A vision of social justice as the foundation of public health: commemorating 150 years of the spirit of 1848

Finding meaning: a realist-informed perspective on social risk screening and relationships as mechanisms of change

Background

Social risk screening rates in many US primary care settings remain low. This realist-informed evaluation explored the mechanisms through which a tailored coaching and technical training intervention impacted social risk screening uptake in 26 community clinics across the United States.

Methods

Evaluation data sources included the documented content of interactions between the clinics and implementation support team and electronic health record (EHR) data. Following the realist approach, analysis was composed of iterative cycles of developing, testing and refining program theories about how the intervention did-or didn't-work, for whom, under what circumstances. Normalization Process Theory was applied to the realist program theories to enhance the explanatory power and transferability of the results.

Results

Analysis identified three overarching realist program theories. First, clinic staff perceptions about the role of standardized social risk screening in person-centered care-considered "good" care and highly valued-strongly impacted receptivity to the intervention. Second, the physicality of the intervention materials facilitated collaboration and impacted clinic leaders' perception of the legitimacy of the social risk screening implementation work. Third, positive relationships between the implementation support team members, between the support team and clinic champions, and between clinic champions and staff motivated and inspired clinic staff to engage with the intervention and to tailor workflows to their settings' needs. Study clinics did not always exhibit the social risk screening patterns anticipated by the program theories due to discrepant definitions of success between clinic staff (improved ability to provide contextualized, person-centered care) and the trial (increased rates of EHR-documented social risk screening). Aligning the realist program theories with Normalization Process Theory constructs clarified that the intervention as implemented emphasized preparation over operationalization and appraisal, providing insight into why the intervention did not successfully embed sustained systematic social risk screening in participating clinics.

Conclusion

The realist program theories highlighted the effectiveness and importance of intervention components and implementation strategies that support trusting relationships as mechanisms of change. This may be particularly important in social determinants of health work, which requires commitment and humility from health care providers and vulnerability on the part of patients.

Patients' Willingness to Accept Social Needs Navigation After In-Person versus Remote Screening

BACKGROUND

Social needs screening and referral interventions are increasingly common in health care settings. Although remote screening offers a potentially more practical alternative to traditional in-person screening, there is concern that screening patients remotely could adversely affect patient engagement, including interest in accepting social needs navigation.

METHODS

We conducted a cross-sectional study using a multivariable logistic regression analysis and data from the Accountable Health Communities (AHC) model in Oregon. Participants were Medicare and Medicaid beneficiaries in the AHC model from October 2018 through December 2020. The outcome variable was patients' willingness to accept social needs navigation assistance. We included an interaction term (total number of social needs + screening mode) to test whether in-person versus remote screening was an effect modifier.

RESULTS

The study included participants who screened positive for ≥1 social need(s); 43% were screened in person and 57% remotely. Overall, 71% of participants were willing to accept help with social needs. Neither screening mode nor interaction term were significantly associated with willingness to accept navigation assistance.

CONCLUSIONS

Among patients presenting with similar numbers of social needs, results indicate that type of screening mode may not adversely affect patients' willingness to accept health care-based navigation for social needs.

The Faculty of Public Health: past, present and future

This year we celebrate 50 years of the UK Faculty of Public Health (FPH). This commentary serves as a reflection on the history of the FPH, considering the origins of public health in the UK and the role of the FPH in shaping public health practice and policy. The genesis and evolution of the FPH are discussed, drawing upon reflections from past presidents and the wider literature. Historical shifts in the identity and roles of public health practitioners are also explored in the context of an increasingly complex and dynamic health and social care system. Key changes in public health practice are described, including the development of a multidisciplinary public health workforce and an increased focus on health inequalities over recent decades. Building upon this is a discussion of the current purpose of the FPH and perspectives on the future of the FPH amidst a changing public health landscape.

"It Made Me Feel like Things Are Starting to Change in Society:" A Qualitative Study to Foster Positive Patient Experiences during Phone-Based Social Needs Interventions

Many healthcare organizations are screening patients for health-related social needs (HRSN) to improve healthcare quality and outcomes. Due to both the COVID-19 pandemic and limited time during clinical visits, much of this screening is now happening by phone. To promote healing and avoid harm, it is vital to understand patient experiences and recommendations regarding these activities. We conducted a pragmatic qualitative study with patients who had participated in a HRSN intervention. We applied maximum variation sampling, completed recruitment and interviews by phone, and carried out an inductive reflexive thematic analysis. From August to November 2021 we interviewed 34 patients, developed 6 themes, and used these themes to create a framework for generating positive patient experiences during phone-based HRSN interventions. First, we found patients were likely to have initial skepticism or reservations about the intervention. Second, we identified 4 positive intervention components regarding patient experience: transparency and respect for patient autonomy; kind demeanor; genuine intention to help; and attentiveness and responsiveness to patients' situations. Finally, we found patients could be left with feelings of appreciation or hope, regardless of whether they connected with HRSN resources. Healthcare organizations can incorporate our framework into trainings for team members carrying out phone-based HRSN interventions.

