Community-level Benefits Research Articles

The effect of group involvement on post-disaster mental health: A longitudinal multilevel analysis

Involvement in voluntary associations is a key form of social capital and plays an especially important role following disaster as a venue for coordination and decision-making for the wider community. Yet, relatively little attention has been paid to how group involvement affects mental health, at either the individual or community level. The aim of this study was to assess the impact of involvement in voluntary associations on mental health among residents of bushfire-affected communities. A longitudinal sample of 642 individuals affected by the 2009 Victorian bushfires in south-eastern Australia were surveyed in 2012 and 2014 (3- and 5-years post-disaster). A further subsample (n = 552) of residents residing continuously within 22 bushfire-affected communities were examined for community-level effects using multilevel regression methods. After adjusting for demographics, disaster exposure, and network variables, group involvement at time 1 bore a curvilinear relationship with PTSD at both time points: moderate involvement was most beneficial, with no participation, or high amounts, yielding poorer outcomes. High amounts of group involvement was likewise linked to a greater risk of major depression. Furthermore, communities with higher median levels of group involvement reported lower levels of PTSD symptoms and major depression two years later. With respect to group involvement, more is not always better. For individuals, moderation – if possible – is key. Meanwhile, community-level health benefits come when most people participate to some extent, suggesting that the distribution of involvement across the community is important.

Assessment of community-level effects of intermittent preventive treatment for malaria in schoolchildren in Jinja, Uganda (START-IPT trial): a cluster-randomised trial

SummaryBackgroundIntermittent preventive treatment (IPT) is a well established malaria control intervention. Evidence that delivering IPT to schoolchildren could provide community-level benefits is limited. We did a cluster-randomised controlled trial to assess the effect of IPT of primary schoolchildren with dihydroartemisinin-piperaquine (DP) on indicators of malaria transmission in the community, in Jinja, Uganda.MethodsWe included 84 clusters, each comprising one primary school and the 100 closest available households. The clusters were randomly assigned 1:1 to receive IPT with DP or standard care (control) by restricted randomisation to ensure balance by geography and school type. Children in intervention schools received IPT monthly for up to six rounds (June to December, 2014). We did cross-sectional community surveys in randomly selected households at baseline and in January to April, 2015, during which we measured participants' temperatures and obtained finger-prick blood smears for measurement of parasite prevalence by microscopy. We also did entomological surveys 1 night per month in households from 20 randomly selected IPT and 20 control clusters. The primary trial outcome was parasite prevalence in the final community survey. The primary entomological survey outcome was the annual entomological inoculation rate (aEIR) from July, 2014, to April, 2015. This trial is registered at ClinicalTrials.gov, number NCT02009215.FindingsAmong 23 280 students registered in the 42 intervention schools, 10 079 (43%) aged 5–20 years were enrolled and received at least one dose of DP. 9286 (92%) of 10 079 received at least one full course of DP (three doses). Community-level parasite prevalence was lower in the intervention clusters than in the control clusters (19% vs 23%, adjusted risk ratio 0·85, 95% CI 0·73–1·00, p=0·05). The aEIR was lower in the intervention group than in the control group, but not significantly so (10·1 vs 15·2 infective bites per person, adjusted incidence rate ratio 0·80, 95% CI 0·36–1·80, p=0·59).InterpretationIPT of schoolchildren with DP might have a positive effect on community-level malaria indicators and be operationally feasible. Studies with greater IPT coverage are needed.FundingUK Medical Research Council, UK Department for International Development, and Wellcome Trust.

