Securing health or just health care? The effect of the health care system on the health of America.
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Delivery of Health Care↗
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[The actions of health centres in realising the partial amendment of the law on mental health and welfare for people with mental disorders. A questionnaire survey of prefectural health centres].
OBJECTIVE: In accordance with the partial amendment of the Law on Mental Health and Welfare for People with Mental Disorders, some mental health and welfare work is now under the jurisdiction of cities, towns and villages instead of prefecture. What is the role of prefectural health centres in realizing the change? To assess the smoothness of the transfer of the work from prefectures to the municipalities, we investigated the situation in the latter and the actual support provided by health centres. METHODS: A total of 103 health centres in the administrative divisions were recruited. A questionnaire survey was carried out to study the mental health and welfare work, the department in change and other data for cities, towns, and villages in the administrative division of each prefectural health centre. The actions of health centres were also investigated and analyzed. In addition, Japan was divided into 6 blocks of health centres, and comparisons among the 6 blocks were made based on the answers to survey questions. RESULTS: A total of 83 health centres responded to the questionnaire (the response rate was 80.6%), with 683 cities, towns and villages included in their territories about 60% of the municipalities had designated a person in charge of the transferred mental health and welfare services, the responsible department was decided in less than 40% of cases. There were differences among the 6 blocks in Japan in the rates of actions on mental health and welfare, and in the designation of the department in charge in municipalities. Over 95% of the health centres provided educational courses related this transfer of work for municipalities. About 80% of the health centres evaluated the merit of the partial amendment for promotion of mental health and welfare, and 60% were anxious about retrogressive policies for people with mental disorders. CONCLUSIONS: Educational courses supported the smooth transfer of services. The department in charge of the transfer of service in the cities, towns and villages was designated in less than 60% of municipalities.
Community Health Centers↗
Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women.
BACKGROUND: There is a dearth of validated information about lesbian and bisexual women's health. To better understand some of these issues, we used population-based data to assess variations in health behaviors, health status, and access to and use of health care based on sexual orientation. METHODS: Our study population was drawn from a population-based sample of women, the 1997 Los Angeles County Health Survey. Participants reported their sexual orientation and these analyses included 4697 women: 4610 heterosexual women, 51 lesbians, and 36 bisexual women. We calculated adjusted relative risks to assess the effect of sexual orientation on important health issues. RESULTS: Lesbians and bisexual women were more likely than heterosexual women to use tobacco products and to report any alcohol consumption, but only lesbians were significantly more likely than heterosexual women to drink heavily. Lesbians and bisexual women were less likely than heterosexual women to have health insurance, more likely to have been uninsured for health care during the preceding year, and more likely to have had difficulty obtaining needed medical care. During the preceding 2 years, lesbians, but not bisexual women, were less likely than heterosexual women to have had a Papanicolaou test and a clinical breast examination. CONCLUSIONS: In this first population-based study of lesbian and bisexual women's health, we found that lesbians and bisexual women were more likely than heterosexual women to have poor health behaviors and worse access to health care. These findings support our hypothesis that sexual orientation has an independent effect on health behaviors and receipt of care, and indicate the need for the increased systematic study of the relationship between sexual orientation and various aspects of health and health care. Arch Fam Med. 2000;9:1043-1051
Adult↗
The contribution of the World Health Organization to a new public health and health promotion.
The author traces the development of the concept of health promotion from 1980s policies of the World Health Organization. Two approaches that signify the modernization of public health are outlined in detail: the European Health for All targets and the settings approach. Both aim to reorient health policy priorities from a risk factor approach to strategies that address the determinants of health and empower people to participate in improving the health of their communities. These approaches combine classic public health dictums with "new" strategies, some setting explicit goals to integrate public health with general welfare policy. Health for All, health promotion, and population health have contributed to this reorientation in thinking and strategy, but the focus of health policy remains expenditure rather than investment.
Canada↗
Prevention and health education: how recent advances in the science and art of health education have been applied in practical ways within medical and other settings for prevention and public health.