Solidarity and Public Health

We argue that an unqualified use of the term solidarity in public health is not only equivocal but problematic toward the ends of public health. The term may be deployed normatively by public health advocates to strengthen the bonds among public health practitioners and refer to an ideal society in which the importance of interdependence among members ought to be acknowledged throughout the polity. We propose an important distinction between partisan solidarity and societal solidarity. Because any moralized belief in a vision of a broad societal solidarity will be a contested political ideal, political reality would limit solidarity based on such a vision to partisan solidarity. An idealized vision of societal solidarity is simply not politically feasible in pluralistic, liberal, democratic societies. However, although societal solidarity is unlikely with respect to any particular policy, it might be hoped for with respect to constitutional procedures that provide boundaries for the agon of the political process. We suggest that moralizing assertions of a solidaristic ideal in a pluralistic society might be counterproductive to generating the political support necessary for public health per se and establishing legitimate public health policy. A pragmatic political approach would be for public health advocates to generate sufficient strong political support for those public health policies that are most amenable to the political and social realities of a time and place.

Social Needs Resource Connections: A Systematic Review of Barriers, Facilitators, and Evaluation

INTRODUCTION

Healthcare organizations increasingly are screening patients for social needs (e.g., food, housing) and referring them to community resources. This systematic mixed studies review assesses how studies evaluate social needs resource connections and identifies patient- and caregiver-reported factors that may inhibit or facilitate resource connections.

METHODS

Investigators searched PubMed and CINAHL for articles published from October 2015 to December 2020 and used dual review to determine inclusion based on a priori selection criteria. Data related to study design, setting, population of interest, intervention, and outcomes were abstracted. Articles' quality was assessed using the Mixed Methods Appraisal Tool. Data analysis was conducted in 2021.

RESULTS

The search identified 34 articles from 32 studies. The authors created a taxonomy of quantitative resource connection measures with 4 categories: whether participants made contact with resources, received resources, had their social needs addressed, or rated some aspect of their experience with resources. Barriers to resource connections were inadequacy, irrelevancy, or restrictiveness; inaccessibility; fears surrounding stigma or discrimination; and factors related to staff training and resource information sharing. Facilitators were referrals' relevancy, the degree of support and simplicity embedded within the interventions, and interventions being comprehensive and inclusive.

DISCUSSION

This synthesis of barriers and facilitators indicates areas where healthcare organizations may have agency to improve the efficacy of social needs screening and referral interventions. The authors also recommend that resource connection measures be explicitly defined and focus on whether participants received new resources and whether their social needs were addressed.

Visualizing Health Equity: Qualitative Perspectives on the Value and Limits of Equity Images

BACKGROUND

Health educators and advocacy groups often use side-by-side visual images to communicate about equity and to distinguish it from equality. Despite the near-ubiquity of these images, little is known about how they are understood by different audiences.

AIMS

To assess the effectiveness of an image commonly used to communicate about health equity.

METHOD

In 167 interviews with health stakeholders in Greater Cleveland, Ohio, in 2018 to 2019, a commonly used health equity image was shown to participants, who were asked to interpret its meaning. Interviewees included 21 health professionals, 21 clinicians, 22 metro-wide decision makers, 24 community leaders, and 79 community members.

RESULTS

About two thirds of our socioeconomically, racial/ethnically, educationally, and professionally diverse sample said the equity image helped clarify the distinction between "equality" and "equity." Yet less than one third offered an interpretation consistent with the image's goals of foregrounding not only injustice but also a need for systemic change. Patterns of misinterpretation were especially common among two groups: ideological conservatives and those of lower socioeconomic status. Conservatives were most likely to object to the image's message.

CONCLUSIONS

Equity images are widely used by public health educators and advocates, yet they do not consistently communicate the message that achieving equity requires systemic change. In this moment of both public health crisis and urgent concern about systemic racism, new visual tools for communicating this crucial message are needed.

Training for mandated reporters of child abuse and neglect: Content analysis of state-sponsored curricula

BACKGROUND

Child abuse and neglect is a public health concern around the world, with well-established impacts and costs to children, families, and society. While mandated reporters make the majority of reports, child abuse is still under-reported and many mandated reporters fail to report known and suspected cases.

OBJECTIVE

This study was designed to evaluate the content of US state-sponsored online mandated reporter training in order to identify gaps and need for improvement in mandated reporter training.

METHODS

A deductive qualitative content analysis of the publicly available curricula was conducted. Variables coded were identified through a literature review and consultation with experts.

RESULTS

Numerous gaps were identified in the curricula including: few trainings identified reasons why reports should be made, only about one fourth included a definition, indicators, and examples of each type of maltreatment, the average number of suggestions for responding to a disclosure made by a child was 3, and few curricula addressed barriers to reporting or the impact of reporting on the reporter.

CONCLUSIONS

The trainings as a whole are not providing mandated reporters with comprehensive information about definitions, examples, and indicators of the major types of childhood maltreatment. In addition, the trainings contain only limited information to motivate reporters to see their role as part of a collective endeavor to protect children, and they are failing to adequately address reluctance about reporting. However, improvements are readily achievable. A partnership approach to curriculum design and delivery is recommended to develop effective training that will promote sound reporting.

Toward an Intersectional Approach to Health Justice

Despite unprecedented global wealth creation, health inequity-the unjust health inequality between classes and groups among and within countries-persists, reviving the relevance of social justice as a lens to understand and as an instrument to intervene in these issues. However, the theoretical aspects and polysemous character of social justice as applied in the field of public health are often assumed rather than explicitly explained. An intersectional justice approach to understanding health inequality, inequity, and injustice might be useful. It argues that preexisting class-, race/ethnicity-, and gender-based health injustice and the socially differentiated impacts of the COVID-19 pandemic are shaped, interconnectedly, by economic maldistribution, cultural misrecognition, and political misrepresentation. Pursuing health justice requires analyses, strategies, and interventions that integrate the economic, cultural, and political spheres of redistribution, recognition, and representation, respectively. Such an intersectional approach to health justice is even more relevant and compelling in light of the COVID-19 pandemic. This article is broadly about class, race/ethnicity, and gender political economy of public health-but with a narrower focus on maldistribution, misrecognition, and misrepresentation, shaping social and health injustices.