Risk creating and risk reducing: Community perceptions of supervised consumption facilities for illicit drug use

Progressive public health authorities in high-income countries have advocated supervised consumption facilities, where people who use illicit drugs can consume them in a hygienic, supervised environment, as a way of reducing drug-related risks to both people who use drugs and communities. However, the planning of such facilities has often met with strong reactions from the local community. ‘Not in my backyard’ (NIMBY) type reactions are frequently encountered and public opinion polling is limited in its ability to provide detailed insights into the reasons why people support or oppose these facilities in Toronto and Ottawa. We explore perceptions of residents and business representatives to the proposed implementation of supervised consumption facilities, and examine their perceptions of risks from these facilities. We collected qualitative data from 2008–2010 using focus groups and interviews with 38 residents and 17 business representatives in these two large Canadian cities lacking supervised consumption facilities. We used thematic analysis to examine expressed benefits and risks regarding supervised consumption facilities amongst community members. These participants saw these facilities as potentially risk-reducing, but recognised that the facilities could also create risks for their communities. While community members accepted that facilities could have positive health effects, they expressed a level of concern regarding the risk of public nuisance associated with supervised consumption facilities that seemed unwarranted based on the existing evidence. Discussions on the risks involved in the establishment of supervised consumption facilities should move beyond a focus on the benefits to facility users, to exploring community-level benefits and risks, and integrate evidence regarding actual risk experiences from other locations. Similar approaches may apply to NIMBY concerns related to other contentious issues.

Extending Conifer Removal and Landscape Protection Strategies from Sage-grouse to Songbirds, a Range-Wide Assessment

Recent and unprecedented scale of greater sage-grouse (Centrocercus urophasianus) conservation in the American West enables assessment of community-level benefits afforded to other sagebrush-obligate species. We use North American Breeding Bird Survey (BBS) count data and machine-learning to assess predictors influencing spatial distribution and abundance of three sagebrush-obligate songbirds (Brewer’s sparrow [Spizella breweri], sagebrush sparrow [Artemisiospiza nevadensis], and sage thrasher [Oreoscoptes montanus]). We quantified co-occurrence of songbird abundance with sage-grouse lek distributions using point pattern analyses and evaluated the concurrence of songbird abundance within sage-grouse habitat restoration and landscape protection. Sagebrush land-cover predictors were positively associated with the abundance of each songbird species in models that explained 16−37% of variation in BBS route level counts. Individual songbird models identified an apparent 40% threshold in sagebrush land-cover, over which songbird abundances nearly doubled. Songbird abundances were positively associated with sage-grouse distributions (P < 0.01); range-wide, landscapes supporting > 50% of males on leks also harbored 13−19% higher densities of songbirds compared with range-wide mean densities. Eighty-five percent of the conifer removal conducted through the Sage Grouse Initiative coincided with high to moderate Brewer’s sparrow abundance. Wyoming’s landscape protection (i.e., “core area”) strategy for sage-grouse encompasses half the high to moderate abundance sagebrush sparrow and sage thrasher populations. In the Great Basin half the high to moderate abundance sagebrush sparrow and sage thrasher populations coincide with sage-grouse Fire and Invasive Assessment Tool priorities, where conservation actions are being focused in an attempt to reduce the threat of wildfire and invasive plants. Our work illustrates spatially targeted actions being implemented ostensibly for sage-grouse largely overlap high abundance centers for three sagebrush obligate passerines and are likely providing significant conservation benefits for less well-known sagebrush songbirds and other sagebrush-associated wildlife.

Assessing potential health impacts of waste recovery and reuse business models in Hanoi, Vietnam.

In resource-constrained settings, the recovery of nutrients and the production of energy from liquid and solid waste are important. We determined the range and magnitude of potential community health impacts of six solid and liquid waste recovery and reuse business models in Hanoi, Vietnam. We employed a health impact assessment (HIA) approach using secondary data obtained from various sources supplemented with primary data collection. For determining the direction (positive or negative) and magnitude of potential health impacts in the population, a semiquantitative impact assessment was pursued. From a public health perspective, wastewater reuse for inland fish farming, coupled with on-site water treatment has considerable potential for individual and community-level health benefits. One of the business models investigated (i.e. dry fuel manufacturing with agro-waste) resulted in net negative health impacts. In Hanoi, the reuse of liquid and solid waste-as a mean to recover water and nutrients and to produce energy-has considerable potential for health benefits if appropriately managed and tailored to local contexts. Our HIA methodology provides an evidence-based decision-support tool for identification and promotion of business models for implementation in Hanoi.