The terms health education, patient education, self-care education, school health education, and health promotion are distinguished from each other as follows. Health education is a subset or strategy within each of these but is the primary and dominant strategy in health promotion. Health education occurs through the health care providers in various settings: worksites, medical, community agencies and schools. Nurses and midwives are the most important health care providers to train people for health promotion and cancer prevention. We appreciate the importance of the "Fight against Cancer" movement in the primary health care centre and its health care providers who inform people about cancer and its symptoms, how to find lesions and early stages, and how to avoid hazardous factors. This is as process of continuous information transfer by in-service education. Primary prevention should encompass all actions aimed to reducing the occurrence of cancer. In reviewing recent advances in science and how the art of health education has been applied in practical ways within medical and other settings for prevention and public health, we can point ot the necessity for facilities like an APOCP Training Centre as a venue for scientific courses.
Breast Neoplasms↗
Longitudinal study on the health status of children in a rural Tanzanian community: comparison of community-based clinical examinations, the diseases seen at village health posts and the perception of health problems by the population.
Standardised household interviews among adults and children, open-ended questionnaires, and clinical examinations administered during cross-sectional health status surveys, as well as the registers of village health posts (VHP), were used to assess the pattern of health problems of a rural community in southeastern Tanzania, and their results compared. All four approaches gave very similar results for the two major health problems (fever/malaria and abdominal pain or discomfort) which were mentioned by both children and adults. The parasitological data from the cross-sectional surveys also revealed hyperendemic P. falciparum malaria and a high prevalence and incidence for infections with hookworm (N. americanus), Strongyloides, and G. lamblia. However besides consistently revealing the two major health problems, each approach showed a distinct pattern for the additional health problems: household interviews and open-ended questionnaires resulted in a higher ranking of problems that had not yet been solved by the health care facilities available in the community at the time of the interview. This view was further biased by the fact that the interviews were done by people representing the health professionals. The statistics from the registers of VHP clearly reflected the types of treatment provided by this service. Malnutrition and various eye problems only became evident during the clinical examination of the population. However, the clinical examination did not identify the importance of the abdominal problems in the community. The cross-sectional survey (questionnaires, clinical examination) chiefly showed the health problems affecting the population around the time of the surveys (end of the dry season). Interestingly, the registers of the VHP did not show marked seasonal variations in the morbidity statistics for this community. Both questionnaire approaches and the registers of VHP showed a change in both the morbidity and the disease perception pattern that may reflect the effects of interventions launched at community level (activities of village health workers, mass-treatment against hookworm and G. lamblia). The study indicated that the individual ranking of the major health problems matched with data from health status surveys. It also pointed to the possibility that disease perception patterns could become a tool for community diagnosis and for the monitoring of health care programs.
Abdomen↗
[Home care and nursing administration in community health nursing--the integration of individual health care with community health care].
There has been a paradigm shift in community health nursing. In 1992, visiting nursing stations were first introduced. In 1994, the Community Health Act came into force and in recent years public health care insurance has become a major issue. In this paradigm shift, one of the roles of nursing in the community is to train people to become more autonomous as consumers of health care services, and to design and implement a system that enhances community members' health and provides support when they are ill. In 1990 and 1996, the national nursing curriculum was revised to reflect changes in the age of the population. Community health nursing now faces the challenge of developing a new nursing model that is in tune with Japanese cultural values. Dr. Katsunuma (1996) proposed two alternative approaches to health care services: the public health approach and the clinical approach. In this paper, it is suggested that home care offers a third alternative, which integrates the clinical approach with the public health approach. This third approach provides a paradigm for community health nursing that integrates individual health care with community health care. New roles and specialties for public health nurses include care management, care planning, community health nursing administration, and supervision. Community-based nursing centers that cooperate with schools of nursing will provide a setting and a concept for community health nursing.
Case Management↗
Interregional variations in measures of health from the Health and Lifestyle Survey and their relation with indicators of health care need in England.
