amazon, Pacific, and Uraba-Bajo Cauca-Alto Sinú regions. The factors associated with a municipality belonging to a high-incidence cluster were identified using a logistic regression model with mixed effects and showed a positive association for the variables (forest coverage and minimum multi-year average rainfall). An inverse relationship was observed for aqueduct coverage and the odds of belonging to a cluster. A 1% increase in forest coverage was associated with a 4.2% increase in the odds of belonging to a malaria cluster. The association with minimum multi-year average rainfall was positive (OR = 1.0011; 95% CI 1.0005-1.0027). A 1% increase in aqueduct coverage was associated with a 4.3% decrease in the odds of belonging to malaria cluster. The identification of malaria cluster determinants in Colombia could help guide surveillance and disease control policies.

Impact of weekday and weekend mobility and public policies on COVID-19 incidence and deaths across 76 large municipalities in Colombia: statistical analysis and simulation

BACKGROUND

Despite widespread restrictions on residents' mobility to limit the COVID-19 pandemic, controlled impact evaluations on such restrictions are rare. While Colombia imposed a National Lockdown, exceptions and additions created variations across municipalities and over time.  METHODS: We analyzed how weekend and weekday mobility affected COVID-19 cases and deaths. Using GRANDATA from the United Nations Development Program (UNDP) we examined movement in 76 Colombian municipalities, representing 60% of Colombia's population, from March 2, 2020 through October 31, 2020. We combined the mobility data with Colombia's National Epidemiological Surveillance System (SIVIGILA) and other databases and simulated impacts on COVID-19 burden.  RESULTS: During the study period, Colombians stayed at home more on weekends compared to weekdays. In highly dense municipalities, people moved less than in less dense municipalities. Overall, decreased movement was associated with significant reductions in COVID-19 cases and deaths two weeks later. If mobility had been reduced from the median to the threshold of the best quartile, we estimate that Colombia would have averted 17,145 cases and 1,209 deaths over 34.9 weeks, reductions of 1.63% and 3.91%, respectively. The effects of weekend mobility reductions (with 95% confidence intervals) were 6.40 (1.99-9.97) and 4.94 (1.33-19.72) times those of overall reductions for cases and deaths, respectively.

CONCLUSIONS

We believe this is the first evaluation of day-of-the week mobility on COVID-19. Weekend behavior was likely riskier than weekday behavior due to larger gatherings and less social distancing or protective measures. Reducing or shifting such activities outdoors would reduce COVID-19 cases and deaths.

Education and COVID-19 excess mortality

We study the role of education during the COVID-19 epidemic in Italy. We compare excess mortality in 2020 and 2021 compared to the pre-pandemic mortality between municipalities with different shares of educated residents. We find that education initially played a strong protective role, which however quickly faded out. After pondering several alternative explanations, we tentatively interpret this finding as the outcome of the interplay between education, information and public health communication, whose availability and coherence varied along the epidemic.

Municipal healthcare professionals' interprofessional collaboration during older patients' transitions in the municipal health and care services: a qualitative study

Background

Interprofessional collaboration is vital to assist patients towards a healthy transition in the municipal health and care services. However, no study has so far investigated municipal health care providers’ inter-professional collaboration during older patients’ transition in the municipal health and care services. The aim of this study is therefore to describe and explore what influence health care providers’ inter-professional collaboration within and across municipal facilities during older patients’ transitions in the municipal health and care services.

Method

The study has a descriptive, interpretive design. Focus group interviews and individual interviews with municipal health care providers different professions were performed.

Results

Municipal health care providers’ inter-professional collaboration during older patients transitions in the municipal health and care services was challenging. Two main themes were identified: The patient situation itself and Professional. Personal, and Practical circumstances. The results show that the municipal priority of patients staying at home as long as possible facilitated inter-professional collaboration across the short-term care facility and the home care services. Inter-professional collaboration across facilities with the long-term care facility was downgraded and health care providers in this facility had to cope as best they could.

Conclusion

Prioritising and facilitating inter-professional collaboration between the short-term care facility and the home care services, contributed to health care providers experiencing doing a proper and safe patient assistance. Yet, this priority was at a cost: Health care providers in the long-term care facility, and in particular registered nurses felt squeezed and of less worth in the municipal health and care services. It was a strain on them to experiencing unplanned and often rushed patient transition into long-term care facility. To focus on municipal inter-professional and inter-facility collaboration during patients in transition to long-term care placement is vital to maintain the patients, and the health care providers working in these facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08226-5.

Municipal resources to promote adult physical activity - a multilevel follow-up study

Background

In Finland, local authorities (municipalities) provide many services, including sports and physical activity facilities such as pedestrian and bicycle ways and lanes, parks, sports arenas and pools. This study aimed to determine whether local authorities can promote physical activity by allocating resources to physical activity facilities.

Methods

The data on municipality expenditure on physical activity and sports, number of sports associations receiving subsidies from the municipality, kilometers of ways for pedestrians and bicycles and hectares of parks in 1999 and 2010 were gathered from national registers. These data were combined using unique municipal codes with individual survey data on leisure-time physical activity (N = 3193) and commuting physical activity (N = 1394). Panel data on physical activity originated from a national health survey, the Health 2000 study, conducted in 2000–2001 and 2011–2012. We used the data of persons who answered the physical activity questions twice and had the same place of residence in both years. In the data, the individuals are nested within municipalities, and multilevel analyses could therefore be applied. The data comprised a two-wave panel and the individuals were followed over 11 years.

Results

The resources for physical activity varied between municipalities and years. Municipal expenditure for physical activity and total kilometers of pedestrian ways increased significantly during the 11 years, although a clear decrease was observed in individuals’ physical activity. In our models, individual characteristics including higher education level (OR 1.87) and better health status (OR 7.29) increased the odds of increasing physical activity. Female gender was associated with lower (OR 0.83) leisure-time physical activity. Living in rural areas (OR 0.37) decreased commuting physical activity, and age (OR 1.05) increased it. Women (OR 3.16) engaged in commuting physical activity more than men.

Conclusions

Individual-level factors were more important for physical activity than local resources. A large part of the variation in physical activity occurs between individuals, which suggests that some factors not detected in this study explain a large part of the overall variation in physical activity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13617-8.

Prefectural public health nurses' support in human resource development of municipal public health nurses in Japan

Objective　This study aimed to explore the support extended by prefectural public health nurses (PHNs) toward the human resource development (HRD) of municipal PHNs in Japan.Methods　We performed a qualitative descriptive study involving nine prefectural PHNs from April 2019 to May 2020. The data were collected through semi-structured interviews using an interview guide, described qualitatively, coded, and then categorized.Results　Five categories were extracted. "Clarifying the needs and problems related to HRD and daily PHN activities in the municipalities," "Creating an environment where all municipal PHNs have equal opportunities for off-the-job training," and "Helping municipal PHNs recognize the meaning of practice and develop an evaluation perspective" were extracted from the prefectural government PHNs and prefectural health center (HC) PHNs. "Clarifying problems and future prospects to encourage the growth of PHNs" and "Creating an environment where the significance and value of the activities of PHNs are recognized within the organization and HRD can easily take place" were extracted from the HC PHNs.Conclusion　Much of the HRD support provided by the prefectural PHNs to the municipal PHNs was analogous to the PHN activities provided to the community and residents. To promote HRD effectively, prefectural PHNs should apply their individual care skills to the HRD of municipal PHNs.

