Examining Whether The Health-In-All-Policies Approach Promotes Health Equity

Investigating the Role of Local Board of Health Governance on Local Health Department Policymaking Behavior

OBJECTIVES

This study sought to identify groupings of policymaking behavior among local governmental health departments (LHDs) across the country and assess whether such groupings were associated with the governance activity of their board of health (BOH).

DESIGN

We conducted latent class analysis (LCA) to identify possible classes of policymaking behavior among LHDs. Once classes were identified, we used multinomial logistic regression (MLN) to estimate the association between an LHD's policymaking behavior and the governance activity of their BOH.

SETTING

2019 wave of the National Association of City and County Health Officials (NACCHO) Profile Survey.

PARTICIPANTS

All LHDs with BOHs in the 2019 NACCHO Profile Survey (n = 1003).

OUTCOME MEASURES

Within our MLN, our primary outcome of interest was the association between an LHD's policymaking class (the main dependent variable) and the governance activity of its BOH (the main independent variable).

RESULTS

Based on our LCA, we determined our sample to be composed of what we characterized as "Limited Policy-Involvement," "Average Policy Involvement," and "Expanded Policy Involvement" LHDs. Those in the Expanded Class were more likely to be involved across all policy areas compared to the Limited and Average class, especially among social determinants of health (SDOH)-related areas. Our MLN estimated that having a BOH active in legal authority was associated with an 86% increased chance that an LHD would be in the "Average Class" compared to the "Limited Class" and having a BOH active in partnership engagement was associated with an 86% more likely chance that an LHD is in the "Expanded Class" compared to the "Average Class."

CONCLUSION

Using nationally representative data on LHD activity, we found distinct groups of policymaking behavior, including a quarter of LHDs that are highly active in traditional and SDOH-related policy areas. We also found that groupings of policymaking behavior, as indicated by class designation, are strongly associated with the BOH's governance activity.

Economic Determinants of Health Disparities and the Role of the Primary Care Provider

The economic determinants of adverse personal health outcomes and population level disparities pose a daunting challenge for primary care providers in promoting health for persons experiencing poverty and neighborhood deprivation. Until they are addressed, however, the health and economic well-being of persons experiencing neighborhood deprivation is not likely to be improved. There is growing evidence of effective interventions that primary care providers can adopt to address social and economic determinants of health. Primary care providers can participate in clinic and community-based approaches that target individual, neighborhood and social level drives of health and disparities.

An action research partnership in an urban Texas county to explore barriers and opportunities for collaborative community health needs assessments

Background

The Affordable Care Act mandated triennial community health needs assessments (CHNAs) for greater nonprofit hospital accountability in responding to community health needs. Over 10 years later, hospital spending on community benefits remains largely unchanged. While greater collaboration in CHNA implementation can increase hospital investment in community-based initiatives, nonprofit hospitals in conservative states are subject to policy, political, and economic factors that inhibit public health partnerships and magnify existing disparities in health care access. This participatory action research study explores the decision-making environment of collaborative CHNA implementation within a group of nonprofit hospitals in a north Texas urban county.

Methods

In 2017 faculty from an urban anchor institution initiated an academic-community partnership with a coalition of nonprofit hospitals, public health departments, and academic institutions. An interdisciplinary research team engaged in multi-method document review and qualitative data collection to describe historical barriers for local CHNA processes and develop practical strategies for joint CHNA initiatives. Local CHNA documents were first reviewed through team-based content analysis and results applied to develop a qualitative study protocol. Key informants were recruited from county-based nonprofit hospitals, community-based nonprofit organizations, and public health systems. Seventeen senior- and mid-level professionals participated in semi-structured research interviews to describe their perspectives relating to CHNA-related planning and implementation decisions. Through iterative data collection and analysis, the research team explored CHNA-related knowledge, experiences, and processes. A constructivist lens was subsequently applied to examine historical barriers and future opportunities for local collaboration.