STUDY OBJECTIVE: The aim was to assess the extent to which a range of routinely available need indicators which have been suggested for use in NHS spatial resource allocation formulas were associated geographically in England with the different dimensions of population health status collected in the 1985/86 Health and Lifestyle Survey (HLS). DESIGN: Regional health authorities were ranked according to each of the HLS health variables which varied significantly between authorities. The HLS health variables were regressed on a selection from the range of routinely available morbidity and socioeconomic indicators available from the 1981 census. The potential need indicators were also regressed on the health variables. SETTING: The analyses were undertaken at individual level and at regional health authority level in England. SUBJECTS: The study comprised the English component of the HLS random sample representative of the population in private households in Great Britain. MAIN RESULTS: The different HLS health variables did not yield consistent regional health authority rankings. Among the variables, forced expiratory volume in one second (FEV1) and self assessed health appeared to be associated with most of the other health and need variables except longstanding illness. Longstanding illness was not strongly associated with any of the other HLS health variables but appeared to show some association with three deprivation indices constructed from the 1981 Census. CONCLUSIONS: There may be a case for including a measure of chronic ill health in the new NHS system of capitated finance in addition to the all cause standardised mortality ratio which is used currently as a measure of need for health care.
Chronic Disease↗
Improving the health and health behaviors of women aging with physical disabilities: A peer-led health promotion program.
OBJECTIVE: To examine the efficacy of a health promotion program for women aging with physical disabilities. METHOD: A sample of 137 middle-aged and older women with physical disabilities was randomly assigned to either an 8-week health promotion program or to a wait-list control group. Both groups completed questionnaires before, immediately after, and 3 months after the intervention. RESULTS: Relative to women in the control group, women in the health-promotion program demonstrated improvements in health behaviors, most of which were maintained at follow-up. The intervention group showed some improvements on measures of physical health, but there was little evidence of improvement in psychological health outcomes. Testing our theoretical model, self-efficacy was supported as a mediator of the effect of the intervention on health behaviors, and health behaviors combined with self-efficacy were supported as mediators of the effect of the intervention on physical health outcomes. Contrary to our hypotheses, our measures of social support and social connectedness were not affected by the intervention. CONCLUSIONS: A brief, peer-led, group health promotion program resulted in improved scores on measures of self-efficacy, increased health behavior, and physical health. Self-efficacy, which was supported as a mediator in the effect of the intervention on behaviors and health outcomes, should remain an important focus of future interventions with this population.
Aged↗
Wealth, equity and health care: a critique of a "population health" perspective on the determinants of health. Critical Social Science Group.
In this paper we examine the recent ascendancy of a "population health" perspective on the "determinants of health" in health policy circles as conceptualized by health economists and social epidemiologists such as Evans and Stoddart [Evans and Stoddart (1990) Producing health, consuming health care. Social Science & Medicine 31(12), 1347 1363]. Their view, that the financing of health care systems may actually be deleterious for the health status of populations by drawing attention away from the (economic) determinants of health, has arguably become the "core" of the discourse of "population health". While applauding the efforts of these and other members of the Canadian Institute for Advanced Research for "pushing the envelope", we nevertheless have misgivings about their conceptualization of both the "problem" and its "solutions", as well as about the implications of their perspective for policy. From our critique, we build an alternative point of view based on a political economy perspective. We point out that Evans and Stoddart's evidence is open to alternative interpretations--and, in fact, that their conclusions regarding the importance of wealth creation do not directly reflect the evidence presented, and are indicative of an oversimplified link between wealth and health. Their view also lacks an explicit substantive theory of society and of social change, and provides convenient cover for those who wish to dismantle the welfare state in the name of deficit reduction. Our alternative to the "provider dominance" theory of Evans and Stoddart and colleagues stresses that the factors or forces producing health status, which Evans and Stoddart describe, are contained within a larger whole (advanced industrial capitalism) which gives the parts their character and shapes their interrelationships. We contend that this alternative view better explains both how we arrived at a situation in which health care systems are as costly or extensive as they are, and suggests different policy avenues to those enunciated by Evans, Stoddart and their confrères.
Canada↗
Health-related worries, perceived health status, and health care utilization.
This study examines the association of health-related worries (over cancers, diabetes, work-related stress, heart attack, obesity, general physical fitness, and/or other health conditions) and perceived health status (excellent, good, fair or poor) to the utilization of health care services for 19, 139 Japanese local public service employees. Data on health-related worries and health status were obtained from a self-administered questionnaire survey in 1988 and analyzed in relation to the subsequent 12-month utilization of health care. Results showed that perceived health status was associated with the utilization for almost all medical conditions and so was worry over a specific condition and the subsequent utilization of health care services. The implication of these findings is that measures targeting the relief of an employee's health-related worries, through either health consultation or other health programs, may contribute to the reduction of an employee's health care utilization and costs.
