Changing Behaviours,Improving Outcomes? Governing Healthy Lifestyles Through Social Marketing

Recent public health policy and practice in the UK and beyond has promoted behavioural and lifestyle change as key methods for health improvement and the reduction of inequalities. These methods contrast with more upstream and structural interventions intended to address environmental and material determinants of health. A current exemplar of this approach is the use of social marketing. These changes represent a shift from the social to the individual as the target of public health interventions and raise a number of critical questions for health social scientists concerned not only with health improvement but also equity and social justice. Further, they can be identified as part of broader social and economic shifts that posit the individual as responsible for the management of their own bodies and selves in late modern societies characterised by ‘government at a distance’ and the repeal of welfare. This paper offers a review of shifting paradigms of public health and considers the implications of newer modes of health governance such as social marketing and their role as a modern form of health governance.     

Pachedu‐Zenzele in the Diaspora: Promoting Sexual Health Amongst Zimbabweans in England

Migrants have been found to be at enhanced risk for the Human Immune Deficiency Virus (HIV) in comparison with settled populations. As they migrate, they often bring with them their traditions and cultural values, which may influence the ways they access or make sense of health promotion interventions in the host country. In the diaspora, should they experience compromised citizenship, marked by an unresolved immigration status, some may need to remain invisible and this may include not accessing or presenting late for vital health care interventions. Addressing the needs of such invisible populations is key to health promotion work and paramount to public health interests. This paper describes how ever‐changing “traditions”, in particular the notions of Pachedu and Zenzele, were harnessed to develop ethically grounded sexual health care interventions amongst Zimbabweans in Luton, Bedfordshire, England. These interventions were delivered in mundane settings that formed some of the key everyday networks of this population. The reinvention of “tradition” for the purposes of delivering health and social care interventions has been one of the cornerstones of health promotion interventions in Africa, where the rates of HIV are some of the highest in the world. The concept of Pachedu harnessed confidentiality in the delivery of sexual health interventions with Zenzele calling for communal involvement in such initiatives. A key point that resulted in the success of this intervention was partnership work between statutory providers and the local Zimbabwean population throughout the project’s life span. Rather than being construed as passive recipients of health and social care interventions, local Zimbabweans and their statutory partners were engaged in mutual capacity building initiatives. Local Zimbabweans were also engaged and consulted throughout, from the conceptualization of the project, delivery, monitoring, and dissemination of the findings.     

Couple and family interventions in health problems

Intervention research for couples and families managing chronic health problems is in an early developmental stage. We reviewed randomized clinical trials of family interventions for common neurological diseases, cardiovascular diseases, cancer, and diabetes, which is similar to the content of previous reviews discussed later. One overriding theme of these studies is that patients with chronic illnesses and their families face a variety of challenges to which researchers have responded with an array of treatment modalities. Very few of the interventions reviewed, with the exception of treatment for adolescents with diabetes, tested family psychotherapy models. Most interventions were time-limited therapeutic interventions that trained families to improve their communication and problem-solving skills, individual and family coping skills, and medical management. Researchers more clearly described mechanisms of change in intervention studies with cancer and diabetes than with other diseases, and not surprisingly, they found greater empirical support for their interventions. Family interventions show promise to help patients and family members manage chronic illnesses. To develop an empirical base for family approaches to managing chronic illnesses, interventions must be based on theories that delineate mechanisms of change in family processes and skills in medical management necessary to maintain patients' and family members' health.     

PEGASE Program: Identification of babies in the child protection system at risk of developmental delays or disorders and the implementation of a ‘supra-optimal’ care pathway

The importance of the first three years of life for children's development and the consequences for their general health in adulthood have been widely documented in the international literature, including the benefits of early identification and intervention programs. Additionally, convergent research has highlighted wide-ranging negative trajectories attributable to both the short and long-term consequences of abuse and neglect and their neurobiological impact on health and development. However, formal identification processes and the use of standardised screening tools in child protection remain relatively rare despite the potential societal impact of child maltreatment in terms of public and economic health. Moreover, delays between the initial identification of mental health problems and health and developmental disorders, and the introduction of appropriate interventions persist. Abused and neglected infants risk an exacerbation of the consequences of early maltreatment due to insufficient access to prompt assessment and treatment, including appropriate responses to their health needs. The aim of this article is to present the PEGASE program, an innovative French program for very young children in care, which is modelled on the care of premature babies. By setting up an early care pathway, it aims to ensure adequate medical follow-up – both somatic and psychiatric – through standardised examination and tailored interventions in order to limit the adverse health and developmental consequences of abuse. The presentation of the PEGASE program is supplemented by a case study.     