Organizing the health interview survey at the local level: design of a pilot study

Background

The local Health Interview Study (LHIS) was developed to gain health information at the level of the municipality in Flanders, the northern part of Belgium. It enables municipalities to make evidence-based decisions in their public health policy. To test the feasibility of implementing the LHIS, a pilot study was conducted in Melle, a small Flemish municipality with 11.736 inhabitants.

Methods

The target sample size was 1000 (≥ 15 years). A systematic sampling technique was applied with substitutes for non-respondents who were matched in terms of statistical sector, age and sex. Selected persons were contacted by post to complete the questionnaire and in case of non-response, a reminder was sent. Questionnaires were collected using a concurrent mixed-mode design: a paper and pencil, and web option. All questions were selected from the Belgian Health Interview Survey relating to health status and determinants of health.

Results

One thousand twenty-two questionnaires were obtained after inviting 3137 individuals (response rate = 32.6%). Older adults were more likely to participate than younger adults, and women more than men. The final sample resembled the initial sample in terms of sex and statistical sector, but not in terms of age. Younger adults were underrepresented whereas older adults were overrepresented. Lastly, older adults were more likely to fill in the questionnaire on paper than younger adults, and women more than men.

Conclusion

The LHIS can be successfully implemented in Flemish municipalities. The method, however, does not guarantee that the composition of the final sample reflects the initial sample. Therefore, weights should be added in the analyses to correct for potential deviations in sample composition. Furthermore, implementing a sequential mixed-mode design with a web option preceding a paper and pencil option in future studies could reduce costs and improve data quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00909-z.

En route to flourishing - a longitudinal mixed methods study of long-term unemployed citizens in an interdisciplinary rehabilitation program

BACKGROUND

Interdisciplinary rehabilitation programmes (IRP) are used in municipality settings to assist unemployed citizens with complex health and/or life issues. Individually tailored IRP activities help people develop their personal working life skills and increase their chances of re-entering the work force. The aims of this paper were to describe citizens' wellbeing in terms of health aspects, explore the impact of stressful life events on wellbeing and obtain understanding of how IRP activities affect the participants' development towards future employment.

METHODS

A mixed methods exploratory approach has been used. For data collection a quantitative longitudinal survey (baseline and 1-year follow-up) and qualitative interviews were conducted. Descriptive statistics were used for the analysis of survey data, while the data material from interviews was analysed using directed content analysis. Results were discussed with the theory of flourishing as a framework to develop understanding.

RESULTS

At baseline, 146 respondents (71% females) filled in the survey and seven participants were interviewed. The analysis of survey data and interviews revealed five themes: (1) Stressful life events, (2) Positive emotions - how IRP-activities positively impacted wellbeing and physical capacity, (3) Appreciation of engagement, (4) Relationships, and (5) Meaning and optimal functioning. Results showed that IRP participants from the outset experienced high general pain intensity as well as distress, anxiety and depression. Life events relating both to physical health and work life were significant for their wellbeing. IRP activities supported participants' positive development towards future employment in ways that were specific to each individual.

CONCLUSIONS

From this study it can be derived that participants' development took place around self-acceptance, acceptance by others, physical capacity, psychological resources and capacity to balance engagement to cultivate the best version of themselves. In future programmes, it may be emphasized that participants' interest may be an important driver for wellbeing and future employment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02641704, date of registration December 29, 2015.

Municípios in the Time of Covid-19 in Brazil: Socioeconomic Vulnerabilities, Transmission Factors and Public Policies

This paper aims at identifying the Covid-19 infection and mortality risk factors in Brazil during the pandemic's first wave. Three groups of variables are considered: socioeconomic and health vulnerabilities, factors related to the virus transmission channels (mobility and density) and the effects of the policy responses. The analysis at the level of all 5,570 municipalities, drawing on a matching of different statistical and administrative databases, returns three main results. First, structurally vulnerable populations are hardest hit-non-white, poor, in poor health, favela residents and informal workers-showing the impact of socioeconomic inequalities. Second, we highlight some policy repercussions. The Auxilio Emergencial (emergency cash transfer) has had a mitigating effect in communities with relatively more informal workers. Finally, Covid-19 has hit hardest in municipalities that are more pro-Bolsonaro. The president's rhetoric and attitudes may have prompted his supporters to adopt more risky behaviour, suffer the consequences and infect others.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1057/s41287-021-00487-w.

A climate-dependent spatial epidemiological model for the transmission risk of West Nile virus at local scale

In this study, initial elements of a modelling framework aimed to become a spatial forecasting model for the transmission risk of West Nile virus (WNV) are presented. The model describes the dynamics of a WNV epidemic in population health states of mosquitoes, birds and humans and was applied to the case of Greece for the period 2010–2019. Calibration was performed with the available epidemiological data from the Hellenic Centre for Disease Control and Prevention and the environmental data from the European Union's earth observation program, Copernicus. Numerical results of the model for each municipality were evaluated against observations. Specifically, the occurrence of WNV, the number of infected humans and the week of incidence predicted from the model were compared to the corresponding numbers from observations. The results suggest that dynamic downscaling of a climate-dependent epidemiological model is feasible down-to roughly 80km². This below nomenclature of territorial units for statistics (NUTS) 3 level represents the municipalities being the lowest level of administrative units, able to cope with WNV and take actions. The average detection probability in hindcast mode was 72%, improving strongly as the number of infected humans increased. Using the developed model, we were also able to show the fundamental importance of the May temperatures in shaping the WNV dynamics. The modeling framework couples epidemiological and environmental dynamical variables with surveillance data producing risk maps downscaled at a local level. The approach can be expanded to provide targeted early warning probabilistic forecasts that can be used to inform public health policy decision making.

•

Downscaling of a climate-dependent epidemiological model feasible to roughly 80 km².

•

The model demonstrates competence in reproducing WNV event occurrence spatially at the municipality scale.

•

The average detection probability is 72%, improving with increasing human infections.

•

The hardest to model WNV events occurred at municipalities and years with only one human infection annually.

•

Temperatures in May are found most critical in shaping the WNV dynamics.

