Community-based Public Health Programs Research Articles

Potential Strategies to Increase Gynecologic Oncologist Treatment for Ovarian Cancer.

Evidence shows that treatment by gynecologic oncologists (GOs) increases overall survival among women with ovarian cancer. However, specific strategies for institutions and community-based public health programs to promote treatment by GOs are lacking. To address this, we conducted a literature review to identify evidence-based and promising system- and environmental-change strategies for increasing treatment by GOs, in effort to ensure that all women with ovarian cancer receive the standard of care. We searched for English-language literature published from 2008 to 2018. We used PubMed, PubMed Central, OVID, and EBSCO for peer-reviewed literature and Google and Google Scholar for gray literature related to increasing receipt of care by GOs among ovarian cancer patients. Numerous suggested and proposed strategies that have potential to increase treatment by GOs were discussed in several articles. We grouped these approaches into five strategic categories: increasing knowledge/awareness of role and importance of GOs, improving models of care, improving payment structures, improving/increasing insurance coverage for GO care, and expanding or enhancing the GO workforce. We identified several strategies with the potential for increasing GO care among ovarian cancer patients, although currently there is little evidence regarding their effectiveness across US populations. Public health programs and entities that measure delivery of quality health care may pilot the strategies in their populations. Certain strategies may work better in certain environments and a combination of strategies may be necessary for any one entity to increase GO ovarian cancer care. Findings, lessons learned, and recommendations from implementation projects would inform community and public health practice.

Gender norms and mass deworming program access in Comé, Benin: A qualitative assessment of gender-associated opportunities and challenges to achieving high mass drug administration coverage

The World Health Organization’s Neglected Tropical Disease Roadmap has accelerated progress towards eliminating select neglected tropical diseases (NTDs). This momentum has catalyzed research to determine the feasibility of interrupting transmission of soil-transmitted helminths (STH) using community-wide mass drug administration (MDA). This study aims to identify potential gender-specific facilitators and barriers to accessing and participating in community-wide STH MDA, with the goal of ensuring programs are equitable and maximize the probability of interrupting STH transmission. This research was conducted prior to the launch of community-wide MDA for STH in Comé, Benin. A total of 10 focus group discussions (FGDs) were conducted separately among 40 men, 38 women, and 15 community drug distributors (CDDs). Salient themes included: both men and women believe that community-wide MDA would reduce the financial burden associated with self-treatment, particularly for low income adults. Community members believe MDA should be packaged alongside water, sanitation, and other health services. Women feel past community-wide programs have been disorganized and are concerned these distributions will be similar. Women also expressed interest in increased engagement in the implementation of future community-based public health programs. Men often did not perceive themselves to be at great risk for STH infection and did not express a high demand for treatment. Finally, the barriers discussed by CDDs generally did not align with gender-specific concerns, but rather represented concerns shared by both genders. A door-to-door distribution strategy for STH MDA is preferred by women in this study, as this platform empowers women to participate as health decision makers for their family. In addition, involving women in planning and implementation of community-wide programs may help to increase treatment coverage and compliance.

Digital Segmentation of Priority Populations in Public Health.

The rapid growth and diffusion of digital media technologies has changed the landscape of market segmentation in the last two decades, including its use in promoting prosocial and behavior change. New, population-specific and culturally appropriate prevention strategies can leverage the potential of digital media to influence health outcomes, especially for the greatest users of digital technology, including youth and young adults. Health behavior change campaigns are increasingly shifting resources to social media, creating opportunities for innovative interventions and new research methods. This article examines three case studies of digital segmentation: (1) tobacco control from the Truth Initiative, (2) community-based public health programs from the Centers for Disease Control and Prevention, and (3) substance use (including opioids) and other risk behavior prevention from Public Good Projects. These case studies of recent digital segmentation efforts in the not-for-profit, government, and academic sectors show that it increases reach and frequency of messages delivered to priority populations. The practice of digital segmentation is rapidly growing, shows early signs of effectiveness, and may enhance future public health campaigns. Additional research could optimize its use and effectiveness in promoting prosocial and behavior change campaign outcomes.