Phase 4 Studies in Heart Failure - What is Done and What is Needed?

Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 – 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.

Effective coverage and systems effectiveness for malaria case management in sub-Saharan African countries.

Scale-up of malaria preventive and control interventions over the last decade resulted in substantial declines in mortality and morbidity from the disease in sub-Saharan Africa and many other parts of the world. Sustaining these gains will depend on the health system performance. Treatment provides individual benefits by curing infection and preventing progression to severe disease as well as community-level benefits by reducing the infectious reservoir and averting emergence and spread of drug resistance. However many patients with malaria do not access care, providers do not comply with treatment guidelines, and hence, patients do not necessarily receive the correct regimen. Even when the correct regimen is administered some patients will not adhere and others will be treated with counterfeit or substandard medication leading to treatment failures and spread of drug resistance. We apply systems effectiveness concepts that explicitly consider implications of health system factors such as treatment seeking, provider compliance, adherence, and quality of medication to estimate treatment outcomes for malaria case management. We compile data for these indicators to derive estimates of effective coverage for 43 high-burden Sub-Saharan African countries. Parameters are populated from the Demographic and Health Surveys and other published sources. We assess the relative importance of these factors on the level of effective coverage and consider variation in these health systems indicators across countries. Our findings suggest that effective coverage for malaria case management ranges from 8% to 72% in the region. Different factors account for health system inefficiencies in different countries. Significant losses in effectiveness of treatment are estimated in all countries. The patterns of inter-country variation suggest that these are system failures that are amenable to change. Identifying the reasons for the poor health system performance and intervening to tackle them become key priority areas for malaria control and elimination policies in the region.

An Exploration of Health, Nutrition and Community Experiences of Gardeners at Wangari Gardens

BackgroundWangari Gardens is a community garden and garden education nonprofit located in the northwest region of Washington, DC. The gardens consist of 110 individual garden plots, public gardens open to harvest by any local resident of DC, and an outdoor classroom that holds free weekly workshops on gardening topics for all community members.ObjectiveTo explore the health and community related experiences of community members who hold garden plots at Wangari Gardens.Methods17 semi‐structured qualitative interviews were conducted at the community garden. Interviews lasted a half hour on average, and covered topics of how one chose to garden both broadly and at Wangari, benefits of gardening, and challenges associated with community gardening. Interviews were recorded and transcripts analyzed using qualitative data analysis software.ResultsCommunity members chose to begin gardening to improve nutrition, manage chronic disease symptoms, cultivate an ongoing hobby, and establish a greater connection with nature and their surrounding community. Community members continued gardening to maintain relationships created at the gardens, physical benefits, harvest from garden plots, and feelings of self‐efficacy.ConclusionCommunity gardens provide multi‐faceted benefits to community members, including individual level benefits such as a greater sense of physical well‐being and enjoyment of healthy food, and community level benefits such as bringing community members together and creating a sense of community ownership of the land and their health. This work adds to the growing body of literature on the benefits of utilizing green spaces in urban areas for community growth and health initiatives.

Impact of health systems factors on effectiveness of malaria case management in Sub-Saharan African countries

Background Scale-up of malaria preventative and control interventions over the last decade resulted in substantial declines in mortality and morbidity of the disease. Sustaining these gains in the future will depend on the health system performance. Treatment provides individual benefits by curing infection and preventing progression to severe disease as well as community-level benefits by reducing the infectious reservoir and averting the emergence and spread of drug resistance. However many patients with malaria do not access care, providers do not always comply with treatment guidelines, so patients do not necessarily receive the correct regimen. Even when the correct regimen is administered there is concern that patients will not adhere, leading both to treatment failures and potentially to the spread of drug resistance.