Naming racism in the public health classroom

OBJECTIVE

The discussion of racism within undergraduate public health classrooms can be highly influenced by local and national conversations about race. We explored the impact of local and national events on students' ability to name racism on a public health exam highlighting the impact of racism on maternal and infant health disparities for Black mothers.

METHODS

We undertook this research within the context of an undergraduate introductory public health course at a primarily white institution in the Northeastern part of the United States. A qualitative content analysis of undergraduate student responses to a final exam question soliciting the importance of racism to health outcomes among Black mothers in the United States was undertaken. ANOVA tests were run to assess differences on naming racism, using semantic alternatives, and providing alternative explanations during three main time periods: prior to the election of the 45th president of the United States (pre-Trump), after the election (post-Trump), and after a nationally recognized racist campus incident.

RESULTS

Between the pre- and post-Trump periods we see no differences in naming racism or providing alternative explanations. We do see a reduction in the proportion of students providing semantic alternatives for racism in the post-Trump period (32.2 vs. 25.2%, p = 0.034). After the racist campus incident, we see increases in the proportion of students naming race (53.6 vs. 73.8%, p = 0.021) and decreases in the proportion providing an alternative explanation (43.1 vs. 12.9%, p = 0.004), but no differences in the proportion of students who used semantic alternatives.

DISCUSSION

This work lends itself to our understanding of how local climate affects public health teaching and may also influence students' learning about important social and structural determinants of health. National and local climate should frame and guide public health teaching.

Being at the Bottom Rung of the Ladder in an Unequal Society: A Qualitative Analysis of Stories of People without a Home

Background: Homelessness is rising in the United Kingdom, despite investment in measures to eradicate it made by the government and charity organisations. Aim: The aim is to examine the stories of homeless people in order to document their perceptions of their social status, the reasons that led to their homelessness, and propose a conceptual explanation. Method: We conducted 26 semi-structured interviews in three centres for homeless people in Cheshire, North West of England. Results: Three categories-education, employment, and health-emerged from the data and provided a theoretical explanation for the reasons that led to their homelessness. These are vital not only for the successful negotiation of one's way out of homelessness, but also for achieving other social goods, including social connections, social mobility, and engaging in positive social relationships. Conclusion: Participants catalogued the adverse childhood experiences, which they believe limited their capacity to meaningfully engage with the social institution for social goods, such as education, social services, and institutions of employment. Since not all people who have misfortunes of poor education, poor health, and loss of job end up being homeless, we contend that a combination of these with multiple adverse childhood experiences may have weakened their resilience to traumatic life changes, such as loss of job and poor health.

Humanitarian migrant women's experiences of maternity care in Nordic countries: A systematic integrative review of qualitative research

BACKGROUND

Maternal morbidity and sub-optimal maternity care are more common in humanitarian migrants in comparison to country-born population in the Nordic countries. Statistical reviews on the issue are plenty, whereas little synthesis on humanitarian migrants' lived experiences exists.

AIM

This systematic integrative literature review investigated humanitarian migrant women's experiences on maternity care in Nordic countries, aiming to address possible hindrances for optimal care.

METHODS

Electronic search in PubMed, CINAHL, SocIndex, Scopus, PsycINFO and Web of Science yielded 474 papers. PICoS inclusion and exclusion criteria were used. Critical appraisal was conducted utilising 32-item COREQ tool. The findings of the review articles were synthesised through thematic analysis.

FINDINGS

Ten qualitative studies were included in the review. Altogether 198 women in Sweden, Norway and Finland had participated interviews or focus group discussions. Analysis of the women's reported experiences of care emerged three themes: Diminished negotiation power on care, Sense of insecurity, and Experienced care-related discrimination.

KEY CONCLUSION

Humanitarian migrant women's maternal morbidity and sub-optimal care has multiple potential explanations, and their experiences of care reflect those earlier reported.

IMPLICATIONS FOR PRACTICE

Recommendations for tackling the addressed hindrances are: (1) enabling humanitarian migrant women's negotiation power by acknowledging their vulnerability but also competency, (2) increasing the sense of security, and (3) improving care providers' cultural competence.

A taxonomy of duties to report child sexual abuse: Legal developments offer new ways to facilitate disclosure

BACKGROUND

Child sexual abuse is undisclosed for many reasons that are resistant to change. Citizens can play an important role in disclosing cases of child sexual abuse to authorities. Professionals who deal with children also play a crucial role. Office-holders in organisations have a clear responsibility to prevent cover-ups of sexual abuse. Recently, some countries have created important new legal duties for adults to disclose child sexual abuse.

OBJECTIVES

This article creates a contemporary taxonomy of duties to disclose cases of child sexual abuse, and explains their nature and justification.

PARTICIPANTS AND SETTING

Citizens, professionals dealing with children in the course of their work, and managers of child and youth-serving organisations.

METHODS

Legal analysis created a taxonomy of reporting duties. Analysis of these duties from perspectives of criminal jurisprudence, public health law, children's rights and ethics considered their justification.

RESULTS

Seven legal duties now exist, in criminal law, civil law and child protection law. Some apply to all citizens; others to managers in organisations; others to professionals dealing with children in the course of their work. All the duties are directed to early detection of cases; some are directed towards prevention; and some are focused on avoidance of institutional corruption.