Current issues in HIV disease and AIDS: Implications for health and rehabilitation professionals

HIV disease and AIDS are being redefined as chronic, long-term conditions that are suitable for vocational rehabilitation interventions. With the advent of more effective medical interventions, many individuals with these diseases are living longer and are interested in pursuing employment options. In this article, physiological and neurological symptoms, psychological and mental health issues, psychosocial issues affecting women, and employment-related issues and interventions are discussed as they apply to the health and rehabilitation practitioner working with individuals with HIV disease and AIDS.     

“The People Have No More Love Left for the Commonwealth”: Media,Migration and Identity in the 1961–62 British Smallpox Outbreak1

In the last days of 1961, with a Conservative government gingerly guiding highly controversial immigration restrictions through Britain's Parliament, another unwanted immigrant to the UK suddenly made its presence felt: smallpox. Media reportage, in both Pakistan and Britain, immediately intertwined legislation and outbreak. This article explores the interplay between these two sets of events, and their mutual impact on public, political, and medical perceptions of and responses to post-colonial immigration and immigrants in Britain.     

THE EFFECTIVENESS OF FAMILY INTERVENTIONS IN THE TREATMENT OF PHYSICAL ILLNESS

Although a large body of research demonstrates that the family has a powerful influence on physical health, the evidence for the effectiveness of family interventions in physical illness is less conclusive. Family therapy and other family interventions appear to be most effective in chronic childhood illnesses such as asthma and diabetes. Family interventions have also been shown to be effective in the management of some cardiovascular and neurologic disorders and for the treatment of obesity. Family therapy appears to be more effective than individual therapy for some groups of patients with anorexia nervosa. This research supports the increasingly important role of medical family therapy in the new health care system. Recommendations for future research are discussed.     

Public health research – multidisciplinary,high-benefit,undervalued

The major health problems faced by policy-makers and practitioners at national and local levels require public health approaches. However, public health research is the “poor relative” of biomedical research: it is worthy, but not rich. In the European Commission's health research programme, biomedicine gets 90% of the funding, whereas public health research gets less than 10%. This pattern is repeated nationally in most countries, reflecting public policies to support industries – pharmaceuticals, biotechnology, medical devices – where profits are to be made, rather than not-for-profit, public health research. SPHERE, a study coordinated through the European Public Health Association, conducted bibliometric analyses across public health research themes and mapped the European and national structures and priorities for research. Whilst most European countries have national strategies (and some programmes) for public health, few have public health research strategies and the coordination of public health research is weak. Three further studies are being undertaken. In STEPS, the contribution of civil society organizations in the new EU member states to public health research will be discussed at national workshops with the ministries of health, the science/research councils and the national public health associations. In PHIRE, thematic Sections and the national member associations together evaluate the impact of European-funded health projects within member states. In FAHRE, the specific theme of food and health will be addressed, bridging industry and non-profit research sectors. Arguments for public health research can be made through lobbying at European level, but researchers and practitioners also need to influence the development of public health research within individual countries – leading to a European Public Health Research Area.     

What Do Men Want?

Abstract

Men play a key role in determining good sexual health outcomes for themselves and their sexual partners. However, many interventions and much of the programmatic focus and effort in reproductive and sexual health care delivery, are focused on women. This paper shows how international goals for development (the Millennium Development Goals), and international agreements on population and development (such as that agreed at the International Conference on Population and Development, Cairo,1994) cannot be met without the full and active involvement of men. We argue that achieving international goals and targets requires more than simply encouraging men to take more responsibility for their actions, it requires a detailed understanding of men's own concerns in the field of sexual health and a commitment to address those concerns to achieve better sexual health for all.

Using examples from south Asia, the paper explores the evidence surrounding the burden of men's sexual ill-health in the Region. We find that while public health programmes are (rightly) focused on controlling HIV (and sexually transmitted infections to some degree), evidence from population-based surveys of men across south Asia shows that men are most concerned with ‘psycho-sexual conditions’ including discharge syndromes, weakness, and erectile dysfunction. There is evidence that some of these conditions may be linked to higher rates of risk-taking and gender-based violence in some men. We further review patterns of care seeking for men reporting these and other sexual health problems.