Risk factors for suicide attempts in a clinic-based sample of people living with HIV in Puerto Rico

Puerto Rico (PR) has a large and rapidly growing population of people living with HIV. However, relatively little behavioral or clinical research has been done in this population. As treatment for HIV increasingly moves into a chronic condition model, it is becoming increasingly important to understand the needs of this population so critical social and behavioral interventions can be developed, thus enabling the individual and community-level benefits of antiretroviral (ARV) treatment to be fully realized. To date, however, there has been very little research on the mental health needs of people living with HIV in PR, a fact that constrains intervention development and implementation. This paper describes data from a public sexually transmitted infection (STI) and HIV clinic study in the San Juan metropolitan area between April 2010 and December 2012 (n = 1185), roughly a third (36%) of whom are living with HIV. Descriptive statistics, chi-square, t-tests, and binary logistic regressions were used to assess associations between HIV status and a history of suicide attempt. The overall prevalence of a history of suicide attempt was 20.4%. No statistically significant relationship was found between a history of suicide attempt and being HIV positive, although people with HIV infection did evidence a higher prevalence of attempts than HIV-negative subjects (23.4% vs. 19.0%). Factors associated with having a history of suicide attempt within the overall sample included gender, current employment status, a lifetime history of drug use, and a lifetime history of sex work. Similar patterns were seen in the HIV-positive subsample. There was a nonsignificant trend toward increased risk for a post-diagnosis suicide attempt. These findings suggest that additional research on mental health risks among populations at risk for HIV in PR is needed.

The benefits to communities and individuals of screening for active tuberculosis disease: a systematic review [State of the art series. Case finding/screening. Number 2 in the series

Screening for tuberculosis (TB) disease aims to improve early TB case detection. The ultimate goal is to improve outcomes for people with TB and to reduce Mycobacterium tuberculosis transmission in the community through improved case detection, reduction in diagnostic delays and early treatment. Before screening programmes are recommended, evidence is needed of individual and/or community-level benefits. We conducted a systematic review of the literature to assess the evidence that screening for TB disease 1) initially increases the number of TB cases initiated on anti-tuberculosis treatment, 2) identifies cases earlier in the course of disease, 3) reduces mortality and morbidity, and 4) impacts on TB epidemiology. A total of 28 798 publications were identified by the search strategy: 27 087 were excluded on initial screening and 1749 on full text review, leaving 62 publications that addressed at least one of the study questions. Screening increases the number of cases found in the short term. In many settings, more than half of the prevalent TB cases in the community remain undiagnosed. Screening tends to find cases earlier and with less severe disease, but this may be attributed to case-finding studies using more sensitive diagnostic methods than routine programmes. Treatment outcomes among people identified through screening are similar to outcomes among those identified through passive case finding. Current studies provide insufficient evidence to show that active screening for TB disease impacts on TB epidemiology. Individual and community-level benefits from active screening for TB disease remain uncertain. So far, the benefits of earlier diagnosis on patient outcomes and transmission have not been established.

A SCREENING TOOL FOR CLIMATE CHANGE POPULATION VULNERABILITY ASSESSMENTS

Background and Aims: Conducting vulnerability assessments is one of the key tools for adaptation for climate change. Population vulnerability screening is needed to guide policy makers in planning efforts to address climate change impacts. California has proceeded in implementing cap and trade as a regulatory method to mitigate greenhouse gas (GHG) emissions. Decision-makers need to determine whether there are ways to target GHG mitigation schemes in ways that maximize community-level health benefits from co-pollutant reductions and minimize the likelihood that market-based approaches produce or exacerbate disparities in health benefits. Methods: We utilized an existing environmental justice screening method and targeted it for two areas in California which are likely to experience climate change impacts, Fresno and Los Angeles counties. This method maps cumulative impacts and vulnerability to air pollution and models the locations of pollutant sources as well as vulnerable populations. We further adapted this method with metrics that are associated with adaptation capacity such as population sensitivities (e.g., elderly living alone and senior housing), air conditioning ownership, green space, co-morbidities, and flood and wildfire risk. Results: A cumulative climate change vulnerability score was computed for each census tract for the two counties. A separate score for the climate change vulnerability and environmental justice layers, and a combined score, was computed. The predictive power of the scores was validated by examining the sensitivity to emergency room and hospitalization data for heat-related illness. Conclusions: We developed a geospatial mapping resource that identifies climate change vulnerable populations in two major metropolitan areas of California. This tool can be used by multiple stakeholders to identify locations of high cumulative exposures to environmental hazards and social vulnerability that may require targeted efforts to promote adaptation to climate change impacts, and increase the likelihood that mitigation strategies will yield maximum decreases in localized co-pollutants.