Differences in depressive symptoms by rurality in Japan: a cross-sectional multilevel study using different aggregation units of municipalities and neighborhoods (JAGES)

Background

Rurality can reflect many aspects of the community, including community characteristics that may be associated with mental health. In this study, we focused on geographical units to address multiple layers of a rural environment. By evaluating rurality at both the municipality and neighborhood (i.e., a smaller unit within a municipality) levels in Japan, we aimed to elucidate the relationship between depression and rurality. To explore the mechanisms linking rurality and depression, we examined how the association between rurality and depression can be explained by community social capital according to geographical units.

Methods

We used cross-sectional data from the 2016 wave of the Japan Gerontological Evaluation Study involving 144,822 respondents aged 65 years or older residing in 937 neighborhoods across 39 municipalities. The population density quintile for municipality-level rurality and the quintile for the time required to reach densely inhabited districts for neighborhood-level rurality were used. We calculated the prevalence ratios of depressive symptoms by gender using a three-level (individual, neighborhood, and municipality) Poisson regression. Community social capital was assessed using three components: civic participation, social cohesion, and reciprocity.

Results

The prevalence of depressive symptoms was higher in municipalities with lower population density than those with the highest population density; the ratios were 1.22 (95% confidence intervals: 1.15, 1.30) for men and 1.22 (1.13, 1.31) for women. In contrast, when evaluating rurality at the neighborhood level, the prevalence of depressive symptoms was 0.9 times lower for men in rural areas; no such association was observed for women. In rural municipalities, community civic participation was associated with an increased risk of depressive symptoms. In rural neighborhoods, community social cohesion and reciprocity were linked to a lower risk of depressive symptoms.

Conclusions

The association between rurality and depression varied according to geographical unit. In rural municipalities, the risk of depression may be higher for both men and women, and the presence of an environment conducive to civic participation may contribute to a higher risk of depression, as observed in this study. The risk of depression in men may be lower in rural neighborhoods in Japan, which may be related to high social cohesion and reciprocity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12942-021-00296-8.

Reablement in a small municipality, a survival analysis

BACKGROUND

Reablement is a municipal service given to patients at home. The purpose of the service is to assist recovery after hospital discharges or other sudden changes in a patient's functional level. The service is often provided by a team of nurses, physiotherapists, and occupational therapists. The purpose of this paper is to compare users of this service to users who receive traditional home care services. Outcomes to be measured are risk of long-term care and mortality.

METHODS

All users of health and care services in a Norwegian municipality were eligible for inclusion. Data was extracted from the local user administrative database. Users were divided in two groups: those who received reablement and those home care users who did not receive reablement service. Propensity score matching was used to match users based on age, sex, and level of functioning in activities of daily living (ADL). Survival analysis was deployed to test if the reablement users had different risk of becoming long-term care users, and whether the mortality rate differed for this group.

RESULTS

153 reablement users were included in the study. These were matched to 153 non-reablement home care users. The groups had similar distributions of age, sex, and level of functioning when starting their service trajectories. Regressions showed that reablement users had lower risk of using long-term care services in the study period (time at risk up to 4 years), and lower mortality. However, none of these estimates were statistically significant.

CONCLUSIONS

The study indicates that the reablement users in one municipality had lower use of long -term care and lower mortality when properly estimated, but numbers were too small for statistical significance to be found.

A factorial emission-focused general equilibrium model for investigating composite effects of multiple environmental policies

With the rapid growth of the economy, there are increasing conflicts between economic development and environmental protection. Among these conflicts, the wastewater emission management as one of the significant ways to alleviate water scarcity has been paid increasing attention across the developing countries, such as China. It is thus essential to comprehensively investigate the enviro-economic effects induced by wastewater-related policies. In this study, a factorial emission-focused general equilibrium model (FEGE) is first developed to facilitate examine the composite enviro-economic effects of multiple policy scenarios with regards to wastewater-related environmental taxes and the related subsides. A special case study for the Municipality of Chongqing, China, is conducted to illustrate the potential benefits of its use in the formulation of wastewater-related policies. It is found that the impacts of various wastewater-related policies (i.e., environmental taxes and the related subside) on GDP are different. In detail, green tax policies on GDP are negative, while wastewater emission intensity (WEI) improvement policies on GDP are positive. When green tax reaches 14 yuan/tonne, which is the maximum proposed by the Chinese government, the GDP will drop by 0.37%, which would be deemed acceptable for the Municipality of Chongqing. In addition, the impacts on rural households' consumption are greater than those on urban households' consumption whichever the application of wastewater-related policies; it is because the rural households in the Municipality of Chongqing have a relatively unitary income source. It is thus recommended that the rural household in Chongqing should be paid more attention. For example, some extra allowances could be considered to the rural household to help them cope with the negative economic impacts induced by a new environmental policy. It is expected that the outputs would provide bases for formulating desired wastewater-related policies.

The municipal council, my neighbors and me: Social environmental influences in the city

This study seeks to examine the extent to which the level of municipal environmental management affects and complies with the behavioral norms of urban communities (city norms), and to what extent these affect environmental behavior at the individual level. We used a two-step, mixed-methods approach: a quantitative study of a representative sample of the urban sector (n = 1000) in Israel, followed by a qualitative in-depth interview process (n = 20). Municipal environmental management was found to be strongly correlated with city norms. Multiple regression analyses revealed that the residents' environmental behavior was strongly influenced solely by city norms (and not by the municipal council's conduct). However, our interviews revealed that residents explicitly attributed their pro- or anti-environmental behavior almost solely to the municipal council's conduct (and not to city norms). These relative contributions of municipal environmental management versus city norms on environmental behavior varied across environmental domains. In the Discussion section, we offer an explanation to the seemingly contradictory findings, and offer specific recommendations for several actions and initiatives that local authorities can adopt to promote pro-environmental behavior among its residents' and thus reduce the ecological footprint of the city as a whole.

Epic's implementation of the Willow module and the healthcare workers involving in standardization

BACKGROUND

Implementation of an electronic health record (EHR) that is fully integrated for clinical information, patient scheduling, and billing can effectively be shared by the entire healthcare community, both for the municipality and hospitals in Central Norway. The role and involvement of healthcare workers (HCW) in the implementation process might affect the standardization process.

PURPOSE

This article focuses on the HCW' involvement in the Willow module's standardization and how they will support the adapted systems from Epic's implementation process of the electronic health record.

METHODS

This is a descriptive 6-month follow-up study, based on observations of 35 directions and building sessions from August to January 2019 in the Willow module. Structured interviews of 20 informants in November were used to cross-check and validate the observations. The analytical approach was conducted in four general contexts: a) traditional, b) practical, c) emotional, and d) analytical, obtained from the contextual-content analysis. This is discussed based on the system theory.

RESULTS

A) Traditional: Epic's normative perspective predominates with a tight agenda, questions that should be answered, focuses on standardization of workflow and concepts and had low degree of discussion and involvement, especially in direction sessions. b) Practical: HCW' involvement in standardization provides a high degree of practicality in the sessions, which is also a rational achievement. c) Emotional: The sessions' expressive and affective achievement is guided by the HCW' engagement in standardization, dependent on knowledge and background. d) Analytic: The HCW' intellectual involvement in the standardization of workflows and concepts will be, to some degree, an agreement of objective terms.