Strategies to improve treatment coverage in community-based public health programs: A systematic review of the literature

BackgroundCommunity-based public health campaigns, such as those used in mass deworming, vitamin A supplementation and child immunization programs, provide key healthcare interventions to targeted populations at scale. However, these programs often fall short of established coverage targets. The purpose of this systematic review was to evaluate the impact of strategies used to increase treatment coverage in community-based public health campaigns.Methodology/ principal findingsWe systematically searched CAB Direct, Embase, and PubMed archives for studies utilizing specific interventions to increase coverage of community-based distribution of drugs, vaccines, or other public health services. We identified 5,637 articles, from which 79 full texts were evaluated according to pre-defined inclusion and exclusion criteria. Twenty-eight articles met inclusion criteria and data were abstracted regarding strategy-specific changes in coverage from these sources. Strategies used to increase coverage included community-directed treatment (n = 6, pooled percent change in coverage: +26.2%), distributor incentives (n = 2, +25.3%), distribution along kinship networks (n = 1, +24.5%), intensified information, education, and communication activities (n = 8, +21.6%), fixed-point delivery (n = 1, +21.4%), door-to-door delivery (n = 1, +14.0%), integrated service distribution (n = 9, +12.7%), conversion from school- to community-based delivery (n = 3, +11.9%), and management by a non-governmental organization (n = 1, +5.8%).Conclusions/significanceStrategies that target improving community member ownership of distribution appear to have a large impact on increasing treatment coverage. However, all strategies used to increase coverage successfully did so. These results may be useful to National Ministries, programs, and implementing partners in optimizing treatment coverage in community-based public health programs.

Toward Innovative Models of Health Care and Financing

WHOEVER WISHES TO PURSUE PROPERLY THE SCIence of medicine,” wrote Hippocrates, must consider the conditions “peculiar to each particular region” and “the mode of life of the inhabitants.” Two millennia later, Flexner wrote that when confronted with preventable disease, the “intelligent and conscientious” physician should endeavor “equally to heal the sick and to protect the well,” noting a duty to “promote social conditions that conduce to physical well-being.” The US health care system is out of balance, favoring treatment of disease and disease complications over prevention and wellness. To establish a more sustainable balance, the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services are providing new funding for public health efforts and new opportunities for health delivery reforms. Individual states, which face the human and economic consequences of poor health outcomes, have a special incentive to facilitate this transition. Oregon is pursuing fundamental restructuring of health delivery systems by promoting coordinated care organizations. Vermont is considering adopting a single-payer model of health care. Other states, including Colorado, Massachusetts, Maryland, Minnesota, and Ohio, are considering other innovative payment and delivery reforms. Complementing these approaches is the opportunity for all states to encourage creative, local partnerships to accomplish the triple aim—a better experience for patients, lower costs, and better outcomes. In one corner are large health care institutions, including hospitals and large specialty practices. These entities have existed largely in a world driven by fee-for-service billing. Many are wondering how to adapt to new financial incentives that favor better patient outcomes and discourage overutilization of technology and unnecessary readmissions. In the other corner are community-based primary care practices and innovative public health programs that specialize in attention to high-risk patients, home visiting, and case management. Over the years, these types of programs have identified ways to manage high-acuity patients or prevent illness from occurring. Some programs, with support from research grants and partnership with academic institutions, have been rigorously evaluated; others, due to limitations in funding or technical expertise, have not had the opportunity. Many promising programs have struggled to sustain themselves after grants run out or have difficulty scaling their programs for larger or different populations. In July 2011, Maryland launched a matchmaking project to bring these 2 types of health organizations together and make better use of emerging financial incentives. State health authorities sought public comment about innovative models of financing and clinical care in Maryland and received 80 submissions from 47 entities. Innovations were divided into 3 categories: (1) supportive financial mechanisms (n = 8), defined as alternative approaches to paying for care that replace fee-for-service with models that reward clinicians, practices, and hospitals, for keeping their patients healthier and incentivize strategies that reduce the need for expensive acute care services; (2) clinical innovations (n = 27), defined as novel health care and community strategies that prevent illness and reduce complications of disease, and lower health care costs; and (3) integrated programs (n=7), defined as projects that combine clinical innovations with supportive financing mechanisms in a partnership that uses savings to fund creative solutions to health care challenges. Twenty-nine promising efforts were initially identified that met the definitions of these categories and provided a data evaluation plan, a summary of the project, and contact information for key leaders (BOX). The state then created the Health Care Innovations in Maryland website as a resource to make these promising