Results

Findings reveal CHNA implementation is a multi-stage cyclical process in organizational environments with accountability to a wide range of public and private stakeholders. This promotes varied levels of inclusivity and conservatism in data collection and community benefit implementation. Decisions to collaborate are hindered by competing priorities, including compliance with existing guidelines, administrative simplicity, alignment with health care service delivery, and efficient resource use. Efforts to promote greater CHNA collaboration may be facilitated through intentional alignment with organizational priorities and clearly communicated benefits of participation for leaders in both public and private nonprofit health systems.

Discussion

We consider implications for policymakers and health systems in restrictive political environments and advance a conceptual framework for greater CHNA collaboration.

Perspectives from gambling expert stakeholders in relation to electronic gaming machines in New Zealand

Electronic gaming machines (EGMs) are one of the most addictive and harmful forms of gambling. Gaming machine characteristics, easy accessibility of EGMs and normalisation of gambling behaviour have exacerbated these effects. We conducted a pilot study investigating the perspectives of gambling expert stakeholders on gambling harm and effective harm-minimisation policies regarding EGMs. In-depth individual interviews were undertaken with 14 health professionals working in the addiction sector, academics in the field of gambling and individuals from a range of government and non-government organisations who have an impact on gambling policy making in New Zealand. Five major themes were identified: the need to shift focus from problematic people to the problematic product, the need for a holistic approach to gambling intervention, focus on creating an empowered population, and improving protective factors and refining public health initiatives to gambling harm. The results suggest the need to challenge current narratives of EGM-related gambling harm and have wide-ranging implications for EGM harm minimisation and health promotion policies.

Adaptive Neuroplasticity in Brain Injury Recovery: Strategies and Insights

This review addresses the relationship between neuroplasticity and recovery from brain damage. Neuroplasticity's ability to adapt becomes crucial since brain injuries frequently result in severe impairments. We begin by describing the fundamentals of neuroplasticity and how it relates to rehabilitation. Examining different forms of brain injuries and their neurological effects highlights the complex difficulties in rehabilitation. By revealing cellular processes, we shed light on synaptic adaptability following damage. Our study of synaptic plasticity digs into axonal sprouting, dendritic remodeling, and the balance of long-term potentiation. These processes depict neural resilience amid change. Then, after damage, we investigate immediate and slow neuroplastic alterations, separating reorganizations that are adaptive from those that are maladaptive. As we go on to rehabilitation, we evaluate techniques that use neuroplasticity's potential. These methods take advantage of the brain's plasticity for healing, from virtual reality and brain-computer interfaces to constraint-induced movement therapy. Ethics and individualized neurorehabilitation are explored. We scrutinize the promise of combination therapy and the difficulties in putting new knowledge into clinical practice. In conclusion, this analysis highlights neuroplasticity's critical role in brain injury recovery, providing sophisticated approaches to improve life after damage.

Environmental Justice: Where It Has Been, and Where It Might Be Going

Taking stock of environmental justice (EJ) is daunting. It is at once a scholarly field, an ongoing social movement, and an administrative imperative adopted by government agencies and incorporated into legislation. Moreover, within academia, it is multidisciplinary and multimethodological, comprising scholars who do not always speak to one another. Any review of EJ is thus necessarily restrictive. This article explores several facets of EJ activism. One is its coalitional and "inside-outside" orientation. EJ activists are constantly forming alliances with other stakeholders, but these coalitions do not flout the importance of engaging with formal institutions. The review next turns to one set of such institutions-the courts and regulatory agencies-to see how well EJ claims have fared there. I then survey scientific findings that have been influenced by EJ. The review concludes with future directions for activists and scholars to consider: the changing nature of EJ coalitions, fragmentation within EJ and with other fields, the historical roots of environmental injustice, and opportunities for stronger infusion of the EJ lens.