CONCLUSIONS

These developments represent historic progress in overcoming normally intractable barriers to disclosure of cases of child sexual abuse. New legal duties are consistent with principles from criminal jurisprudence, public health law, children's rights and ethics. Where adopted, societies should ensure the creation and maintenance of ecological conditions in which these duties can be observed.

Cold War Legacy in Public and Private Health Spending in Europe

Cold War Era (1946-1991) was marked by the presence of two distinctively different economic systems, namely the free-market (The Western ones) and central-planned (The Eastern ones) economies. The main goal of this study refers to the exploration of development pathways of Public and Private Health Expenditure in all of the countries of the European WHO Region. Based on the availability of fully comparable data from the National Health Accounts system, we adopted the 1995-2014 time horizon. All countries were divided into two groups: those defined in 1989 as free market economies and those defined as centrally-planned economies. We observed six major health expenditures: Total Health Expenditure (% of GDP), Total Health Expenditure (PPP unit), General government expenditure on health (PPP), Private expenditure on health (PPP), Social security funds (PPP) and Out-of-pocket expenditure (PPP). All of the numerical values used refer exclusively to per capita health spending. In a time-window from the middle of the 1990s towards recent years, total health expenditure was rising fast in both groups of countries. Expenditure on health % of GDP in both group of countries increased over time with the increase in the Free-market economies seen to be more rapid. The steeper level of total expenditure on health for the Free-market as of 1989 market economies, is due mainly to a steep increase in both the government and private expenditure on health relative to spending by centrally-planned economies as of the same date, with the out-of-pocket expenditure and the social security funds in the same market economies category following the same steepness. Variety of governments were leading Eastern European countries into their transitional health care reforms. We may confirm clear presence of obvious divergent upward trends in total governmental and private health expenditures between these two groups of countries over the past two decades. The degree of challenge to the fiscal sustainability of these health systems will have to be judged for each single nation, in line with its own local circumstances and perspectives.

Implementation and dissemination of the Sikh American Families Oral Health Promotion Program

The Sikh American Families Oral Health Promotion Program used a community-based participatory approach to develop, implement, evaluate, and disseminate a culturally tailored oral health/healthy living curriculum for the Sikh—South Asian community. Here, we examine the impact of community engagement throughout the process of program implementation in five Gurdwaras (places of worship) in New York and New Jersey and dissemination of the findings through targeted venues and the curriculum via e-Health resources. An interactive curriculum was developed (consisting of four core and three special topics) based upon a community-led needs assessment, adaptation of evidence-based oral health curricula, guidance from professional dental and medical associations, and input from Community Advisory Board (CAB) members. The Consolidated Framework for Implementation Research guided a mixed-method evaluation, consisting of both process and outcome measures. Five trained community educators delivered a total of 42 educational sessions. Improved oral hygiene behaviors and self-efficacy were found among program participants. For participants with no dental insurance prior to program enrollment (n = 58), 81.0% credited the program with helping them obtain insurance for themselves or their children. Further, for participants with no dentist prior to program enrollment (n = 68), 92.6% credited the program with helping them or their children find a local dentist. Short videos in Punjabi were created in response to feedback received from community educators and CAB members to reach men, especially. Community engagement was key to successful program implementation and dissemination, from the implementation leaders (community educators) to the opinion leaders and champions (CAB members).

Updating Edwin Chadwick's seminal work on geographical inequalities by occupation

To honour the 175^th anniversary of Edwin Chadwick's seminal 'Report on the Sanitary Conditions of the Labouring Poor', we update Chadwick's famous analysis of geographical differences in occupational based inequalities. Much of the field of Health Geography owes both its direction of development and its initial impetus to his 1842 report. The report presented evidence for the importance of local context to health, with individuals of the lowest occupations in Rutland living longer than individuals of the highest occupations in Liverpool. Here we update the 1842 analysis using data from the Office of National Statistics on individual mortality records by occupation (2010-12) and population data from the 2011 Census. Sex-specific directly standardised premature (16-74) mortality rates were calculated for hierarchical occupational categories similar to Chadwick's categories, for the nearest equivalent areas to those used in Chadwick's report. Although there is no longer consistent evidence on individuals in the lowest occupational group having lower mortality rates than those in the highest group, there were clear social gradients in mortality within each area and the extent of these inequalities varied between areas. Individuals who live in Rutland had lower premature mortality rates across each occupational group compared to the other areas. Our results demonstrate that while life expectancy has nearly doubled since Chadwick's report, social and spatial inequalities in health have persisted. We suggest that Chadwick's legacy on the importance of locality continues.

Optimising implementation of reforms to better prevent and respond to child sexual abuse in institutions: Insights from public health, regulatory theory, and Australia's Royal Commission

The Australian Royal Commission Into Institutional Responses to Child Sexual Abuse has identified multiple systemic failures to protect children in government and non-government organizations providing educational, religious, welfare, sporting, cultural, arts and recreational activities. Its recommendations for reform will aim to ensure organizations adopt more effective and ethical measures to prevent, identify and respond to child sexual abuse. However, apart from the question of what measures institutions should adopt, an under-explored question is how to implement and regulate those measures. Major challenges confronting reform include the diversity of organizations providing services to children; organizational resistance; and the need for effective oversight. Failure to adopt theoretically sound strategies to overcome implementation barriers will jeopardize reform and compromise reduction of institutional child sexual abuse. This article first explains the nature of the Royal Commission, and focuses on key findings from case studies and data analysis. It then analyzes public health theory and regulatory theory to present a novel analysis of theoretically justified approaches to the implementation of measures to prevent, identify and respond to CSA, while isolating challenges to implementation. The article reviews literature on challenges to reform and compliance, and on prevention of institutional CSA and situational crime prevention, to identify measures which have attracted emerging consensus as recommended practice. Finally, it applies its novel integration of regulatory theory and public health theory to the context of CSA in institutional contexts, to develop a theoretical basis for a model of implementation and regulation, and to indicate the nature and functions of a regulatory body for this context.