Cold War, Deadly Fevers: Malaria Eradication in Mexico, 1955–1975

Marcos Cueto is a medical historian who describes the details of malaria eradication efforts in Mexico in the context of the Cold War era authoritarianism. His approach works overall, but occasionally he overreaches. Mr. Cueto asserts that the politics of the time allowed the medical community to be similarly authoritarian in forcing malaria eradication to be the accepted strategy. He states that the political climate relied on fear-based tactics of spreading anxiety about the communist threat and that similar strategies were used to gain public support for the malaria eradication effort, incorporating military jargon such as “enemy” mosquitoes and “campaigns” against disease into the public health lexicon. These campaigns included a propaganda arm in which pop stars became champions for the cause, to make the public sympathetic to their efforts. At one point, the author likens the strategy of screening persons for asymptomatic malaria parasitemia to the 1950s McCarthy-style witch hunts for hidden communists—stretching the analogy beyond tolerable limits. A recurring theme in the book is Mr. Cueto’s skepticism of new technologies, especially those introduced by other (non-Mexican) national or international organizations.He disparages the adoption of chloroquine, DDT, and smear microscopy as “magic bullet” strategies, claiming they distracted from rather than enhanced control efforts. He suggests that current efforts, which tout the use of long-lasting insecticide-treated bed nets and artemisinin-based combination therapy, are similarly flawed. He never really articulates proven alternatives to the adoption of new technologies, but he vaguely suggests relying on community-based broad public health programs at the grassroots level. I found the tone of the book a bit cynical and fatalistic. I got the impression that Mr. Cueto believes that all individuals and organizations attempting malaria eradication were doing so not for its own sake but rather as a front for other agendas such as centralizing national power in Mexico, furthering the international interests of capitalist countries, or personal glory. The author uses the fact that the eradication effort failed to support his contention that it was probably a bad idea in the first place. Fast forward to today when there is a renewed interest in malaria control efforts. Witness the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Bill & Melinda Gates Foundation; the President’s Malaria Initiative; and pop stars such as Bono championing the cause, including the possibility of eradication. Sounds familiar. In light of the current progress of malaria control efforts in Mexico, where most states are now malaria free and the total number of cases has been steadily decreasing, Mexico is well on its way to achieving those original eradication goals. Thus, whether you agree with the author’s politics or not, if you are considering getting into the business of malaria eradication, you could benefit by reviewing this very detailed historical account of a malaria eradication effort that was unsuccessful.

MCLEROY ET AL. RESPOND

We wish to thank Rabin for observing that “[h]ealthy aging begins with the fetus, not the adult.” Clearly, community-based public health programs must take into account health and health-related issues throughout the life span and focus on strengthening communities to support the health of all age groups. We will respond to several inferences that might be drawn from Rabin’s letter. First is the implication that health comes from participating in lifestyle programs. Second is the notion that educating children is the pathway to good health. Third is the implication that our approach allows individuals to comfortably and permanently “change.” Our view is that communities are more than mere settings for delivering individually oriented lifestyle change and health promotion programs. Instead, we believe that (1) many of the social forces that produce health and illness are experienced within communities (whether geographic communities, communities of identity, or relational communities); (2) communities are important resources for addressing health and healthrelated issues; (3) substantive, sustainable improvements in population health require addressing the social forces that produce illness, including social and economic disparities; and (4) building and strengthening communities is an important outcome of public health activities, irrespective of their effects on health status. As a result, we think that the delivery of direct services to individuals and participation in programs are only 2 of the numerous and varied goals of health promotion programs. Educating children (and adults) is important for every society. Nonetheless, health education in the narrow sense of conveying information about the benefits and costs of behaviors is a limited approach to addressing the present and future health needs of communities. To effectively advance the health of children, we need to better ensure safe and healthy environments, access to quality health care, smoke-free schools, enforcement of policies on motor vehicle restraints, and development of effective drug and violence prevention strategies. Moreover, we would suggest that in controversial societal issues, for example, adolescent pregnancy, when there is no consensus about who is to blame for the problem and who is responsible for the solution, our society tends to choose educational strategies over strategies that address more fundamental causes. Certainly, change—be it societal or individual—is uncomfortable. Creating a healthy society is not about seeking comfort or permanence, although sustainability of our efforts is an important goal. Rather, creating a healthy society is about seeking social justice and contributing to a peaceful and equitable world.