Adult↗
Both clinical epidemiology and population health perspectives can define the role of health care in reducing health disparities.
OBJECTIVE: To compare and contrast clinical epidemiology and population health perspectives on the role of health care in reducing socioeconomic disparities in health. STUDY DESIGN AND SETTING: A review of concepts outlined in selected articles on population health and clinical epidemiology and a systematic literature search for randomized controlled trials (RCTs) of therapeutic interventions for cardiovascular disease that contained analysis of outcomes by socioeconomic status. RESULTS: Population health has a focus on health disparities, particularly disparities related to socioeconomic status, and many of its proponents have a pessimistic view of the degree to which health care can reduce these disparities. Clinical epidemiology has a focus on the production of valid evidence on the impact of health care interventions; however, RCTs rarely report the impact of interventions across socioeconomic strata. Both population health and clinical epidemiology share the view that efficacy, effectiveness, and cost-effectiveness are all important in defining the impact of health care on health disparities. CONCLUSION: Principles drawn from both population health and clinical epidemiology could be used to provide a clearer picture of the role that health care interventions can have on socioeconomic disparities in health and to identify implications for policy, research, and clinical practice.
Epidemiologic Methods↗
Health promotion and partnerships: collaboration of a community health management center, county health bureau, and university nursing program.
Effective partnerships were established between a community health management center, a county health bureau and a university nursing program. A health fair was undertaken to heighten public health awareness through the collaboration of these various agencies. In this research, formative, process, and summative evaluations were conducted to determine the benefits of partnerships. Elements evaluated included the planning process, health fair relevancy, integration of community resources, participants satisfaction and knowledge acquisition, and partnership satisfaction. The samples of this study included (1) 529 adult participants who completed the on-site evaluation questionnaires; (2) 1,090 child participants who returned gift-reward cards; (3) 114 partners who gave written feedback on their satisfaction; and (4) 57 third-year and 16 fourth-year undergraduate nursing student participants. Data was collected from the evidence report of the Department of Health, the project proposal, activity protocols, meeting records, the project final report, students term papers, and questionnaires. The chief administrator of the County Health Bureau was very impressed with the creative exhibits in the fair and, therefore, invited a coalition to continue further workshops. Seventeen educational exhibits, two dance programs and two drama programs related to health issues were demonstrated in the fair. Resources from community organizations were successfully integrated and allocated. Community participants expressed satisfaction with the fair and anticipated similar activities in the future. Participants revealed more than 80% accuracy in health knowledge quizzes. The senior nursing students highlighted their interaction with the community, community health nurses, and health volunteers. Community-based health promotion and nursing education can be successfully connected when various disciplines and sectors form effective partnerships.
Adult↗
A longitudinal study of the effects of tobacco smoking and other modifiable risk factors on ill health in middle-aged and old Americans: results from the Health and Retirement Study and Asset and Health Dynamics among the Oldest Old survey.
BACKGROUND: While the effects of smoking and other modifiable risk factors on mortality and specific diseases are well established, their effects on ill health more generally are less known. Using two national, longitudinal surveys, the objective of this study was to analyze the effect of smoking and other modifiable risk factors on ill health, defined in a multidimensional fashion (i.e., disability, impaired mobility, health care utilization, and self-reported health). METHODS: The analyses were based on the Health and Retirement Study (HRS) (12,652 persons 50-60 years old surveyed in 1992, 1994, 1996, and 1998) and the Asset and Health Dynamics among the Oldest Old survey (8,124 persons 60-70 years old surveyed in 1993, 1996, and 1998). RESULTS: Smoking was strongly related to mortality and to ill health, with similar relative effects in the middle-aged and the elderly. There were consistent adverse dose-response relationships between smoking and ill health in the HRS. Persons who had quit smoking at least 15 years prior to the survey were no more likely than never smokers to experience ill health. A dose-response relationship was found between exercise and ill health. For body mass index and alcohol, there were U-shaped relationships with ill health. CONCLUSIONS: Public health efforts designed to encourage smoking cessation should emphasize improvements in ill health in addition to decreased mortality.
