Strengthening Social Determinants of Health through Collaborative Continuum of Care within CRC Community Health Programming

Rural Americans face more health disadvantages than those living in urban and suburban areas. The literature on rural health has found that health inequalities between rural and urban populations continue to grow. Healthcare organizations in rural areas face constraints in improving their communities' health due to institutional barriers complicated by cultural and regulatory factors. Robust strategies are needed to strengthen rural health across the care continuum (prevention, treatment, and maintenance). Accordingly, this dissertation explores three potential strategies for improving rural health – community health programs, telehealth, and home health care. The first study examines rural hospitals' motivations to engage in community health programs and discusses their strategies to address community health issues. In rural communities, hospitals are frequently the primary organization with the resources and capabilities to address health issues. This characteristic highlights their potential to be a partner and leader for community health initiatives. We conducted semi-structured interviews with key leaders from four rural hospitals in a Midwest state in the U.S. These hospitals are located in rural counties that have demonstrated progress in creating healthier communities. On-site and telephone interviews were audio-recorded and transcribed. We applied the combination of inductive and deductive qualitative analysis to identify common themes and categories. We identified three categories of motivations that drove rural hospitals' community health improvement efforts: internal values, economic conditions, and social responsibilities. We also identified three categories of strategies that rural hospitals used to address community health issues: building capacity, building relationships, and building programs. Studies have shown the benefits of telehealth service in rural areas. However, there is evidence of limited adoption and utilization. The second study investigates health systems' experience in implementing telehealth services in rural hospital emergency departments (TeleED) and by analyzing factors influencing its implementation and sustainability. We conducted semi-structured interviews with 18 key informants from six health systems (hub sites) that provided TeleED services to 65 rural emergency departments (spoke sites). All used synchronous high-definition video to provide the service. We applied an inductive qualitative analysis approach to identify relevant quotes and themes related to TeleED service uptake facilitators and barriers. We identified three stages of implementation: 1) the start-up stage; 2) the utilization stage; and 3) the sustainment stage. At each stage, we identified emerging factors that can facilitate or impede the process. We categorized these factors into eight domains: 1) strategies; 2) capability; 3) relationships; 4) financials; 5) protocols; 6) environment; 7) service characteristics; and 8) accountability. The third study examines the impact of Certificate of Need (CON) laws on access to and quality of home health care. Home health care has a significant role in the care of Medicare beneficiaries. It can keep the patients at home while receiving efficient post-acute care services, potentially reducing Medicare expenditures. The CON laws can affect home health agencies' accessibility and quality by limiting their number in affected states. We compared the availability, utilization pattern, and quality performance of urban and rural home health agencies in CON states and non-CON states. Findings indicate that CON states have fewer urban and rural home health agencies available for their Medicare population than non-CON states. Furthermore, the results suggest that urban and rural home health agencies in CON states have less utilization in terms of care episodes and visits. The findings also indicated that the CON laws have a mixed effect on home health agencies' quality in urban and rural areas of CON states. The results showed asymmetrical effects across different star-rating quality categories and locations. Also, there is evidence of some quality measures that home health agencies in CON states performed better and poorer than home health agencies in non-CON states.

Has traditional medicine had its day? The need to redefine academic medicine

Purpose This paper aims to challenge the prevailing focus on “social prescriptions” in social prescribing research and practice and argue for a broader understanding of “social prescribing” as a process of co-creation that prioritizes relationships, community engagement and self-determination. Design/methodology/approach Rather than presenting new empirical data, this paper draws upon key concepts from public health, sociology and political ecology to offer a novel theoretical lens through which to understand and implement social prescribing, critically examining the limitations of framing social prescribing primarily through the lens of “social determinants of health.” Findings We argue that a narrow focus on “social prescriptions” over processes of “social prescribing,” like a narrow focus on “social determinants of health” over complex and intersecting “processes of determination in health,” can lead to a commodification of interventions, reinforce power imbalances and neglect the crucial role of community engagement and self-determination. We propose a place-based, person-centred, politically aware approach that emphasizes the dynamic interplay of people, power and place in shaping health outcomes. Research limitations/implications This conceptual paper primarily focuses on theoretical challenges to existing social prescribing frameworks. Further research is needed to connect this framework with the existing empirical evidence and real-world practice of social prescribing, investigate the nuances of power dynamics within social prescribing initiatives and explore the feasibility of implementing alternative approaches in diverse contexts. Practical implications The paper advocates for a shift away from simply “prescribing” social activities and toward a more collaborative, co-creative approach to social prescribing. In practice, this means that social prescribers consider prioritizing relationships: building trust and fostering strong relationships between patients, link workers and community organizations; focusing on self-determination: empowering individuals and communities to actively participate in shaping their own health pathways; adopting a “political ecology of health” framework: considering the dynamic interplay of people, power and place in shaping health outcomes and implementing culturally safe and trauma-informed practices: addressing existing power imbalances and potential harms within healthcare. Social implications By emphasizing co-creation and self-determination, the proposed approach to social prescribing has the potential to reduce health inequities by better addressing the social and political roots of health disparities, empower marginalized communities by ensuring their voices are heard and their needs are met in a culturally safe manner, strengthen community connections by fostering a sense of belonging and mattering and promote social justice by challenging existing power structures and advocating for more equitable social and environmental conditions. Originality/value This paper challenges the dominant focus on “social prescriptions” by focusing on processes of “social prescribing.” It introduces a political ecology of health framework that provides a more nuanced understanding of the dynamic processes that shape health. This framework emphasizes co-creation, self-determination and community engagement and highlights the importance of relationships and power dynamics in social prescribing. The paper advocates for a more equitable and transformative approach that emphasizes community leadership and strengths and better addresses the social and political roots of health inequities.