CONCLUSIONS

HCW' involvement in standardization will have a supportive function. They will be involved in different contexts and be a part of the end product Willow module, even though Epic controls these.

[Alcohol prevention in municipalities: structures, strategies and challenges]

Alcohol prevention in municipalities is an important and complex aspect of drug prevention in Germany. Based on the principle of subsidiarity, prevention measures are characterised by different legal requirements and prevailing conditions. On the one hand, the federal government set a legal framework with the law of prevention (PrävG) in 2015 and established the national strategy of drug policy and prevention in 2012. On the other hand, municipalities are responsible for the detailed design of local drug policy and interventions together with federal states. Furthermore, preventive measures need to fit local challenges and conditions.Hence, we discuss different strategies of alcohol prevention in municipalities and explain how these strategies fit in administrative frameworks. We also look critically at specific local situations and challenges but also at conditions and possibilities to establish a quality-assured local alcohol policy. Promising approaches from pilot projects are contributed to the discussion.Political decisionmakers, scientists and skilled workers accord that alcohol prevention needs to be implemented in municipal settings and that it is a field of growing importance. We conclude that there is a need to improve local prevention measures by creating better access to qualification programs for skilled workers in combination with a constant transfer between science and pratice of current research results and best practices by providing consultation and support from coordinating institutions for local interventions, especially for the identification of challenges and conditions. Local initiatives should receive better access to interventions that are proven to be effective, and these interventions should be sustainable anchored and evaluated in their municipal settings.

Are protected areas good for the human species? Effects of protected areas on rural depopulation in Spain

Protected areas (PAs) seek to conserve valuable genes, species and ecosystems by applying a legal regime that restricts some socioeconomic activities and also offers opportunities for new ones. As a result, PAs have been claimed by some authors to boost socioeconomic conditions in rural areas mainly through tourism activities. However, others have claimed that PAs contribute to rural depopulation through the worsening of living conditions of local residents because of restrictions resulting from protection regulations. Here, we applied a multiple-paired Before-After-Control-Impact (BACI) research design on a census on protected rural municipalities (cases; N = 52) versus unprotected rural municipalities (controls; N = 55) in Spain to ascertain whether PAs had positive or negative effects on rural populations using three indicators on depopulation with official municipal data from 1996 until 2019: Compound annual growth rate (CAGR); Proportion of reproductive individuals (REP); and Proportion of reproductive females (WREP). We controlled for some confounders such as biophysical characteristics and regional regulations by carefully selecting our sample of municipalities spatially. Our results show that depopulation figures were worse in cases than in controls, with some exceptions whose characteristics should be further explored. Municipalities in Sites of Community Importance (SCIs) performed best against rural depopulation and generally better than their controls, whereas municipalities in Biosphere Reserves and Special Protection Areas (SPAs) showed mostly worse figures. Our findings suggest that, while necessary and important for biodiversity, multiple-use PAs generally entailed negative consequences for Spanish rural populations that need to be offset by State's intervention.

Development of a factorial water policy simulation approach from production and consumption perspectives

Industrial water-management policies are prevalent around the world to alleviate global water scarcity. It is indispensable to simulate the effects of different water-management policies on various industries in the socioeconomic system to explore the most effective water consumption reduction pathways. In this study, a factorial water policy simulation model is developed to investigate the composite effects of multidimensional interactive water-management policies from both production and consumption perspectives. Structural path analysis and factorial analysis are introduced simultaneously to help support policy formulation according to local reality and further examine the impacts of the main factors and their interactions respectively. The developed model has been applied to the Municipality of Chongqing, China to demonstrate the applicability and superiority of the factorial water policy simulation model. It was found that the impacts of industrial technology upgrade policies on different industries vary significantly. The consumption-orientation policies have a similar performance on direct water consumption reductions. In the Municipality of Chongqing, industrial technology upgrade policies applied to the primary industry will generate larger reductions of water consumption (i.e., 10.1 units reduction of total water consumption) in the system since the primary industry can influence other industries through intermediate utilization. The contribution of interactions for the reductions of direct water consumption was 10.38%, where policies implemented on the primary industry and construction industry have the most significant interaction. In addition, the industry of production and supply of water is closely related to most of the industries since its technical improved can reduce the indirect water consumption of the majority of industries. The results provide bases for supporting the Municipality's efforts in formulating desired water-management policies.

Population-level indicators associated with hormonal contraception use: a register-based matched case-control study

Background

Monitoring factors related to hormonal contraception (HC) use is essential to evaluating public health strategies and promoting access to contraception. We aimed to examine municipal social and health indicators of HC use at the population level, and to identify patterns of inequality across Finnish municipalities.

Methods

We identified all women (15–49 years) with a redeemed HC prescription in Finland in 2017 (n = 294,445), and a control group of non-users. Municipal social and health indicators at the population level were retrieved from the nationwide Statistics and Indicator Bank. Differences between the groups across 309 municipalities were calculated, and associations of municipal-specific proportions of HC users with municipal-specific indicators were studied using LASSO (Least Absolute Shrinkage and Selection Operator) models.

Results

Sociodemographic differences between HC users and non-users were non-homogenous across municipalities. Indicators positively associated with HC use included: larger population and higher proportions of population aged 16–24 years, of household-dwelling units with one person, of persons with higher education, and of divorces among those aged 25–64. Lower HC use was associated with higher proportions of Swedish-speaking population, of those aged 7–15 years, of young people not in education/training, and of household-dwelling units in overcrowded conditions. Lower HC use was also associated with indicators of outpatient and inpatient healthcare, and of municipal finances in welfare and healthcare.

Conclusions

Sociodemographic differences in relation to HC use exist across Finnish municipalities. Municipal indicators of social structure, health and welfare, and investment in and use of healthcare services are related to HC use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10512-6.

Profile of children referred to primary health care physiotherapy: a longitudinal observational study in Norway

Background

Physiotherapy services are an important part of the primary health care services for children, serving a broad spectrum of children referred from different sources and for a variety of reasons. There is limited knowledge about their characteristics and outcome. The aim of this study was to describe the profile, i.e. referral patterns, baseline demographical and clinical characteristics, as well as treatment outcome at follow-up 6 months after baseline, of children receiving physiotherapy in primary health care.

Methods

Children referred to primary health care physiotherapy in a large municipality in Norway were invited to participate in this longitudinal observational study. The children’s demographics, referral sources, causes of referral, functional diagnoses, influence on their daily activities, main goals and planned treatments were registered at baseline. Goal attainment and treatment compliance were registered at follow-up maximum 6 months after baseline.