Tuberculosis, human rights and ethics considerations along the route of a highly vulnerable migrant from sub-Saharan Africa to Europe

Migrant health is a critical public health issue, and in many countries attention to this topic has focused on the link between migration and communicable diseases, including tuberculosis (TB). When creating public health policies to address the complex challenges posed by TB and migration, countries should focus these policies on evidence, ethics, and human rights. This paper traces a commonly used migration route from sub-Saharan Africa to Europe, identifying situations at each stage in which human rights and ethical values might be affected in relation to TB care. This illustration provides the basis for discussing TB and migration from the perspective of human rights, with a focus on the right to health. We then highlight three strands of discussion in the ethics and justice literature in an effort to develop more comprehensive ethics of migrant health. These strands include theories of global justice and global health ethics, the creation of 'firewalls' to separate enforcement of immigration law from protection of human rights, and the importance of non-stigmatization to health justice. The paper closes by reflecting briefly on how TB programs can better incorporate human rights and ethical principles and values into public health practice.

Using Health Impact Assessment as an Interdisciplinary Teaching Tool

Health Impact Assessment (HIA) courses are teaching public health and urban planning students how to assess the likely health effects of proposed policies, plans, and projects. We suggest that public health and urban planning have complimentary frameworks for training practitioners to address the living conditions that affect health. Planning perspectives emphasize practical skills for impacting community change, while public health stresses professional purpose and ethics. Frameworks from both disciplines can enhance the HIA learning experience by helping students tackle questions related to community impact, engagement, social justice, and ethics. We also propose that HIA community engagement processes can be enriched through an empathetic practice that focuses on greater personal introspection.

Exposure to Contaminated Drinking Water and Health Disparities in North Carolina

OBJECTIVES

To examine drinking water quality in majority Black periurban neighborhoods in Wake County, North Carolina, that are excluded from nearby municipal water service and to estimate the health benefits of extending water service.

METHODS

We tested 3 samples collected July through December 2014 in 57 private wells for microbial contaminants. We compared contaminant prevalences to those in adjacent community water systems (35 280 samples from routine monitoring). Using a population intervention model, we assessed the number of annual emergency department visits for acute gastrointestinal illness that is preventable by extending water services to the 3799 residents of these periurban communities.

RESULTS

Overall, 29.2% of 171 private well samples tested positive for total coliform bacteria and 6.43% for Escherichia coli, compared with 0.556% and 0.00850% of municipal system samples. An estimated 22% of 114 annual emergency department visits for acute gastrointestinal illness could be prevented by extending community water service.

CONCLUSIONS

Predominantly Black periurban neighborhoods excluded from municipal water service have poorer quality drinking water than do adjacent neighborhoods with municipal services. These disparities increase the risk of emergency department visits for acute gastrointestinal illness.

The challenges of choosing and explaining a phenomenon in epidemiological research on the "Hispanic Paradox"

According to public health data, the US Hispanic population is far healthier than would be expected for a population with low socioeconomic status. Ever since Kyriakos Markides and Jeannine Coreil highlighted this in a seminal 1986 article, public health researchers have sought to explain the so-called "Hispanic paradox." Several candidate explanations have been offered over the years, but the debate goes on. This article offers a philosophical analysis that clarifies how two sets of obstacles make it particularly difficult to explain the Hispanic paradox. First, different research projects define the Hispanic paradox phenomenon in substantially different ways. Moreover, using Bas van Fraassen's pragmatic theory of explanation and Sean Valles's extension of it with the concept of "phenomenon choice," it also becomes clear that there are also multiple ways of explaining each individual definition of the phenomenon. A second set of philosophical and methodological challenges arises during any attempt to study "Hispanic" phenomena, with one key challenge being that the "Hispanic" panethnic concept was intentionally made vague as it was developed and popularized during the 1960s-1970s. After comparing this case with similar cases in the philosophical literature, the article concludes with observations on what makes this problem unique, particularly its ethical features.

Promoting Nature-Based Activity for People With Mental Illness Through the US "Exercise Is Medicine" Initiative

Nature-based physical activity programming (e.g., countryside walks, hiking, horseback riding) has been found to be an effective way to help improve the health of people with mental illness. Exercise referral initiatives, whereby health practitioners prescribe exercise in an attempt to prevent or treat chronic illnesses, have helped make such nature-based activities accessible to this population in the United Kingdom and Australia; however, there is a dearth of research related to the most prominent exercise referral program in the United States: Exercise is Medicine. Taking into account the barriers to physical activity faced by people with mental illness, we explore how nature-based programming for this population might be mobilized in the United States through the growing Exercise is Medicine initiative.

Black Lives Matter: A Commentary on Racism and Public Health

The recent nonindictments of police officers who killed unarmed Black men have incited popular and scholarly discussions on racial injustices in our legal system, racialized police violence, and police (mis)conduct. What is glaringly absent is a public health perspective in response to these events. We aim to fill this gap and expand the current dialogue beyond these isolated incidents to a broader discussion of racism in America and how it affects the health and well-being of people of color. Our goal is not only to reiterate how salient structural racism is in our society, but how critical antiracist work is to the core goals and values of public health.