Applying Population Health Models

In this issue of the Journal, guest editors Daniel Friedman and Barbara Starfield have gathered together and added their voices to an outstanding collection of articles on models for population health. Together, they ask: Do theory and models matter in the conduct of public health research and practice? As researchers involved in community-based public health interventions and programs in Harlem, New York City, our answer is a resounding “yes!” The salience of the population health perspectives presented in this issue is made manifest in relation to 2 of our current projects—namely, evaluation of the Harlem Children’s Zone Asthma Initiative and analysis of the Harlem Household Survey. Both projects were implicitly shaped by what we would now term a population health perspective, in that the health needs of entire communities are embraced and individual, neighborhood, and societal factors are considered important for health and well-being. The theory and models presented in this issue—by explicitly delineating components of population health frameworks and models—can aid such efforts by helping us to conceptualize the pathways through which various factors influence health, thereby suggesting points of intervention and questions to ask when obtaining or analyzing data. The Harlem Children’s Zone Asthma Initiative added a public health component to the longstanding work on school truancy and community-building of the Harlem Children’s Zone, Inc, and the community-based health service delivery efforts of the Department of Pediatrics of Harlem Hospital Center. Building upon a population-based survey of adults in Central Harlem (the Harlem Household Survey), our evaluation perspective was enriched by a history of community-based public health research at the Harlem Health Promotion Center. By embracing a holistic population health perspective, we were able to pull together work with children and with adults, in hospitals and in schools, in our current efforts. This meant shoring up a public hospital center (pediatric ward, emergency department, and clinic) and public school infrastructure with private funding and tailored programs to ensure that the needs of every child in the Harlem Children’s Zone Project are met. One of the things we are learning, according to Dr. Stephen Nicholas, Director of Pediatrics at Harlem Hospital Center, is that coming into people’s homes to deliver interventions helps to remove communication barriers between health care providers and families. In doing so, we hope to improve the health and well-being of all household members—children and adults alike—through home visits for education in medication usage, family-centered primary health care services, and home environmental interventions to remove asthma triggers. The population health perspective does more than encourage these kinds of linkages—it facilitates them. Further, it underscores the need for researchers to use multidisciplinary approaches, to integrate qualitative and quantitative methods, and to recognize the importance of lay knowledge and participatory research (Young TK. Population Health: Concepts and Methods. New York: Oxford University Press Inc; 1998). Steeped in the conduct of community-based research, we can thoughtfully assess which population health models are relevant to our experiences and consistent with our values. Applying population health models—with their emphasis on social processes and conditions—affords an opportunity to test whether interventions that address social inequalities will reduce gaping health disparities across and between populations.

Risk factors for juvenile justice system referral among children in a public mental health system.

The objective of this study is to identify, through the use of secondary data, risk factors for juvenile justice system involvement among children entering a public mental health system. Data-sharing agreements between juvenile justice and mental health systems enabled investigators to examine criminal referrals among 645 children between the ages of 10 to 17 who entered community-based public mental health programs in King County, Washington, over the course of a single year. Univariate and logistic regression analyses were performed. Adjusting for age, gender, and ethnicity, children involved in the public mental health system who had juvenile justice referrals were more likely than children involved in the mental health system without juvenile justice referrals to have parents with a history of incarceration, to abuse drugs and/or alcohol, and to have experienced physical abuse. The study shows that some children who receive public mental health services are at particular risk of having an encounter with the juvenile justice system. Understanding the characteristics and experiences of youth who use multiple service systems has important implications for children's mental health services delivery.

Aversive smoking using printed instructions and audiotape adjuncts

Two promising comprehensive smoking cessation programs emphasizing aversive smoking and self-management were tested using a modified format with reduced supervision. The aversive smoking procedures-rapid smoking (RS) or regular-paced aversive smoking RPAS)—were presented via audiotaped instructions practiced entirely in clients' homes as were the instructions for deep muscular relaxation. Meetings with the consultant were designed for discussion of problems and progress with the home-practice guided by audiotape and a printed workbook. Results of the 6-week program showed significant benefits at termination by both programs (RS=56.3% abstinence and RPAS=71.4% abstinence) with some recovery of baseline at the 8-month follow-up (RS=37.5% abstinence and RPAS=28.6% abstinence). A no-treatment comparison group was found to be smoking significantly more cigarettes at a time corresponding to termination (0% abstinent) but unexplained quitting in this group resulted in a nonsignificant difference at the follow-up (11.8%). Implications for community-based public health programs were explored.