Academic health centers (AHCs) in the United States have had a leading role in educating the medical workforce, generating new biomedical knowledge, and providing tertiary and quaternary clinical care. Yet the health status of the U.S. population lags behind almost every other developed world economy. One reason is that the health care system is not organized optimally to address the major driver of health status, the social determinants of health (SDOH). The United States' overall poor health status is a reflection of dramatic disparities in health that exist between communities and population groups, and these are associated with variations in the underlying SDOH. Improving health status in the United States thus requires a fundamental reengineering of the health delivery system to address SDOH more explicitly and systematically. AHCs' tripartite mission, which has served so well in the past, is no longer sufficient to position AHCs to lead and resolve the intractable drivers of poor health status, such as unfair and unjust health disparities, health inequities, or differences in a population's SDOH.AHCs enjoy broad public support and have an opportunity-and an obligation-to lead in improving the nation's health. This Perspective proposes a new framework for AHCs to expand on their traditional tripartite mission of education, research, and clinical care to include explicitly a fourth mission of social accountability. Through this fourth mission, comprehensive community engagement can be undertaken, addressing SDOH and measuring the health impact of interventions by using a deliberate structure and process, yielding defined outcomes.

Social prescribing is a health and social model of care which is emerging globally. It is a multifaceted intervention shaped by various contextual factors that can affect its implementation. Our aim was to describe community connectors’ (link workers or navigators) perceptions and experiences delivering social prescribing programs, with a particular interest in identifying implementation factors or themes. We conducted 11 online semi‐structured interviews with community connectors who delivered social prescribing in British Columbia (BC), Canada. We used directed content analysis, and two authors explored interviews using an implementation perspective. We sorted findings using a deductive approach based on previously published guidance to consider program acceptability, adoption, reach, dose, fidelity, feasibility, and sustainability, and community connectors’ self‐efficacy in delivering the program. We identified factors or themes which could impact on social prescribing implementation, specifically: variability in people’s unmet social needs, identification of community resources, team relationships, and communication. Participants also shared their experiences and perspectives on community connectors’ training, support, and their roles and scope within the continuum of care. At the client level, participants noted some challenges for people to access services because of low income and/or digital literacy. They further provided suggestions for shaping the future of social prescribing. Overall, participants provided valuable insights into social prescribing implementation opportunities and challenges which contribute to understanding community connectors’ role within the wider scope of this quickly emerging health and social model of care.

Disparities in Vision Health and Eye Care: Where Do We Go from Here?

Institutionalising community health programmes into the Palestinian health-care system: a qualitative study