Social prescription in the US: A pilot evaluation of Mass Cultural Council's "CultureRx"

Introduction

As the field of public health strives to address the impacts of social determinants of health, it has seen increasing interest in community-referral practices that expand health care beyond clinical spaces. However, community arts and culture organizations are rarely included in these practices, despite accumulating evidence of associated health benefits. In addition, such inclusion has not been formally studied. In response, this article offers an evaluation of "CultureRx" in Massachusetts (MA): the first US model of arts on prescription. The program is a partnership between 20 healthcare providers and 12 cultural organizations, in which providers can offer "prescriptions" to cultural experiences to support patients' health.

Methods

Evaluation was undertaken to illuminate participant experiences, program successes and barriers, and recommendations for further development. The cultural organizations collected participant data (n = 84) and completed surveys about their own experiences (n = 12). Authors conducted semi-structured focus groups and interviews with healthcare providers (n = 33). Data analysis was customized for each dataset.

Results

Findings indicate that participants enjoyed and hoped to repeat their prescribed experiences, which they saw as beneficial to wellbeing. Providers identified the program as a new and critical addition to their toolkits; they also indicated it had a positive effect on their own wellbeing. Cultural organizations reported varied challenges, learnings, and recommendations.

Conclusion

The CultureRx pilot suggests that integrating arts/culture assets into health and social care approaches can enrich and improve traditional US models of community referral. By including arts/culture resources when addressing social determinants of health, communities will be better positioned to equitably and holistically advance health.

How to Evaluate Health in All Policies at the Local Level: Methodological Insights Within Municipalities From the WHO French Healthy Cities Network

BACKGROUND

This article proposes a method for analysing the degree of maturity of Health in All Policies (HiAP) among World Health Organization-French Healthy Cities Network (WHO-FHCN) as part of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project. We focused on the creation or enhancement of health-promoting environments, and more specifically, public green spaces.

METHODS

We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a multiple correspondence analysis (MCA) and a hierarchical ascending classification (HAC).

RESULTS

Thirty-two criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies/actions of the sector studied, (2) occasional intersectoral collaboration, ie, one-off initiatives between the health department and others sectors, (3) the existence of joint projects, ie, common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.

CONCLUSION

Four dimensions which allow to the measurement of the degree of progress in implementing health-all-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.

Promoting children's sleep health: Intervention Mapping meets Health in All Policies

Background

To design a comprehensive approach to promote children's sleep health in Amsterdam, the Netherlands, we combined Intervention Mapping (IM) with the Health in All Policies (HiAP) perspective. We aimed to create an approach that fits local infrastructures and policy domains across sectors.

Methods

First, a needs assessment was conducted, including a systematic review, two concept mapping studies, and one cross-sectional sleep diary study (IM step 1). Subsequently, semi-structured interviews with stakeholders from policy, practice and science provided information on potential assets from all relevant social policy sectors to take into account in the program design (HiAP and IM step 1). Next, program outcomes and objectives were specified (IM step 2), with specific objectives for policy stakeholders (HiAP). This was followed by the program design (IM step 3), where potential program actions were adapted to local policy sectors and stakeholders (HiAP). Lastly, program production (IM step 4) focused on creating a multi-sector program (HiAP). An advisory panel guided the research team by providing tailored advice during all steps throughout the project.

Results

A blueprint was created for program development to promote children's sleep health, including a logic model of the problem, a logic model of change, an overview of the existing organizational structure of local policy and practice assets, and an overview of policy sectors, and related objectives and opportunities for promoting children's sleep health across these policy sectors. Furthermore, the program production resulted in a policy brief for the local government.

Conclusions

Combining IM and HiAP proved valuable for designing a blueprint for the development of an integrated multi-sector program to promote children's sleep health. Health promotion professionals focusing on other (health) behaviors can use the blueprint to develop health promotion programs that fit the local public service infrastructures, culture, and incorporate relevant policy sectors outside the public health domain.