Results

The physiotherapists registered baseline characteristics for 148 children. Parent-reported data at baseline were available for 101 (68.2%) of these children. Children were mainly referred from child health care centres (n = 74; 50.0%), hospital (n = 25; 16.9%) and kindergarten (n = 22; 14.9%). The most frequent causes of referral were concerns for motor development (n = 50; 33.8%), asymmetry (n = 40; 27.0%) and orthopaedic conditions (n = 25; 16.9%). Eighty-one (54.7%) children were below the age of 1 year. There was partly agreement between causes of referral and the physiotherapists’ functional diagnoses. Parents of 69 (71.1%) children reported that their child’s daily activities were little to not at all affected by the problem or complaint for which they were referred. Follow-up data were registered for 64 children. The main treatment goal was achieved in 37 (57.8%) and partly achieved in 26 (40.6%) children and the treatment was carried out as planned in 55 (87.3%) children.

Conclusions

The large variation in the profile of children receiving physiotherapy in a primary health care setting in Norway shows how primary health care physiotherapists can contribute to fulfil the broad purpose of the primary health care services.

Trial registration

ClinicalTrials.gov Identifier: NCT03626389. Registered on August 13th 2018 (retrospectively registered).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05988-8.

Groping around in the dark for adequate COPD management: a qualitative study on experiences in long-term care

Background

Chronic obstructive pulmonary disease (COPD) is one of the most common and deadliest chronic diseases worldwide. Since COPD is a chronic and progressive disease, treatment is necessary throughout life. For people with COPD who cannot live independently, long-term care facilities are often required. However, knowledge is very limited about aspects of importance for effective COPD management in these settings in accordance with current treatment guidelines.

The aim of this study was to explore aspects of importance in long-term care facilities for providing interventions according to treatment guidelines for people with COPD, from the perspective of healthcare professionals, in an effort to prove novel knowledge that could be used to facilitate implementation of treatment guidelines in these settings.

Methods

A qualitative study was performed in northern Sweden. In Sweden, municipalities are responsible for providing long-term care. Interviews with 36 healthcare professionals (nurses, physiotherapists, occupational therapists and dieticians) in municipal healthcare were conducted and analysed using qualitative content analysis with triangulation by the authors.

Results

The overarching theme that emerged from the analysis was Groping around in the dark for adequate COPD management. This represents healthcare professionals’ experiences of working with a complex diagnosis somewhat overlooked in the municipal healthcare, an underdog in the healthcare system. The groping around in the dark theme further represents the healthcare professionals’ lack of COPD-related competence, lack of interprofessional collaboration, and insufficient communication with the county council. The fragile group of people with COPD and their relatives were considered in need of support adapted to their context, but routines and resources for COPD management were limited. This lack of routines and resources also resulted in professionals being pragmatic and adopting short-term solutions without focusing on specific needs related to the diagnosis.

Conclusions

The COPD management in long-term care settings showed several insufficiencies, indicating a large gap between clinical practice and treatment guidelines for COPD. It is crucial to improve COPD management in long-term care settings. Consequently, several actions are needed, such as increasing professional competence, establishing new routines, acknowledging and making COPD a higher priority, as well as adapting treatment guidelines to the context.

How performance management regulations shape evaluation practice in South African municipalities

South African municipalities are taking hesitant steps towards institutionalising evaluation practice. This paper explores how evaluation is being institutionalised at a municipal level, looking at both the legislative and regulatory requirements in terms of planning, budgeting, and reporting, as well as opportunities for evaluative practice. A well-established performance management system, coupled with certain constraints to innovation and building an evaluative culture are contributing to the creation of an evaluation function that serves a monitoring purpose. A combination of desktop research and participatory action research was used to understand the municipal practice of evaluation. The results have implications for how decentralised public sector evaluation systems are understood.

Prevalence of modifiable cardiovascular risk factors in Yazd inner-city municipalities

Background

Cardiovascular disease (CVD) is the leading cause of death in the world. With effective intervention and control of cardiovascular risk factors, mortality rates may be reduced. The aim of this study was to investigate the prevalence of modifiable risk factors across five municipalities in Yazd city.

Methods

Ten thousand residents of the Yazd greater area aged 20–69 years were selected using cluster random sampling method. Overall, 200 clusters were randomly selected based on the postcodes of residents who lived in the five municipalities of Yazd. Those who lived in Yazd annexed cities and rural areas were excluded. A valid questionnaire was completed and physical examination performed as done (94.9% response rate). Instances of self-reported diabetes mellitus, high blood cholesterol, tobacco smoking, and unhealthy diet were recorded. Blood pressure, height, and weight were measured and physical activity was classified by International Physical Activity Questionnaire (IPAQ). A chi-square test was used to analyze the differences in variables across municipalities. Statistical analyses were performed using SPSS V. 16.

Results

We analyzed 8749 participants’ data from Yazd city. The prevalence of diabetes mellitus, hypercholesterolemia, and hypertension were 14.1, 16.7 and 18.6%, respectively. One in every four people consumed the recommended five servings of vegetables per day. Fish consumption was less than 5% at least once a week among participants. An unhealthy diet (85.7%); low physical activity (52.2%), hypertension (36.7%) and obesity (26.3%) were the most common cardiovascular risk factors. Only 2.1% of adults had no risk factors for CVD, and almost 75% of people had more than one risk factor. The prevalence of risk factors (excluding hypertension) was significantly different across the municipalities. Residents of region three had the highest prevalence of all risk factors aside from inactivity and unhealthy diet.

Conclusion

unhealthy dietary habits and inactivity are the most common modifiable risk factors of CVD in Yazd. Spatial variations of cardiovascular risk factors observed. This geographic health inequality requires more attention from policymakers to control CVD risk factors across different municipalities accordingly. Promoting healthy lifestyle is the top priority of health intervention programs. It is recommended to increase access to sport arenas and restrict access to tobacconist in high-risk areas.

Data on urban waste collection: The case of the Apulia region in Italy

The collection of urban waste is an important step of the waste management cycle, because the collection of sorted waste that soon separates different kind of materials makes their reusing, recovering, and recycling easier and more efficient, reducing the amount of landfilled waste. In Italy, municipalities have to meet specific targets relative to the yearly percentage of sorted waste collection. Collecting and analyzing data about waste collection and the proportion of sorted waste and the specific type of waste materials is a critical activity to measure the performance and monitor the effort of the municipalities to meet targets. Raw data relative to the yearly amounts of total and sorted waste collected from 2007 to 2017, and data relative to socio-economics in 258 municipalities of the Apulia region were retrieved from public databases and were used to calculate waste statistical indicators. Data about total and sorted waste collection in Italy at the regional and country level were retrieved and analysed to compare the Apulia region and specific groups of regions. The evolution of the per capita total and sorted waste amounts was also analysed over time for Apulia and the rest of Italy. The effects of the municipality surface area, the number of inhabitants and population density on the sorted waste collection rate were investigated by performing regression analysis. These data may help policy makers and stakeholders to evaluate total and sorted waste production over time, set and assess targets, and identify best policy practices.