Michigan passenger rail: An analysis of community benefits

Passenger rail service is perceived to provide important benefits to Michigan communities. However, the extent of these benefits has never been quantified in a systematic way. The study reported on here involved the performance of a broad based assessment of the community level benefits of passenger rail serv ice. The main objective of the research project was to estimate the full range of these benefits at the community level, as opposed to at the state level. Benefits were estimated for individual travelers, Amtrak expenditures, and local businesses. This research indicates local communities currently realize $62.0 million annually in benefits. Additional benefits accrue to the region, state, and nation in the form of congestion relief, air quality improvement, energy conservation, and safety.

Benchmarking and evaluating the comparative efficiency of urban paratransit systems in the United States: A data envelopment analysis approach

Passenger rail service is perceived to provide important benefits to Michigan communities. However, the extent of these benefits has never been quantified in a systematic way. The study reported on here involved the performance of a broad based assessment of the community level benefits of passenger rail serv ice. The main objective of the research project was to estimate the full range of these benefits at the community level, as opposed to at the state level. Benefits were estimated for individual travelers, Amtrak expenditures, and local businesses. This research indicates local communities currently realize $62.0 million annually in benefits. Additional benefits accrue to the region, state, and nation in the form of congestion relief, air quality improvement, energy conservation, and safety.

ETHICAL CONSIDERATIONS IN SURVEYS EMPLOYING RESPONDENT-DRIVEN SAMPLING

DeJong et al. discussed ethical considerations in surveys employing respondent-driven sampling with high-risk populations, including injection drug users (IDUs), in Lebanon.1 While we commend the authors' work, several concerns bear comment. First, almost all concerns raised as ethical problems in implementing respondent-driven sampling apply universally to HIV research with at-risk populations irrespective of the sampling methodology and are not unique to respondent-driven sampling.2 Building on the Belmont report,3 procedures for protecting participants, assessing and differentiating between primary and secondary remuneration, and the timing of such remuneration are increasingly refined.4,5 Respondent-driven sampling does not require reinventing procedures to protect participants but thorough implementation of relevant procedures (e.g., adequate formative research, pilot study, confidential coupon-management system, thorough screening for eligibility, adequate training of recruiters and staff). It is crucial to distinguish implementation concerns from regulatory and ethical concerns, addressing each using pertinent procedures.5,6 Whenever ethical concerns converge synergistically, such as in HIV research employing respondent-driven sampling or other peer-driven sampling methodology with IDUs in stigmatizing environments, use of appropriate procedures is important.5,7–9 Second, the article suggests that recruitment using respondent-driven sampling may expose participants to risk by disclosing illegal or stigmatized behavior. Respondent-driven sampling requires social network recruitment, during which participants recruit those whom they already know from the target population. Participants elect whom to recruit and whether they share information with others. The potential adverse effect of unwanted disclosure on IDUs' reputation appears unlikely when IDUs know they are at risk for HIV and because in most settings peer-to-peer IDU recruitment does not convey new information about drug use or HIV risk. Use of respondent-driven sampling with IDUs permits examination of social linkages across HIV status and ethnic groups. Safeguards against community-level harm to reduce further stigmatization are relevant, especially when HIV is concentrated in particular ethnic groups.10 Third, the article does not discuss adequately community-level benefits of biobehavioral surveys in advancing HIV/AIDS research, prevention, and treatment (e.g, use of data to plan interventions). Respondent-driven sampling provides access to hard-to-reach at-risk populations in high-stigma environments and improves statistical reliability and validity of outcome measures.11 To provide appropriate balance, discussions and publication of ethical concerns need to be based on study data, because describing hypothetical harms could create the impression that harms were actualized, or that study-level protective procedures were inadequate. We believe in the importance of accurately attributing ethical concerns to specific and correct factors to ensure scientifically valid research and use and publication of ethically sound safeguards in research. A patient in a portable tent receives emergency medical care at the Wise County Fairgrounds in Virginia. From July 20–22, 2007, nearly 1200 volunteer physicians and students treated over 2500 Appalachians who could not afford health care. Printed with permission of Magnum Photos.