From Health in All Policies to Health for All Policies

Worldwide responses to the COVID-19 pandemic have shown that it is possible for politicians to come together across departmental boundaries. To this end, in many countries, heads of government and their health ministers work closely with all other ministries, departments, and sectors, including social affairs, internal affairs, foreign affairs, research and education, transport, agriculture, business, and state aid. In this Viewpoint, we ask if and how the Sustainable Development Goals (SDGs) can support intersectoral collaboration to promote health, since governments have already committed to achieving them. We contend that SDGs can do so, ultimately advancing health while offering co-benefits across society.

What Is a "Racial Health Disparity"? Five Analytic Traditions

What exactly is a "racial health disparity"? This article explores five lenses that have been used to answer that question. It contends that racial health disparities have been presented-by researchers both within academia and outside of it-as problems of five varieties: biology, behavior, place, stress, and policy. It also argues that a sixth tradition exploring class-and its connection to race, racism, and health-has been underdeveloped. The author examines each of these conceptions of racial disparities in turn. Baked into each interpretive prism is a set of assumptions about the mechanisms that produce disparities-a story, in other words, about where racial health disparities come from. Discursive boundaries set the parameters for policy debate, determining what is and is not included in proposed solutions. How one sees racial health disparities, then, influences the strategies a society advocates-or ignores-for their elimination. The author ends by briefly discussing problems in the larger research ecosystem that dictate how racial health disparities are studied.

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

Organisations spanning social services, public health and healthcare have increasingly experimented with collaboration as a tool for improving population health and reducing health disparities. While there has been progress, the results have fallen short of expectations. Reflecting on these shortcomings, the Robert Wood Johnson Foundation (RWJF) recently proposed a new framework for cross-sector alignment intended to move the field towards improved outcomes. A central idea in this framework is that collaboratives will be more effective and sustainable if they develop collaborative systems in four core areas: shared purpose, governance, finance and shared data. The goal of this paper is to provide a foundation for research on the four core areas of the cross-sector alignment framework. Accordingly, this study is based on two guiding questions: (1) how are collaboratives currently implementing systems in the four core areas identified in the framework, and (2) what strategies does the literature offer for creating sustainable systems in these four areas? Given the emergent nature of research on health-oriented cross-sector collaboration and the broad research questions, we conducted a systematic scoping review including 179 relevant research papers and reports published internationally from the years 2010-2020. We identified the main contributions and coded each based on its relevance to the cross-sector alignment framework. We found that most papers focused on programme evaluations rather than theory testing, and while many strategies were offered, they tended to reflect a focus on short-term collaboration. The results also demonstrate that starting points and resource levels vary widely across individuals and organisations involved in collaborations. Accordingly, identifying and comparing distinct pathways by which different parties might pursue cross-sector alignment is an imperative for future work. More broadly, the literature is ripe with observations that could be assessed systematically to produce a firm foundation for research and practice.

Trends in Health Equity Among Children in the United States, 1997-2018

OBJECTIVES

Health equity is crucial to population health. To achieve this aim, extensive monitoring efforts beyond traditional disparities research are required. This analysis assesses trends in health equity for children from 1997 to 2018.

METHODS

Health equity in a given year is calculated using a previously developed measure as the mean weighted departure of individual health from the best achievable level of health. This criterion is defined as the median health of the most socially privileged identifiable group: white, non-Latinx boys in upper-income households. Using more than 20 years of data from the National Health Interview Survey, we apply this methodology to six measures of child health: parent-reported health status, school days missed due to illness or injury in the past year, a strength and difficulties questionnaire score, emotional difficulties, a toddler mental health indicator score, and toddler depression. We separately calculate racial/ethnic and income disparities. Monte Carlo simulation is used to assess whether trends are statistically significant.

RESULTS

Health equity among children increased gradually over the past 2 decades, with five of the six measures demonstrating upward trends. Improvements in health equity are stronger among younger children (age 0-3 and 4-7). Unlike previous work examining adults, both types of disparities narrowed over the study period.