Public Health, Embodied History, and Social Justice: Looking Forward

This essay was delivered as a commencement address at the University of California-Berkeley School of Public Health on May 17, 2015. Reflecting on events spanning from 1990 to 1999 to 2015, when I gave my first, second, and third commencement talks at the school, I discuss four notable features of our present era and offer five insights for ensuring that health equity be the guiding star to orient us all. The four notable features are: (1) growing recognition of the planetary emergency of global climate change; (2) almost daily headlines about armed conflicts and atrocities; (3) growing public awareness of and debate about epic levels of income and wealth inequalities; and (4) growing activism about police killings and, more broadly, "Black Lives Matter." The five insights are: (1) public health is a public good, not a commodity; (2) the "tragedy of the commons" is a canard; the lack of a common good is what ails us; (3) good science is not enough, and bad science is harmful; (4) good evidence--however vital--is not enough to change the world; and (5) history is vital, because we live our history, embodied. Our goal: a just and sustainable world in which we and every being on this planet may truly thrive.

Public health nurse educators' conceptualisation of public health as a strategy to reduce health inequalities: a qualitative study

BACKGROUND

Nurses have long been identified as key contributors to strategies to reduce health inequalities. However, health inequalities are increasing in the UK despite policy measures put in place to reduce them. This raises questions about: convergence between policy makers' and nurses' understanding of how inequalities in health are created and sustained and educational preparation for the role as contributors in reducing health inequalities.

AIM

The aim of this qualitative research project is to determine public health nurse educators' understanding of public health as a strategy to reduce health inequalities.

METHOD

26 semi-structured interviews were conducted with higher education institution-based public health nurse educators.

FINDINGS

Public health nurse educators described health inequalities as the foundation on which a public health framework should be built. Two distinct views emerged of how health inequalities should be tackled: some proposed a population approach focusing on upstream preventive strategies, whilst others proposed behavioural approaches focusing on empowering vulnerable individuals to improve their own health.

CONCLUSION

Despite upstream interventions to reduce inequalities in health being proved to have more leverage than individual behavioural interventions in tackling the fundamental causes of health inequalities, some nurses have a better understanding of individual interventions than take population approaches.

[The racialization of public health in the United States : the possibility that the concept be allowed to die out]

Résumé

Aux États-Unis, une intensification de l’usage de la race en santé publique a récemment été notée ; une idée qui est pourtant controversée dans les sciences. La race a été vue dans ce contexte comme un objet de discours entre pouvoirs et savoirs, un objet qui se réfère au corps devenu au cours des derniers siècles un site discursif pour représenter la différence. Cet article s’appuie sur une analyse de documents de la santé publique parus aux États-Unis et issus de bureaux fédéraux et d’une importante revue spécialisée dans le domaine sanitaire, qui ont été publiés entre 2001 et 2009. Cette étude a analysé la manière dont la race est représentée, produite comme objet de connaissance et régulée par les pratiques discursives dans ces documents. Les résultats décrivent deux processus enchevêtrés, la racialisation et la sanitarisation, qui concourent à reformuler l’idée de race. Le premier est un ensemble d’opérations qui visent à identifier, à situer et à opposer les sujets et les groupes à partir de labels standardisés. La sanitarisation assure la traduction des groupes racialisés en termes de maladies, de comportements, de vie ou de mort. Ces pratiques aboutissent à la caractérisation et à la formation d’objets racialisés et sanitarisés et à des stéréotypes ; un ensemble d’opérations qui a tendance à naturaliser la différence. La racialisation apparaît également tiraillée entre un pouvoir sur la vie et un droit de laisser mourir. Enfin, cette étude propose aux acteurs de la santé publique de sortir des frontières imposées par le discours racialisant.

Multinational corporations and infectious disease: Embracing human rights management techniques

Background

Global health institutions have called for governments, international organisations and health practitioners to employ a human rights-based approach to infectious diseases. The motivation for a human rights approach is clear: poverty and inequality create conditions for infectious diseases to thrive, and the diseases, in turn, interact with social-ecological systems to promulgate poverty, inequity and indignity. Governments and intergovernmental organisations should be concerned with the control and elimination of these diseases, as widespread infections delay economic growth and contribute to higher healthcare costs and slower processes for realising universal human rights. These social determinants and economic outcomes associated with infectious diseases should interest multinational companies, partly because they have bearing on corporate productivity and, increasingly, because new global norms impose on companies a responsibility to respect human rights, including the right to health.

Methods

We reviewed historical and recent developments at the interface of infectious diseases, human rights and multinational corporations. Our investigation was supplemented with field-level insights at corporate capital projects that were developed in areas of high endemicity of infectious diseases, which embraced rights-based disease control strategies.

Results

Experience and literature provide a longstanding business case and an emerging social responsibility case for corporations to apply a human rights approach to health programmes at global operations. Indeed, in an increasingly globalised and interconnected world, multinational corporations have an interest, and an important role to play, in advancing rights-based control strategies for infectious diseases.

Conclusions

There are new opportunities for governments and international health agencies to enlist corporate business actors in disease control and elimination strategies. Guidance offered by the United Nations in 2011 that is widely embraced by companies, governments and civil society provides a roadmap for engaging business enterprises in rights-based disease management strategies to mitigate disease transmission rates and improve human welfare outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/2049-9957-3-39) contains supplementary material, which is available to authorized users.