Background:The Canadian healthcare landscape is undergoing a transformative shift, with increasing recognition that health outcomes are influenced not only by medical interventions but also by social determinants of health. Traditional healthcare models often fall short in addressing these determinants, resulting in an overreliance on acute care, service fragmentation, and under-valuing of community supports and services.Social prescribing offers a paradigm shift by enabling healthcare providers to refer patients to dedicated navigators who can connect them to non-medical resources, such as social activities, exercise programs, support groups, and arts initiatives, to improve overall well-being. This practice, well established in the UK and rapidly gaining traction across Canada, places a strong emphasis on person-centred co-creation, empowering individuals to take the lead on their own health. At the same time, social prescribing takes an asset-based approach to foster intentional collaboration across sectors to provide right care in the right place, reducing acute care usage where appropriate, elevate community leadership in integrated care, and strengthen long term resilience.This workshop will explore how social prescribing pathways can be a practical and impactful tool to strengthen integrated health and social care, and offer activities for attendees to apply the practice to their own settings. Audience: This workshop is targeted towards healthcare providers, social services, and community support providers, patients and caregivers, policymakers, and researchers interested in advancing integrated health, social care, and fostering collaboration across sectors. It provides valuable insights for those seeking to enhance healthcare delivery and elevate community leadership by incorporating social prescribing into their practice or policy initiatives. Approach:Drawing on research literature, best practices globally and across Canada, and recent experiences and lessons learned from Healthy Aging Alberta social prescribing initiatives, this workshop will explore the role of social prescribing in promoting integrated care, community health, and inter-sector collaboration. The following structure is suggested:- Introduction (20mins): Canadian Institute for Social Prescribing (CISP) and Healthy Aging Alberta (HAA) will provide an overview of social prescribing, including what it is, how it works, and evidence of impact on health and wellbeing. We will further explore how to build cross-sectoral collaboration through social prescribing pathways and provide tools for community readiness assessment toward implementing this practice.- Group activity (20 min): The audience will be divided into groups and, through a facilitated process, design a social prescribing intervention/initiative based on various provided contexts.- Share back and discussion (20 mins): Each group will share back on their designed initiative and reflect on opportunities and challenges in their own settings.- Closing and final remarks (5mins): CISP and HAA will share final remarks on next steps and thought starters for consideration. Outcomes: After attending the workshop, the audience will:- Be familiar with the definition, pathway, and impact of social prescribing, and the role of community and other diverse sectors- Understand the role of SP in integrated health and social care, and the opportunity to strengthen community leadership and build collaborative partnerships- Learn how to assess community readiness and begin designing social prescribing pathways for diverse contexts

Addressing Social Determinants of Mental Health in Pediatrics During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE Onshore oil and gas projects can have large footprints with potentially significant impacts on local communities over its producing life. In complex developing world country contexts, project execution challenges are often exacerbated by a high background burden of disease and a fragile local health system. The ExxonMobil-constructed and operated Papua New Guinea (PNG) LNG Project (Project), the largest private investment in the history of Papua New Guinea, is an example of a large development in a significantly challenged community health context. Having recognized the health-related risks early, the Project team developed an integrated community health impact mitigation and investment plan consisting of: (i) the development of a private-public partnership with the PNG Institute of Medical Research (PNGIMR) to execute a robust longitudinal surveillance system, (ii) capacity building efforts to strengthen both local and national health care and diagnostic capacity, including (a) a state of the art infectious disease research laboratory managed by PNGIMR and located at the PNG School of Medicine campus and (b) a teaching and clinical support by both PNGIMR and seconded faculty from Texas Children's Hospital and (iii) strategic impact prevention measures, e.g., water/sanitation, domestic violence, health lifestyles, executed by local NGOs across all project areas. METHODS Based on the findings of a pre-project health impact assessment, the Project assessed that a comprehensive integrated impact mitigation and focused capacity building program for potentially impacted communities was essential. Because of the complexity and geographical distribution of the project, control/comparison sites were also developed so that any significant changes in community health outcomes could be placed in context. Health stakeholders included the Project workforce, affected communities and both provincial and national health authorities. Interventions followed best practice in building public-private partnerships and were fit to purpose, i.e., tailored to address local and provincial / national issues that would be directly impacted by the PNG LNG Project. RESULTS Formal Memorandum of Understanding and Investment Agreements between ExxonMobil PNG Ltd and PNG health authorities were executed. Longitudinal surveillance included two project impact sites and two comparison sites covering over 50,000 persons. The entire surveillance system was accepted into the INDEPTH Network and is fully compliant with international health monitoring standards. The PNG LNG Project was the first oil and gas sponsored project in the 45-member, 20-country, 50+site INDEPTH Network. A variety of population demographic and specialty studies have been executed that have accurately tracked changes in socio-economics and in/out migration while determining prevalence and incidence for major diseases such as tuberculosis and sexually transmitted infections, including the first ever study of HPV in PNG women. NOVEL/ADDITIONAL INFORMATION Key findings are presented. The development of an integrated, comprehensive community health program including internationally recognized longitudinal monitoring structure represents a new benchmark both for PNG and the oil and gas industry. As noted through multiple engagements with the PNG government and donor community such an approach can be replicated by others in the extractives as well as non-extractives industries using field proven methods pioneered on the PNG LNG Project. In so doing the improvement in coverage and data quality can assist in improving public health policy development and implementation.