CONCLUSIONS FOR PRACTICE

Progress on health equity requires accountability to an objective metric. This analysis suggests some improvement over the past two decades, although these gains are under threat from potential decreases in government spending on programs affecting children and the COVID-19 pandemic.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

A Mixed-methods Study to Understand Food Environments and Grocery Shopping Patterns of Community Residents in Underserved Neighborhoods in Tampa, Florida

A mixed methods study was conducted to better understand food access, food retail store environment, and perspectives of community residents on their grocery store shopping patterns and access to healthy foods in underserved, predominantly African American neighborhoods. GIS mapping, grocery store observations (n = 4), a food access and grocery store environment survey (n = 126), and focus groups (n = 48) were used. The results indicate that these neighborhoods have a low density of grocery stores, and only two out of four grocery stores meet the standard for a healthy retail store. Barriers to getting healthy foods and solutions to improve food access are discussed.

Policy Implementation Science to Advance Population Health: The Potential for Learning Health Policy Systems

Many health policies are designed with the intention of improving health outcomes for all. Yet implementation of policies are variable across contexts, potentially limiting its impact on population health outcomes. The potential impact of a policy to advance health equity depends both on the design and its implementation, requiring ongoing evaluation and stakeholder engagement. Despite the importance of health policies in shaping public health, health care policy implementation science remains underrepresented in research. We argue that enhanced integration of policy questions within implementation science could reduce the time lag from policy to practice and improve population health outcomes to build a body of evidence on effective policy implementation. In this commentary, we argue that approaches to studying policy implementation science should reflect the dynamic and evolving policy context, analogous to the “learning healthcare system,” to better understand and respond to systematic and multilevel impacts of policy. Several example opportunities for a learning health policy system are posed in building a broader agenda toward research and practice in policy implementation science in public health.

A Qualitative Study of Health in All Policies at the Local Level

Health in All Policies (HiAP) encourage health-conscious policymaking in non-health sectors; however, there are no standardized measures or guides for assessing progress in HiAP implementation. The purpose of this study was to describe how HiAP in local public health agencies (LPHAs) are implemented at the local level in Colorado and identify challenges and opportunities for implementation. We conducted semi-structured interviews with 13 key informants identified through purposive sampling. Interviews were recorded, double-coded, and analyzed using thematic analysis. The themes we identified relating to the implementation of different HiAP approaches were as follows: the importance of building trusting relationships, a need to understand the work of LPHAs and public health, and LPHA structure and role clarity. Tools and tactics that respondents identified in their implementation and practice of HiAP are sharing data and data platforms, community dashboarding, providing services to partners, sharing programs or services, attending meetings regularly, and measurement instruments. This study demonstrates HiAP approach variation and the need for a state-wide standardized framework for initiatives and progress. Future HiAP implementation research should focus on county-level analysis using outcomes that LPHAs are targeting based on their health priorities and should also capture the activities of sectors outside of public health.

Building Back Better: Local Health Department Engagement and Integration of Health Promotion into Hurricane Harvey Recovery Planning and Implementation

Disaster recovery provides an opportunity to build healthier and more resilient communities. However, opportunities and challenges encountered by local health departments (LHDs) when integrating health considerations into recovery have yet to be explored. Following Hurricane Harvey, 17 local health and emergency management officials from 10 agencies in impacted Texas, USA jurisdictions were interviewed to describe the types and level of LHD engagement in disaster recovery planning and implementation and the extent to which communities leveraged recovery to build healthier, more resilient communities. Interviews were conducted between December 2017 and January 2018 and focused on if and how their communities were incorporating public health considerations into the visioning, planning, implementation, and assessment phases of disaster recovery. Using a combined inductive and deductive approach, we thematically analyzed interview notes and/or transcripts. LHDs reported varied levels of engagement and participation in activities to support their community’s recovery. However, we found that LHDs rarely articulated or informed decision makers about the health impacts of recovery activities undertaken by other sectors. LHDs would benefit from additional resources, support, and technical assistance designed to facilitate working across sectors and building resilience during recovery.