Black physicians and the struggle for civil rights: lessons from the Mississippi experience: part 2: their lives and experiences

Little information is available on the lives and experiences of black physicians who practiced in the South during the Jim Crow era of legalized segregation. In Mississippi and elsewhere, it is a story of disenfranchised professionals who risked life, limb, and personal success to improve the lot of those they served. In this second article on this topic, we present the stories of some of the physicians who were leaders in the civil rights movement in Mississippi as examples. Because the health disparities they sought to address have, not of their own making, been passed on to the next generation of physicians, the lessons learned from their experience are worthy of consideration.

Epidemiology and 'developing countries': writing pesticides, poverty and political engagement in Latin America

The growth of the field of global health has prompted renewed interest in discursive aspects of North-South biomedical encounters, but analysis of the role of disciplinary identities and writing conventions remains scarce. In this article, I examine ways of framing pesticide problems in 88 peer-reviewed epidemiology papers produced by Northerners and their collaborators studying pesticide-related health impacts in Latin America. I identify prominent geographic frames in which truncated and selective histories of Latin America are used to justify research projects in specific research sites, which nevertheless function rhetorically as generic 'developing country' settings. These frames legitimize health sector interventions as solutions to pesticide-related health problems, largely avoiding more politically charged possibilities. In contrast, some epidemiologists appear to be actively pushing the bounds of epidemiology's traditional journal article genre by engaging with considerations of political power, especially that of the international pesticide industry. I therefore employ a finer-grained analysis to a subsample of 20 papers to explore how the writing conventions of epidemiology interact with portrayals of poverty and pesticides in Latin America. Through analysis of a minor scientific controversy, authorial presence in epidemiology articles, and variance of framing strategies across genres, I show how the tension between 'objectivity' and 'advocacy' observed in Northern epidemiology and public health is expressed in North-South interaction. I end by discussing implications for postcolonial and socially engaged approaches to science and technology studies, as well as their relevance to the actual practice of global health research. In particular, the complicated interaction of the conflicted traditions of Northern epidemiology with Latin American settings on paper hints at a far more complex interaction in the form of public health programming involving researchers and research participants who differ by nationality, ethnicity, gender, profession, and class.

"Is always that sense of wanting … never really being satisfied": Women's Quotidian Struggles With Food Insecurity in a Hispanic Community in New Mexico

In this article, we explore women's everyday experiences with food insecurity. Women's narratives from a Hispanic community in New Mexico depict the poignant struggles women confront as they actively engage with buffering the experience of hunger to hide scarcity and mask and cope with emotional distress. These data give us a lens for understanding women's lives in the context of disparity as it relates to food insecurity as a public health issue and provide a way to conceptualize how social determinants operate and integrate with quotidian life activities and processes.

An evaluation of the public health paradigm: a view of social work

This article engages in a critical review of the public health paradigm to determine the compatibility with social work's guiding value of social justice. This critical examination explores the history, epistemology, and view of health underlying the public health paradigm. Implications of the public health paradigm's view of health on social work practice and discourse is examined.

Research funded by the National Institutes of Health on the health of lesbian, gay, bisexual, and transgender populations

OBJECTIVES

We examined the proportion of studies funded by the National Institutes of Health (NIH) that focused on lesbian, gay, bisexual, and transgender (LGBT) populations, along with investigated health topics.

METHODS

We used the NIH RePORTER system to search for LGBT-related terms in NIH-funded research from 1989 through 2011. We coded abstracts for LGBT inclusion, subpopulations studied, health foci, and whether studies involved interventions.

RESULTS

NIH funded 628 studies concerning LGBT health. Excluding projects about HIV/AIDS and other sexual health matters, only 0.1% (n = 113) of all NIH-funded studies concerned LGBT health. Among the LGBT-related projects, 86.1% studied sexual minority men, 13.5% studied sexual minority women, and 6.8% studied transgender populations. Overall, 79.1% of LGBT-related projects focused on HIV/AIDS and substantially fewer on illicit drug use (30.9%), mental health (23.2%), other sexual health matters (16.4%), and alcohol use (12.9%). Only 202 studies examined LGBT health-related interventions. Over time, the number of LGBT-related projects per year increased.

CONCLUSIONS

The lack of NIH-funded research about LGBT health contributes to the perpetuation of health inequities. Here we recommend ways for NIH to stimulate LGBT-related research.

Research funded by the National Institutes of Health on the health of lesbian, gay, bisexual, and transgender populations

OBJECTIVES

We examined the proportion of studies funded by the National Institutes of Health (NIH) that focused on lesbian, gay, bisexual, and transgender (LGBT) populations, along with investigated health topics.

METHODS

We used the NIH RePORTER system to search for LGBT-related terms in NIH-funded research from 1989 through 2011. We coded abstracts for LGBT inclusion, subpopulations studied, health foci, and whether studies involved interventions.

RESULTS

NIH funded 628 studies concerning LGBT health. Excluding projects about HIV/AIDS and other sexual health matters, only 0.1% (n = 113) of all NIH-funded studies concerned LGBT health. Among the LGBT-related projects, 86.1% studied sexual minority men, 13.5% studied sexual minority women, and 6.8% studied transgender populations. Overall, 79.1% of LGBT-related projects focused on HIV/AIDS and substantially fewer on illicit drug use (30.9%), mental health (23.2%), other sexual health matters (16.4%), and alcohol use (12.9%). Only 202 studies examined LGBT health-related interventions. Over time, the number of LGBT-related projects per year increased.

CONCLUSIONS

The lack of NIH-funded research about LGBT health contributes to the perpetuation of health inequities. Here we recommend ways for NIH to stimulate LGBT-related research.