We conclude that the challenges facing public health professionals are how to ensure that men receive interventions which are appropriate (and affordable and accessible and of high quality) for addressing their own sexual health concerns whilst also meeting wider public health goals of improving population levels of sexual and reproductive health.     

Modern health services and health care behavior: a survey in Kathmandu, Nepal

The most important problem regarding health service utilization in Third World countries is that established indigenous forms of health care are readily available and compete with modern health care. Thus, in addition to understanding the components of the decision to seek medical help, we must understand the conditions that affect the choice of a specific health care system. This study examines the impact of medical pluralism on the use of modern forms of health care in Nepal. The findings show that the presence of medical pluralism is a significant factor which delays use of modern health services. Policy implications are discussed, and the need for more research in this area is stressed.     

Inequities in health outcomes and access to health care in South Africa: a comparison between persons with and without disabilities

Health is a fundamental human right and if health care is to be universal and equitable it should not be less accessible to some sectors of society than to others. The objective of this study was to compare health outcomes and access to health care between persons living with disabilities and their non-disabled counterparts. The research was based on secondary data analysis of wave 1 of the National Income Dynamic Survey. Results from the study indicated that people with disabilities reported a higher incidence of communicable and non-communicable diseases, lower access to medical insurance and greater use of public health care than their non-disabled counterparts. In conclusion, the findings highlight the inequities in health outcomes and access to health services for people with disabilities and emphasise the need for disability-friendly health care policies that reduce barriers to accessing health care.     

Youth tobacco sales-to-minors and possession-use-purchase laws: a public health controversy

Tobacco use among youth remains one of our nation's most significant public health problems, and yet available evidence from prevention and cessation person-centered approaches has been mixed. Given these disappointing outcomes, some have recommended more public health approaches, and these include tobacco sales-to-minors and possession-use-purchase laws. While community members and police officials have endorsed these types of public health initiatives, many within the public health community have been either guarded or even oppositional to such approaches. The primary reasons for this controversy are reviewed in this article. Outcome studies indicate that sales-to-minors laws can be an effective step toward the reduction of youth access to commercial sources of tobacco. However, even with these laws in place, many youth indicate that they continue to have easy access to tobacco, often by means of social sources. Advocates of these approaches have argued that more comprehensive public health interventions are needed, such as programs that combine youth access and possession-use-purchase laws. This article reviews the ongoing debate behind these types of public health efforts, and examines the evidence of such programs to reduce youth tobacco use.     

The Evolution of Community Mental Health Services in Asian American Communities

This paper explores the history of Asian immigration to the United States, and its intersections with the mental health system. As mental health care have evolved since the 1960s from institutions to the community, public mental health services for Asian Americans have become increasingly culturally relevant. Major policy shifts, trends in immigration, and mental health practice will be presented with a focus on the Bridge Program at the Charles B. Wang Community Health Center. Integrative practice and research models that extend evidence-based knowledge to Asian American communities and practice implications are discussed.     

The Causes of Pro-Immigration Voting in the United States Supreme Court1

During the pre-confirmation debate over Supreme Court Justice Sonia Sotomayor, critics accused her of allowing her background to influence her judicial decisions. This article assesses the validity of such a claim for all sitting justices from 1875 to 2007 in one relevant policy area, immigration. In this article, we look at all 185 immigration-related decisions by the Supreme Court from its creation through 2007. Logistic general estimating equation regression analysis of Supreme Court voting on these cases suggests that justices who were nominated by Democratic presidents, who were urbanites, and who had previous judicial experience were more likely to vote in favor of immigration. However, justices who grew up in the Southwest, had Southern European ancestors, or were ideological conservatives were more hostile to immigration. Although public opinion, the unemployment rate, and the percent foreign-born in a given year did not affect justices’ votes, non-asylum cases and appeals from the Eighth Circuit were more likely to receive favorable treatment. The mean level of racial liberalism of the Senators in office during a particular justice’s confirmation hearings likewise had a large impact on his or her subsequent rulings. These findings suggest that Supreme Court voting on immigration is substantially influenced by justices’ background and political preferences as well as by some political and legal structures. These results thus support Legal Realism and New Institutionalism instead of the Traditional Legal Model of Supreme Court behavior.     