Background The Whitlam Labor government established the Community Health Program (CHP) in Australia in 1973 to improve access to health and related welfare services nationally. States reacted differently to the program. Designated Australian Government funding for the program ended in 1981. In spite of fluctuating state government support and changing legislative frameworks over time, Victoria is the only state that continues to operate a generic community health centre (CHC) program reflecting the original CHP. Methods Data were collected from policy documents and archival material, as well as interviews with 29 key stake holders from Victoria. Transcripts from the interviews were reviewed by the interviewees and permission given to include identifiable quotes. The research is part of a larger Australian Research Council project looking at the history of community health in Australia. Results In Victoria the CHP broke new ground in several respects including creating a public primary health care (PHC) sector, promoting equitable access to PHC, introducing salaried GPs, creating multidisciplinary PHC teams, valuing community involvement (in planning, accountability, health promotion) and taking action on the social determinants of health. Key stakeholders described the challenges that the sector has faced in the decades from 1973 to the current day. The basis for the sector's survival ultimately rests with how it was initially established and the cultural environment in which it developed and continues to operate. In addition to the (albeit irregular) geographically wide distribution of CHCs, their high level of public recognition and sense of community ownership were seen as critical factors that aided their survival and worked against their closure or absorption into hospital networks. Conclusions Based on a synthesis of our findings and personal experiences, we propose five new directions for policy, management and practice that could support this model to have a greater contribution to the health system in Australia.

Ten years have passed since the release of the final report of the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH),1 a landmark document that provided a global blue‐print for the health promotion community and the stakeholders we work with. Three overarching recommendations were outlined, improving daily living conditions; tackling the inequitable distribution of power, money and resources; and measuring and understanding the problem and assessing the impact of action.1 The extent to which progress has been, and continues to be, made is contested. This editorial briefly reflects on what has been achieved over the past decade—in broad terms—about action on the social determinants of health (SDH) in Australia. We deliberately take a balanced view by highlighting the weaknesses and strengths in what has been achieved by governments, non‐government organisations, research institutions, peak bodies and civil society. We also reflect on the ongoing role that the Australian Health Promotion Association (AHPA) has played in advancing our understanding about, and action on, the SDH.

INTRODUCTION Guinea’s Ministry of Health has proposed a standardized national community health program, including health promotion, case management, and referral; historically however the system has been implemented piecemeal by various actors. MSF has been present in Kouroussa, northern Guinea, since 2017. MSF activities there have been focused on community healthcare, through training and support for community health workers, or “recos”. Before exiting, MSF conducted a mixed-methods study to understand differences in the models and effects of MSF community health program, as compared to those implemented by other actors. METHODS We implemented an explanatory, sequential, mixed-methods study in Kouroussa and in three other zones, Mandiana, Télimélé, and Boussou; sites were selected to represent a diversity of situations, and those outside Kouroussa are supported by non-MSF actors. During the quantitative phase, 137 recos and 13 supervisory community health agents were interviewed about their demographic and professional details, availability of tools, the package of activities, activity levels, and practical knowledge. A qualitative phase, including 24 focus group discussions and 65 individual interviews followed, aiming to better understand the community and local health professional perceptions of community health programmes in each of the four zones. Quantitative data were analyzed using R (Vienna, Austria) to calculate descriptive measures; differences were compared between zones using chi-square and t-tests. Qualitative data audio recordings were translated and transcribed, read, and re-read to identify codes and themes. ETHICS This study was approved by the MSF Ethics Review Board and by the Comité National de la Recherche, Guinea. RESULTS Overall, recos in Mandiana and Télimélé were primarily involved in health promotion and referral, while recos in Kouroussa (supported by MSF), and some in Boussou, additionally conducted case management. In Kouroussa, recos conducted a median of 16.5 malaria consultations per month, compared to 8.0 in Boussou, 2.1 in Télimélé, and 0 in Mandiana (p<0.0005). The zones where recos conducted case management were those where medicines were more available, with 92% of recos in Kouroussa possessing anti-malarials at the time of visit, compared to 38% in Boussou, 3% in Télimélé, and 7% in Mandiana (p<0.0005). Qualitative data revealed that for recos to expand from health promotion into case management, medicines must be available, and in Kouroussa the community emphasized the importance of free care. Moreover, qualitative data showed the primary motivation for recos was their loyalty to their community, and that recos were better accepted and more effective when they came from the same community they served, or were a “child” of the village. CONCLUSION To consistently achieve stated national ambitions of having recos that conduct case management, including in Kouroussa after MSF exits, medicine availability must be assured through appropriate resourcing. Additionally, our data suggest that each community should continue to have the power to choose their own reco. CONFLICTS OF INTEREST None declared.