Public-private partnership in solid waste management sector in the West Bank of Palestine

Palestine, being a developing country, faces lots of obstacles and deficiencies in the existing solid waste management (SWM) field. In wake of these circumstances, it seems hard for the public sector to run sustainable SWM systems. The overall objective of the research presented in this paper was to study the current status of the SWM field in the West Bank of Palestine under the perspective of potential private sector involvement. For this purpose, twelve Joint Service Councils (JSCs) for solid waste management were investigated. Out of them, only two are currently having a Public-Private Partnership (PPP) contract for the management and operation of the transfer station and the sanitary landfill. On the other hand, two JSCs are currently making arrangements and implementing studies for future PPPs on waste-to-energy, biowaste management and recycling projects. Jenin and Tubas Joint Service Council (JSC) had 3-month-duration PPP contract for the implementation of a recycling project, which is a worst case scenario as it failed to meet its objectives. The parameters that could encourage JSCs or ease the implementation of PPP in local SWM field are analysed. Overall conclusion is that sustainability can be accelerated once the government-represented by the Ministry of Local Government (MoLG)-is involved; providing legal support to local authorities and incentives to potential contractors in order to encourage them to join PPPs. Parameters that are believed to facilitate PPPs include the following: development or updating existing laws and regulations, facilitation of licensing procedures, and activation of the Investment Promotion Law. Feasibility and market analysis study implementation will indicate the appropriate actions required locally to achieve environmental and financial sustainability in all contracted PPPs.

The background context matters: Local-scale socioeconomic conditions and the spatial distribution of wildfires in Italy

Wildfires, a key socio-environmental challenge in Mediterranean regions, are influenced by anthropogenic factors shaping land-use and socioeconomic spatial structures. By assuming that the dominant socioeconomic structure of local districts exerts a variable impact on wildfire spatial regimes, the present study investigates 174 indicators on a municipal scale in Italy, identifying a multidimensional relationship between wildfire characteristics and socioeconomic contexts. An exploratory statistical approach was adopted to identify linear and non-linear relationships among variables assessing socioeconomic contexts and wildfire patterns. Empirical results demonstrate that characteristic wildfire attributes (frequency, intensity and severity) are systematically higher in socioeconomic contexts characterized by rural poverty, unemployment and deregulated urban expansion, especially in southern Italy. A higher fire frequency was typically observed in (i) peri-urban districts with a dynamic socio-demographic profile and (ii) in rural districts with intensive cropping systems. Joint information on socioeconomic structure/dynamics and environmental change, is crucial for a better understanding of local-scale spatial patterns of wildfires in the Mediterranean region. Integrated socio-environmental information provides a better understanding of the local communities' role in the management of wildfire-prone land, contributing to implement more effective strategies aimed at minimizing wildfire impact on land resources.

When does population growth pay off? A case study of suburban land consumption to assess the Lower Austrian infrastructural cost calculator

'To increase the number of inhabitants' is a commonly stated top objective in municipal strategies across European countries. Not differently in Austria, local policy follows a logic of growth as financial tax and redistribution systems reward according to population figures; but is demographic growth necessarily financially beneficial for a municipality, irrespective of the type of land use changes, and potentially urban sprawl, that it triggers? The Federal State of Lower Austria offers to its municipalities a strategic online planning tool to pre-assess eventual municipal infrastructural costs and tax revenues that would come with certain population increase. This study tests the Lower Austrian infrastructural cost calculator and, in so doing, seeks to add a spatial perspective to an otherwise oversimplified financial calculation of planning for growth. The case study municipality of Michelhausen formulated an ambitious objective of 25% population growth (+ 700 inhabitants) within a few years in its local development strategy, to be realised by enlarging a rural settlement area. The study will assess five possible alternatives of settlement enlargement with varying housing types for their municipal financial consequences. In conducting this case study, the infrastructural cost calculator, a strategic planning tool offered by the federal planning authority of Lower Austria to their municipalities, will be assessed for its current potential as well as possible enhancement as strategic planning instrument to support municipalities in financial questions when developing building land. Normative lessons drawn from the whole exercise directly address actors and decision-makers in local and regional planning context in Lower Austria. The study ends with a short outlook of possible learnings and transfer into other national and international planning practice contexts.

Characteristics, course and outcome of patients receiving physiotherapy in primary health care in Norway: design of a longitudinal observational project

Background

Physiotherapists (PTs) in primary health care manage patients with large variation in medical diagnosis, age, functional status, disability and prognosis. Lack of knowledge and systematically collected data from patients treated by PTs in primary health care has prompted this longitudinal observational physiotherapy project. This paper aims to describe a method for developing a database of patients managed by PTs in primary health care, with the main purpose to study patients’ characteristics, treatment courses and prognostic factors for favourable outcome.

Methods

This is a longitudinal observational project, following patients through their physiotherapy treatment periods in primary health care in Norway and until one year after inclusion. The project involves both private practitioners and municipally employed PTs working in primary health care in nine municipalities in Norway. The patients are recruited to three different cohorts depending on age and whether they are referred to a private practitioner or a municipally employed PT. All data are recorded electronically, transferred and stored securely. For all patients we have included extensive questionnaires to obtain information about demographics, disability and function, pain-related variables, psychosocial factors, treatments and evaluation of treatment as well as response to clinical tests. The PTs have access to use their own patients’ data. We have also prepared for linkage to national patient registers and data collected in population-based studies to be able to gather further important data.

Discussion

This project will have important implications for physiotherapy services in primary health care. The database contains more than 3000 patients, and data collection is ongoing. Data collected so far suggest that the patients included are representative of the larger population of patients treated by private practitioners or municipally employed PTs in Norway. This large scale prospective physiotherapy project will provide knowledge about the patient groups, applied treatments and short- and long-term outcome of the patients.

Trial registration

ClinicalTrials.gov Identifier: NCT03626389. Registered on August 13th 2018 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3729-y) contains supplementary material, which is available to authorized users.

Intersectoral Planning for Public Health: Dilemmas and Challenges

BACKGROUND

Intersectoral action is often presented as essential in the promotion of population health and health equity. In Norway, national public health policies are based on the Health in All Policies (HiAP) approach that promotes whole-of-government responsibility. As part of the promotion of this intersectoral responsibility, planning is presented as a tool that every Norwegian municipality should use to integrate public health policies into their planning and management systems. Although research on implementing the HiAP approach is increasing, few studies apply a planning perspective. To address this gap in the literature, our study investigates how three Norwegian municipalities experience the use of planning as a tool when implementing the HiAP approach.

METHODS

To investigate planning practices in three Norwegian municipalities, we used a qualitative multiple case study design based on face-to-face interviews. When analysing and discussing the results, we used the dichotomy of instrumental and communicative planning approaches, in addition to a collaborative planning approach, as the theoretical framework.