Age Distribution↗
Social capital, trust in the health-care system and self-rated health: the role of access to health care in a population-based study.
This paper investigates the relationship between institutional trust in the health-care system, i.e. an institutional aspect of social capital, and self-rated health, and whether the strength of this association is affected by access to health-care services. The 2004 public health survey in the Scania region of Sweden is a cross-sectional study; a total of 27,963 respondents aged 18-80 years answered a postal questionnaire, which represents 59% of the random sample. Logistic regression model was used to investigate the association between institutional trust and self-rated health. Multivariate analyses of self-rated health were performed in order to investigate the importance of possible confounders (age, country of origin, education, economic stress, generalized trust in other people, and care-seeking behaviour) on this association. A 28.7% proportion of the men and 33.2% of the women reported poor self-rated health. A total of 15.0% and 58.3% of the respondents reported "very high" and "rather high" trust in the health-care system, respectively. Almost one-third of all respondents reported low institutional trust. Respondents born outside Sweden, with low/medium education, low generalized trust and low institutional trust had significantly higher odds ratios of poor self-rated health. Multiple adjustments for age, country of origin, education, economic stress, and horizontal trust had some effect on the significant relationship between institutional trust and poor self-rated health, for both men and women, but the additional introduction of care-seeking behaviour in the model substantially reduced the odds ratios. In conclusion, low trust in the health-care system is associated with poor self-rated health. This association may be partly mediated by "not seeking health care when needed". However, this is a cross-sectional exploratory study and the causality may go in both directions.
Adolescent↗
Health promotion in different medical settings: women's health, community health and private practice.
This paper describes the health promotion role of doctors in two medical practice settings: women's and community health centres, and fee-for-service practice. It proposes the establishment of divisions of primary health care in Australia which would be multi-disciplinary and focus on community-wide health issues. The paper is based on data from an interview survey of medical practitioners who had worked in metropolitan Adelaide women's and community health centres and from a questionnaire survey of GPs in private practice. The types of health promotion activity by the doctors in the different settings are discussed. It is concluded that private practice GPs are involved primarily in providing health education advice to individual patients. Doctors within women's and community health centres are more likely to report involvement in group health promotion activity and broader community development initiatives. The study concludes that health promotion which focuses on the health of the local community is best conducted within multidisciplinary health centres. GPs in private practice are limited by the structure of their setting (particularly the fee-for-service basis and reliance on a single discipline) to health promotion which focuses on the needs of individual patients.
Attitude of Health Personnel↗
Perspectives on the place of environmental health and protection in public health and public health agencies.
The field of environmental health and protection and the entire field of public health have repeatedly found themselves isolated from one another, unable to articulate the definition, mission, and goals of public health and the essential role for environmental health and protection in the provision of a healthy ecological and human environment. Environmental agencies often forget that they, too, are public health agencies; public health agencies that have had environmental health functions have divided and abdicated their environmental responsibilities, considering these to be "regulatory" rather than public health. This article reviews the history of environmental health and protection, its involvement within the field of public health, its eventual separation from other public health programs with resulting benefits and consequences, and what the future may hold for environmental health and protection activities as well as for the broader scope of public health of which these activities are a part.
Association↗
Adolescent health, school health activities, community contexts, and health surveys in Sweden.
School health activities have been very important in improving adolescent health in Sweden for almost 200 years. In the 1800s, emphasis was on medical services. Vaccination programs and medical examinations became the key issues. Deterioration of adolescent health in the 1960s changed the objectives of both school education and health services to health promotion. Important members of the community followed suit and involvement of the local community has remained a hallmark, even though the extent and direction varies. The subsequent period was characterized by substantial improvement in adolescent health behavior. The latter years of the 1980s and the 1990s saw deterioration of adolescent health behavior. Less emphasis on health promotion, decentralization of school health responsibility from physicians to administrators, and heavy savings directed toward schools were important mediators. Adolescents were also more engaged in international youth cultures with liberal practices, such as drug use. Community surveys of adolescent health behaviors have proven to be important in mobilizing broad local involvement in adolescent health promotion. The lesson learned is that health promotion has to involve as many community members as possible. Coordinating resources and having unified objectives is cost efficient
Adolescent↗