Changes in Physical Activity from Walking to School

Changes in Physical Activity from Walking to School

Optimizing the Dose of Pre-Pandemic Influenza Vaccines to Reduce the Infection Attack Rate

BackgroundThe recent spread of avian influenza in wild birds and poultry may be a precursor to the emergence of a 1918-like human pandemic. Therefore, stockpiles of human pre-pandemic vaccine (targeted at avian strains) are being considered. For many countries, the principal constraint for these vaccine stockpiles will be the total mass of antigen maintained. We tested the hypothesis that lower individual doses (i.e., less than the recommended dose for maximum protection) may provide substantial extra community-level benefits because they would permit wider vaccine coverage for a given total size of antigen stockpile.Methods and FindingsWe used a mathematical model to predict infection attack rates under different policies. The model incorporated both an individual's response to vaccination at different doses and the process of person-to-person transmission of pandemic influenza. We found that substantial reductions in the attack rate are likely if vaccines are given to more people at lower doses. These results are applicable to all three vaccine candidates for which data are available. As a guide to the magnitude of the effect, we simulated epidemics based on historical studies of immunogenicity. For example, for one of the vaccines for which data are available, the attack rate would drop from 67.6% to 58.7% if 160 out of the total US population of 300 million were given an optimal dose rather than 20 out of 300 million given the maximally protective dose (as promulgated in the US National Pandemic Preparedness Plan). Our results are conservative with respect to a number of alternative assumptions about the precise nature of vaccine protection. We also considered a model variant that includes a single high-risk subgroup representing children. For smaller stockpile sizes that allow vaccine to be offered only to the high-risk group at the optimal dose, the predicted benefits of using the homogenous model formed a lower bound in the presence of a risk group, even when the high-risk group was twice as infective and twice as susceptible.ConclusionsIn addition to individual-level protection (i.e., vaccine efficacy), the population-level implications of pre-pandemic vaccine programs should be considered when deciding on stockpile size and dose. Our results suggest that a lower vaccine dose may be justified in order to increase population coverage, thereby reducing the infection attack rate overall.

Breast carcinoma chemoprevention in the community setting

The United States Preventive Services Task Force recommends that women who are at both high risk for breast carcinoma and low risk for adverse events should receive counseling regarding tamoxifen for chemoprevention. Estimates of the risks and benefits of tamoxifen based on results from clinical trials may not reflect the real-world experience. The authors determined the prevalence of women in a community-based cohort who would meet the definition of high risk for breast carcinoma and calculated the number of women needed to screen to determine one for whom the benefits of tamoxifen would outweigh the risks. Baseline incidence also was examined for adverse health events in this community-based cohort compared with participants in the Breast Cancer Prevention Trial. The study participants were women ages 40-70 years (n = 6048 women) who were members of the CLUE II cohort, which started in 1989, and who responded to questionnaire surveys in 1996 and 2000. Eighteen percent of all women had a 5-year risk of invasive breast carcinoma > or = 1.66%. The number of women needed to screen to find 1 woman for whom the benefits outweighed the risks of tamoxifen ranged from 26 women ages 40-49 years to 142 women ages 60-70 years. For women who had undergone a hysterectomy, the numbers needed to screen were lower. Baseline incidence rates of fracture and thromboembolic disease were higher in the community-based cohort compared with the rates observed among prevention trial participants; thus, fewer women had to be treated with tamoxifen to prevent one fracture. However, fewer women in the community also had to be treated to observe harm with a thromboembolic event. Clinicians who counsel women about tamoxifen should take into consideration community-level risks and benefits.