RESULTS

The municipalities encounter several dilemmas when using planning as a tool for implementing the HiAP approach. Balancing the use of qualitative and quantitative knowledge and balancing the use of structural and processual procedures are two such dilemmas. Other dilemmas include balancing the use of power and balancing action and understanding in different municipal contexts. They are also faced with the dilemma of whether to place public health issues at the forefront or to present these issues in more general terms.

CONCLUSION

We argue that the dilemmas experienced by the municipalities might be explained by the difficult task of combining instrumental and communicative planning approaches because the balance between them is seldom fixed.

Critical issues for employees in inter-municipal health care services: a multiple case study

Background

Traditional, hierarchical government structures have recently been challenged by increased complexity, fragmented services and heavy public demand. When healthcare services become fragmented and decentralised, they require redesign. Inter-municipal cooperation is a strategy to deal with current challenges and future demographic changes. Few studies exist that can help us conceptualize challenges regarding employment in this context and inform managers in the involved municipalities. This study aims to identify critical issues for employees in inter-municipal health care services and to elaborate on how and why these issues are experienced.

Methods

A multiple qualitative case study was conducted with data from interviews, observation studies, a participant workshop and inter-municipal healthcare service project documents and reports. The study involved two districts in Norway and six cases including 17 informants. First, a within-case analysis was conducted for all cases; second, a cross-case analysis was conducted in each district to examine replication, contrasts and extension to emergent findings; and, eventually, replicated findings in Districts 1 and 2 were analysed across districts.

Results

Three critical issues were identified: support, differences, and geographical distances. Employees working in teams experienced fewer challenges than did those working as isolated individuals.

Conclusions

Critical issues for employees represent an important aspect of inter-municipal cooperation, and additional research should be undertaken to inform future policy and practice.

Impact of support agreement between municipalities and convenience store chain companies on store staff's support activities for older adults

In the continuously aging society, private sectors are expected to play a role in older adult care. Implementing an agreement between municipalities and private sectors is one of the key mechanisms for encouraging private sectors to participate in supporting older adults. The study's aim was to evaluate whether the support agreement has promoted support activities by convenience store staff for older adults. A retrospective observational study was conducted between 2013 and 2016 using data from a nationwide survey of convenience stores. The municipality-level matching produced 168 municipality pairs, with 2242 convenience stores that entered into a support agreement with municipalities from 2014 to 2015, and 2141 stores without such an agreement. Convenience store-level logistic regression analysis evaluated the impact of the agreement on staff activities. The analysis showed that some staff activities increased significantly with the support agreement, such as corresponding or collaborating with community support centers (AOR = 3.40; 95% CI: 2.22 to 5.26), participating in role-playing programs for older adult care (AOR = 2.05; 95% CI: 1.01 to 4.26), and attending dementia support lectures (AOR = 18.21; 95% CI: 8.27 to 45.34). Emergency protection for older adults did not increase with the support agreement. The results suggest that the support agreement positively influenced some convenience store staff's support activities for older adults.

The role of the natural and built environment in cycling duration in the Netherlands

Background

Cycling for transportation has the potential to contribute to an increase in people’s physical activity levels. A growing body of evidence links the natural and the built environment to cycling. Whereas previous studies were mostly done within one city or one region, the present study covers the whole of the Netherlands, allowing an investigation of whether associations between environmental characteristics and cycling are context-specific. The study examines the extent to which objectively measured natural and built environment characteristics contribute to cycling duration in the Netherlands, as well as the differential effect of environmental characteristics on cycling duration by municipality size.

Methods

Our sample from the Dutch National Travel Survey 2010–2014 comprised 110,027 people aged 20–89 years, residing in 3163 four-digit postal code areas, nested within 387 municipalities across the whole of the Netherlands. Multilevel Tobit regression models were fitted to assess the associations between the natural and the built environment with average daily cycling duration (in minutes), while adjusting for individual and household characteristics. Interaction effects of natural and built environment characteristics and municipality size on cycling duration were also investigated.

Results

Higher address density, more bus stops, and shorter distance from home to the nearest train station were positively related to cycling duration. Respondents were more likely to cycle on days with higher temperatures, less wind, and less precipitation. Interaction tests showed that increased street density and address density were less cycling-promotive in small urban areas compared to medium or large cities. On the other hand, the positive association between number of bus stops and cycling duration was weaker in the largest and medium-sized cities compared to small urban and rural areas.

Conclusions

Interactions suggest that relations between environmental characteristics and cycling duration are context-specific (i.e., dependent on circumstances that differ between highly urbanized and less urbanized areas). Our findings need to be replicated in other countries to gain more insight into the interplay between environmental factors and municipality size.

Embedding health equity strategically within built environments

BACKGROUND

Population health approaches are visible among multidisciplinary methods used in urban design and planning, but attention to health equity is not always an explicit focus. Population and Public Health-Saskatoon Health Region recognized the need for frameworks to prioritize, integrate and measure health equity within local built environments.

SETTING

A cross-department healthy built environment (HBE) initiative coordinated activities involving Health Promotion, Environmental Public Health, Public Health Observatory, and Medical Health Officers engaged with municipal, academic and community partners in Saskatoon, Saskatchewan.

INTERVENTIONS

The HBE team conducted evidence reviews and consulted with partners to identify common health equity issues in built environments and best and leading practices to address them. The HBE team then prioritized and undertook projects to model a health equity approach.

OUTCOMES

Projects included the following: (1) developing a Health Equity in Healthy Built Environment Framework; (2) engaging in a partner campaign highlighting built environment and health equity during a municipal election; (3) producing a Health Equity Impact Assessment (HEIA) report on the City of Saskatoon's growth plan; and (4) developing a monitoring and evaluation framework for health equity outcomes. Other outputs include making new connections between local HBE and poverty reduction efforts and promoting social inclusion guidelines in consultation processes.

IMPLICATIONS

Within a population health approach to HBE, an explicit focus on health equity can be a catalyst for engaging partners in cross-sectoral action for building inclusive physical and social environments.

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guideline´s aim of uniform, evidence-based content of CR services across settings.

Hierarchical ordered model for injury severity of pedestrian crashes in South Korea

INTRODUCTION

The high percentage of fatalities in pedestrian-involved crashes is a critical social problem. The purpose of this study is to investigate factors influencing injury severity in pedestrian crashes by examining the demographic and socioeconomic characteristics of the regions where crashes occurred.

METHOD

To understand the correlation between the unobserved characteristics of pedestrian crashes in a defined region, we apply a hierarchical ordered model, in which we set crash characteristics as lower-level variables and municipality characteristics as upper-level. Pedestrian crash data were collected and analyzed for a three-year period from 2011 to 2013. The estimation results show the statistically significant factors that increase injury severity of pedestrian crashes.