<p>INTRODUCTION</p><p>Guinea’s Ministry of Health has proposed a standardized national community health program, including health promotion, case management, and referral; historically however the system has been implemented piecemeal by various actors. MSF has been present in Kouroussa, northern Guinea, since 2017. MSF activities there have been focused on community healthcare, through training and support for community health workers, or “recos”. Before exiting, MSF conducted a mixed-methods study to understand differences in the models and effects of MSF community health program, as compared to those implemented by other actors.</p><p></p><p>METHODS</p><p>We implemented an explanatory, sequential, mixed-methods study in Kouroussa and in three other zones, Mandiana, Télimélé, and Boussou; sites were selected to represent a diversity of situations, and those outside Kouroussa are supported by non-MSF actors. During the quantitative phase, 137 recos and 13 supervisory community health agents were interviewed about their demographic and professional details, availability of tools, the package of activities, activity levels, and practical knowledge. A qualitative phase, including 24 focus group discussions and 65 individual interviews followed, aiming to better understand the community and local health professional perceptions of community health programmes in each of the four zones. Quantitative data were analyzed using R (Vienna, Austria) to calculate descriptive measures; differences were compared between zones using chi-square and t-tests. Qualitative data audio recordings were translated and transcribed, read, and re-read to identify codes and themes.</p><p></p><p>ETHICS</p><p>This study was approved by the MSF Ethics Review Board and by the Comité National de la Recherche, Guinea.</p><p></p><p>RESULTS</p><p>Overall, recos in Mandiana and Télimélé were primarily involved in health promotion and referral, while recos in Kouroussa (supported by MSF), and some in Boussou, additionally conducted case management. In Kouroussa, recos conducted a median of 16.5 malaria consultations per month, compared to 8.0 in Boussou, 2.1 in Télimélé, and 0 in Mandiana (p<0.0005). The zones where recos conducted case management were those where medicines were more available, with 92% of recos in Kouroussa possessing anti-malarials at the time of visit, compared to 38% in Boussou, 3% in Télimélé, and 7% in Mandiana (p<0.0005). Qualitative data revealed that for recos to expand from health promotion into case management, medicines must be available, and in Kouroussa the community emphasized the importance of free care. Moreover, qualitative data showed the primary motivation for recos was their loyalty to their community, and that recos were better accepted and more effective when they came from the same community they served, or were a “child” of the village.</p><p></p><p>CONCLUSION</p><p>To consistently achieve stated national ambitions of having recos that conduct case management, including in Kouroussa after MSF exits, medicine availability must be assured through appropriate resourcing. Additionally, our data suggest that each community should continue to have the power to choose their own reco.</p><p></p><p>CONFLICTS OF INTEREST</p><p>None declared.</p>

BackgroundEffective referral systems from the community to the health care facility are essential to save lives and ensure quality and a continuum of care. The effectiveness of referral systems in Mozambique depends on multiple factors that involve three main stakeholders: clients/community members; community health workers (CHWs); and facility-based health care workers. Each stakeholder is dependent on the other and could form either a barrier or a facilitator of referral within the complex health system of Mozambique.MethodsThis qualitative study, aiming to explore barriers and enablers of referral within the lens of complex adaptive health systems, employed 22 in-depth interviews with CHWs, their supervisors and community leaders and 8 focus group discussion with 63 community members. Interviews were recorded, transcribed and read for identification of themes and sub-themes related to barriers and enablers of client referrals. Data analysis was supported by the use of NVivo (v10). Results were summarized in narratives, reviewed, discussed and adjusted.ResultsAll stakeholders acknowledged the centrality of the referral system in a continuum of quality care. CHWs and community members identified similar enablers and barriers to uptake of referral. A major common facilitator was the existence of referral slips to expedite treatment upon reaching the health facility. A common barrier was the failure for referred clients to receive preferential treatment at the facility, despite the presence of a referral slip. Long distances and opportunity and transport costs were presented as barriers to accessibility and affordability of referral services at the health facility level. Supervisors identified barriers related to use of referral data, rather than uptake of referral. Supervisors and CHWs perceived the lack of feedback as a barrier to a functional referral system.ConclusionsThe barriers and enablers of referral systems shape both healthcare system functionality and community perceptions of care. Addressing common barriers to and strengthening the efficiency of referral systems have the potential to improve health at community level. Improved communication and feedback between involved stakeholders – especially strengthening the intermediate role of CHWs – and active community engagement will be key to stimulate better use of referral services and healthcare facilities.