Who will deliver on the promise?

The Doctor of Public Health (DrPH) Core Competency Model aspires to rigorously train future leaders of public health practice to direct and advance societal efforts that address socially rooted causes of health and illness. Although there is no proven formula for success, 3 principles derived from practice may guide the way forward: (1) institutionalize mutual learning and reciprocity between schools of public health and public health agencies and organizations, (2) capitalize on the full resources of the larger university to enrich the educational experiences of DrPH candidates and public health leaders, and (3) globalize the search for model DrPH programs that may be adapted for US schools. Schools of public health must ensure that DrPH programs gain the status and resources needed to fulfill their societal mandate.

Do "illegal" im/migrants have a right to health? Engaging ethical theory as social practice at a Tel Aviv open clinic

As the notion of a "right to health" gains influence, it is increasingly deployed in ways that are diverse, contextually variable, and at times logically inconsistent. Drawing on extended fieldwork at an Israeli human rights organization that advocates for "illegal" migrants and other vulnerable groups, this article contends that medical anthropologists cannot simply rally behind this right. Instead, we must take it as an object of ethnographic analysis and explore bow it is invoked, debated, and resisted in specific contexts. Critical ethnographies of right to health discourse and practice can enlighten us, and help us enlighten scholars in other fields, to the complexity, messiness, and "mushiness" (Sen 2009) of this right, especially in the context of advocacy on unauthorized im/migrants' behalf. It can also deepen understanding of the complicated and sometimes tense relationships among human rights, humanitarianism, and other contemporary idioms of social justice mobilization, especially in the health domain.

How is health-related "deservingness" reckoned? Perspectives from unauthorized im/migrants in Tel Aviv

Do unauthorized im/migrants have a right to health? Do they deserve health care, or health protection, or access to the social determinants of good health? Are they party to prevailing social contracts, or does their exclusion from mainstream systems of health promotion, prevention, and care "make sense"? Questions like these, which generate considerable attention in multiple spheres of scholarship, policy, and public debate, revolve around an issue that merits substantially greater consideration among social scientists of health: health-related "deservingness." In addition to putting the issue of health-related deservingness squarely on the map as an object of analysis, this article further argues that we cannot focus solely on those with power, influence, and public voice. Rather, we also must investigate how deservingness is reckoned in relation to--and, furthermore, from the perspectives of-- unauthorized im/migrants and members of other groups commonly constructed in public and policy discourse as undeserving. Additionally, we must consider the complicated relationship between universalizing juridical arguments about formal entitlement to health rights, on one hand, and situationally specific, vernacular moral arguments about deservingness, on the other. The paper analyzes findings from a 29-month mixed-methods study conducted in Tel Aviv, Israel, that approached unauthorized im/migrants as subjects, rather than simply objects, of ethical deliberation. Participants' conceptions of health-related deservingness are investigated using two sources of data: (1) quantitative findings from a self-administered, closed-ended survey conducted with 170 im/migrant patients at an NGO-run Open Clinic (2002-2003), and (2) qualitative findings from the larger ethnographic study of which the survey was part (2000-2010). The study findings both (1) contradict commonly circulating assumptions that unauthorized im/migrants are "freeloaders," and (2) highlight the need for rigorous investigation of how unauthorized im/migrants, among other marginalized and vulnerable groups, conceptualize their own relative deservingness of health-related concern and investment.

Dissecting the social body: social inequality through AIDS counter-narratives

HIV/AIDS conspiracy theories constitute a loosely grouped set of meanings that share the notion of secret collusion among allied parties. This paper traces one woman's etiological narrative of HIV/AIDS. Such embodied experience and cultural understanding when placed against the backdrop of current thinking on the topic in the United States builds a new framework for understanding the emergence and circulation of HIV/AIDS conspiracy theories as "counter-narratives" employed by individuals and publics in the face of the AIDS pandemic. Such counter-narrative creates a rhetorical space for challenges to power through the articulation of oppositional ideas about dominant scientific knowledge. Without a critical exploration of HIV/AIDS conspiracy theories that examines their emergence and effects as a form of discourse circulating in the public domain, public health advocates will not be able to trace and respond to these narratives' impact on HIV prevention efforts or consider their relevance for other emerging infectious diseases.

Vulnerability of health to market forces

OBJECTIVES

This article reviews adverse influences of for-profit enterprises on health care and public health, and examines significance for public policy.

RESEARCH DESIGN

Narrative review.

RESULTS

For-profit health-care industries may increase costs and reduce quality, leading to market failure and contributing to the USA's unflattering position in international comparisons of health-care efficiency. Drug and device corporations use strategies such as making biased inferences, influencing scientists and physicians, marketing rather than informing the public, and lobbying to control their own industry regulations to create market advantage. Successful marketing leads to the increased use of costly profit-making drugs and procedures over cheaper, nonpatented therapies. Because resources are limited, the overuse of costly modalities contributes to expensive health care, which presents a challenge to universal coverage. The free market also fosters the proliferation of industries, such as tobacco, food, and chemicals, which externalize costs to maximize profits, seek to unduly influence research by paying experts and universities, and attempt to control the media and regulatory agencies. Most vulnerable to the cumulative harm of these tactics are children, the poor, the sick, and the least educated.

CONCLUSIONS

The free market can harm health and health care. The corporate obligation to increase profits and ensure a return to shareholders affects public health. Such excesses of capitalism pose formidable challenges to social justice and public health. The recognition of the health risks entailed by corporation-controlled markets has important implications for public policy. Reforms are required to limit the power of corporations.