RESULTS

At the crash level, the factors associated with increased severity of pedestrian injury include intoxicated drivers, road-crossing pedestrians, elderly pedestrians, heavy vehicles, wide roads, darkness, and fog. At the municipality level, municipalities with low population density, lower level of financial independence, fewer doctors, and a higher percentage of elderly residents experience more severe pedestrian crashes. Municipalities ranked as having the top 10% pedestrian fatality rate (fatalities per 100,000 residents) have rates 7.4 times higher than municipalities with the lowest 10% rate of fatalities. Their demographic and socioeconomic characteristics also have significant differences. The proposed model accounts for a 7% unexplained variation in injury severity outcomes between the municipalities where crashes occurred.

CONCLUSION

To enhance the safety of vulnerable pedestrians, considerable investments of time and effort in pedestrian safety facilities and zones should be made. More certain and severe punishments should be also given for the traffic violations that increase injury severity of pedestrian crashes. Furthermore, central and local governments should play a cooperative role to reduce pedestrian fatalities. Practical applications: Based on our study results, we suggest policy directions to enhance pedestrian safety.

The Prevalence of Hepatitis B Virus Among Municipal Solid Waste Workers: Necessity for Immunization of At-Risk Groups

BACKGROUND

Hepatitis B virus (HBV) is likely to be more prevalent in certain populations and occupational groups, such as municipal solid waste workers (MSWWs).

OBJECTIVES

The current study aimed to estimate the prevalence of HBV and its risk factors among MSWWs compared to other municipal employees not exposed to waste.

PATIENTS AND METHODS

The current cross-sectional study included 654 municipal employees in Zahedan (south-eastern Iran). A sample of blood was taken from each participant and tested for HBsAg through the enzyme-linked immunosorbent assay (ELISA). Demographic and other data on high risk behaviors were also collected through in-depth interviews. Data were analyzed using chi-square test and multiple regression analysis by STATA.

RESULTS

The overall prevalence of HBV among municipal employees was 3.06% (95% CI: 1.70 - 4.30); however, it varied among the different employee subgroups as follows: 6.20% (95% CI: 2.70 - 9.70) in MSWWs, 3.3% (95% CI: 0.08 - 5.80) in drivers and 1% among staff who were not exposed to waste. Multiple regression analysis showed that exposure to waste [OR = 9.36; 95% CI = 2.01 - 43.7], lack of vaccination against HBV [OR = 3.83; 95% CI = 1.86 - 25.2], jaundice [OR = 6.91; 95% CI = 1.51 - 31.5], history of endoscopy [OR = 2.86; 95% CI = 1.08 - 7.62], and high risk behaviors [OR = 4.80; 95% CI = 1.96 - 27.2] were independently associated with HBV.

CONCLUSIONS

Greater encouragement for immunization against HBV as well as better education on HBV transmission routes and work safety precautions should be implemented to reduce the prevalence of HBV in MSWWs.

Long-term impact of the 2011 Great East Japan Earthquake and tsunami on functional disability among older people: A 3-year longitudinal comparison of disability prevalence among Japanese municipalities

It has been unclear whether the prevalence of disability is higher in an area affected by natural disaster than in other areas even if more than one year has passed since the disaster. The aim of this ecological study was to examine whether the rate of increase in disability prevalence among the older population was higher in disaster-stricken areas during the 3 years after the Great East Japan Earthquake (GEJE) and tsunami. This analysis used public Long-term Care Insurance (LTCI) data covering 1570 municipalities. "Disaster areas" were considered to be the three prefectures most affected by the earthquake and tsunami: Iwate, Miyagi, and Fukushima. The outcome measure was the number of aged people (≥65 years) with LTCI disability certification. Rates of change in disability prevalence from January 2011 to January 2014 were used as the primary outcome variable, and compared by analysis of covariance between "coastal disaster areas", "inland disaster areas" and "non-disaster areas". The mean rate of increase in disability prevalence in coastal (14.7%) and inland (10.0%) disaster areas was higher than in non-disaster areas (6.2%) (P < 0.001). During the 3 years after the earthquake, the increase of disability prevalence from before the GEJE continued to be higher in the disaster-stricken areas.

The effect of organisational system on self-rated depression in a panel of male municipal firefighters

Objectives

The present study evaluated the effects of job stress, including organisational system to self-rated depression through a panel study of male municipal firefighters in the Republic of Korea.

Methods

A panel of 186 municipal firefighters reported self-rated depressive symptoms according to the Beck Depression Inventory (BDI). The effects of job stress were evaluated using the Korea Occupational Stress Scale, taken one year earlier and classified by the median value. Panel members were classified into Depression or Control groups according to BDI scores, with a cut-off level of ‘over mild depression’ in a follow-up survey.

Results

The Depression group included 17 (9.1%) workers. Firefighters who scored high on occupational system had an 8.3 times greater risk of being assigned to the Depression group than those who had not (adjusted odds ratio [OR] = 8.03, 95% confidence interval (CI) = [1.73–37.22]). In contrast, job stress from a ‘difficult physical environment’ revealed negative risks related to being classified in the Depression group (AOR = 0.20, 95% CI = [0.04–0.92]).

Conclusions

Although the healthy worker effect may be involved, job stress based on perceptions of organisational system was a strong risk factor for depression. A comprehensive approach should be considered that encompasses social issues when assessing or mental health in high-risk groups, as well as the practical issue of physiochemical hazards.

How do municipality employees in Ankara approach persons with disabilities?

BACKGROUND

Municipalities have a crucial role in the adaptation of urban spaces, buildings, and public services for full use by persons with disabilities.

OBJECTIVE

The aim of this study was to determine the attitudes toward persons with disabilities in municipal employees.

METHODS

This descriptive study included 338 municipal employees of a major municipality in Ankara, Turkey. Data were collected via a questionnaire and the Attitude towards Persons with Disabilities Scale (ATPDS) (Dokmen, 2000). Descriptive statistics, the t test, ANOVA, and ordinal logistic regression were used to analyze the data.

RESULTS

Among the participants, 5.1% had some type of disability, 15.0% had a family member with a disability, and 6.9% cared for a person with a disability. Pity was the most common feeling (30.6%) toward persons with disabilities. Mean ATPDS score was 115.6 ± 15.1 out of 150. The attitudes of the employees with a family member or a friend with a disability, as well as those of the employees that had cared for a person with a disability were more favorable than their counterparts (p < 0.05).

CONCLUSIONS

The present findings showed that close contact and interaction with persons with disabilities were associated with more positive attitudes. Therefore, promoting positive attitudes among municipal employees and the development of a supportive organizational culture with respect to the rights of persons with disabilities may be useful. Interventions aimed at increasing awareness of and interaction with persons with disabilities may improve the attitudes of municipal employees, and consequently improve the services municipalities provide to persons with disabilities.