The politics of immigration reform

The US is the target for international migration, now more than ever. Population growth and economic stragnation in the Third World are increasing the pressures for out-migration, and current immigration law is wholly incapable of responding to the ever increasing flow of illegal immigrants. Border apprehensions of illegal aliens in the US were up 40% during 1983, and total apprehensions reached 1.25 million by the year's end. Recent public opinion polls have disclosed that an overwhelming majority of the American public demands immigration reform, and yet we as a nation have been distinctly unwilling or unable to respond to this clear public sentiment. This paper discusses the politics of the "Simpson-Mazzoli" Immigration Reform and Control Act, previous immigration legislation, current counterproposals for US immigration policy, and the political realities of immigration reform.     

Addressing Sexually Transmitted Infections (STIs), including HIV/AIDS,in the Context of Sexual Health

ABSTRACT

Sexually transmitted infections (STIs) have occupied a central place in public health agendas for at least the past 500 years, but have been the subject of opinions, decrees and “moral positions” for much longer. Societies have long tried to control the sexual behaviors of their populations, not only for reasons of social control, but also with the objective of controlling the spread of disease—HIV is the latest example of how societies respond to infections spread through the most private of individual behaviors. The article outlines the burden of disease associated with sexually transmitted infections including HIV, and explores their impact on efforts to achieve the Millennium Development Goals (MDGs). A large number of options for prevention and care of the sexually transmitted infections and HIV are currently available in both resource-rich and resource-constrained settings. In this article I move beyond the narrow focus of biomedical interventions concentrated on the individual and explore the evidence for public health measures aimed at controlling these infections. Using a public health framework I outline the various measures that can be implemented for STI/HIV control, and in addition to exploring the evidence for their public health effectiveness, I also look at how each of these interventions can be delivered within a paradigm of sexual health more generally. Finally, the article proposes recommendations for which effective strategies should be incorporated into a broader framework for promoting sexual health.     

“The Politics of the HealthCare Reform Debate: Public Support of Including Undocumented Immigrants and Their Children in Reform Efforts in the U.S.”

Although U.S. immigration and health care policies appear to be highly correlated, scholarship has yet to gauge the public's views toward providing undocumented immigrants with health coverage at the state level. We analyze support for including undocumented immigrants in health care reform in New Mexico. Utilizing an original public opinion survey of New Mexico adults, we find that individuals are more supportive of the state providing health care to the children of undocumented immigrant than to their parents. Multivariate logistic regression analyses suggest that factors such as liberal ideology and perceptions of commonalities with Latinos increase support levels. Despite a lack of support among a majority of respondents, the influence of perceived commonalities with immigrants suggests that reform advocates and political elites who mobilize along ethnic or human solidarity may be successful in creating conditions for the inclusion of undocumented immigrants in the public provision of health care at the state level.     

Severe self-neglect: an epidemiological and historical perspective

Older adults with severe self-neglect have multiple deficits in various social, functional and physical domains, and often live insqualor. These individuals often present with poor personal hygiene, domestic squalor and hoarding which results in a threat to their own health as well as personal and public safety. Severe self-neglect occurs along a continuum with older adults often having cognitive and affective disorders compared with younger individuals presenting with psychiatric illnesses. In cases of severe self-neglect with hoarding, evidence has shown this behavior occurs in diverse social strata and not among the wealthy and professionals alone as believed earlier. Due to the multiple conditions associated with severe self-neglect, this population will require an interdisciplinary, multidimensional approach to reduce morbidity and mortality rates including nursing home placement. Research on this group has been limited and is rarely described in the medical and nursing literature. Future research is needed to provide practitioners with effective screening instruments and interventions on cases of severe self-neglect.     

Perceptions of Immigrant Criminality: Crime and Social Boundaries

Researchers studying the relationship between immigration and crime frequently note the discrepancy between actual rates and public perceptions of criminal behavior by immigrants. Analyzing staff‐ and reader‐generated texts in a local newspaper, we find that this connection is maintained through a conflation of key terms, assumptions of the legal status of immigrants, and a focus on high‐profile criminal acts. We argue that the discourse of immigrant criminality has been critical in constructing social boundaries used in recent immigration legislation. Our analysis helps explain why current scholarly findings on immigration and crime have had little influence in changing public opinion.     

Limitations of evidence in the practice of evidence-based medicine

The goal of evidence-based medicine (EBM) is to support population-based policies and individual medical decisions that serve to improve health outcomes through the use of the most proven effective treatments. The essence of EBM is to use evidence (typically research data) related to the effectiveness of medical interventions to guide decisions about whether to use those interventions in clinical practice. The quality of evidence is the critical component in understanding and using EBM. This article discusses the kinds and limitations of the evidence used in the practice of EBM.