Tackling physical inactivity and inequalities: implementing a whole systems approach to transform community provision for disabled people and people with long-term health conditions.

BACKGROUND: Physical inactivity is a global public health priority. There are known health and well-being consequences of being inactive, and the benefits of being physically active are well established. However, there are persistent inequalities when it comes to how physically active people are, with disabled people, people living with long-term health conditions, and people residing in areas of socio-economic deprivation being particularly affected. Methods such as whole system approaches (WSAs), which are dynamic, multifaceted, and engage all relevant stakeholders, have gained momentum as an approach to address such complex public health problems. However, evidence relating to the implementation of WSAs to address physical inactivity is lacking. The aim of the Prevention and Enablement Model (PEM) was to take a whole system approach in Essex to encourage and support disabled people and/or individuals living with long-term health conditions to be more active, happier, and to live more independently. METHODS: The aim of this study was to explore the enablers, challenges, and reflections associated with the process of designing and implementing the PEM. Semi-structured interviews (n = 12) were used to collect data from people involved in the PEM's design, implementation and/or delivery. Data was analysed using Braun and Clarke's reflexive thematic analysis. RESULTS: Four themes were identified: (1) Working collaboratively: Specific enablers of time and space were identified as important in the planning and implementation of a WSA (2) Leadership and planning: Distributed and flexible leadership was identified as central to successful implementation (3) Re-orientating practice: Highlighted the transformative potential of a whole system approach and how it contrasts with conventional work practices, and (4) Reflection and learning: Informing ongoing refinements and further implementation of successful system change. CONCLUSIONS: These findings highlight the challenge and complexity of implementing a WSA that involves diverse stakeholders from across adult social care, the NHS, and the third sector. Several important enablers are identified, such as leadership and planning, and the challenges and discomfort that can arise whilst changing systems. Ongoing efforts are required to ensure that different elements of the system collaborate effectively to address inequalities in physical activity participation, through the implementation of a WSA.

Biosecurity in multifunctional landscapes: challenges for approaches based on the concept of 'shared responsibility'.

Biosecurity policy in NSW is based on the concept of 'shared responsibility' that emphasises small government and devolution of responsibility to stakeholders. This paper draws on a case study of the cattle tick program to illustrate the challenges for governments implementing a 'shared responsibility' biosecurity strategy in the multifunctional rural landscapes that are now typical of the more closely settled regions of south-eastern Australia. Agriculture may remain the dominant land use in these regions but other values underpin landownership and management for an increasing proportion of landholders who are not farmers by occupation, are disconnected from traditional producer networks, and often lack the knowledge and skills to effectively manage biosecurity threats. We describe the challenges posed by multifunctionality including a high property turnover rate, rapidly increasing rural land values, in-migration of new landholders and multiple landholder types holding different values and beliefs that influence their cattle tick management practices. We suggest ways biosecurity programs within a 'shared responsibility' framework can more effectively engage producers. These include negotiating with industry or a representative body the level of responsibility and management decisions being delegated, and to building the social and human capital of landholders taking into account the specific information and training needs of new and non-farmer landholders in addition to cattle tick management.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 1. rationale, methods and database description.

BACKGROUND: Community-based primary health care (CBPHC) is an approach used by health programs to extend preventive and curative health services beyond health facilities into communities and even down to households. Evidence of the effectiveness of CBPHC in improving maternal, neonatal and child health (MNCH) has been summarized by others, but our review gives particular attention to not only the effectiveness of specific interventions but also their delivery strategies at the community level along with their equity effects. This is the first article in a series that summarizes and analyzes the assessments of programs, projects, and research studies (referred to collectively as projects) that used CBPHC to improve MNCH in low- and middle-income countries. The review addresses the following questions: (1) What kinds of projects were implemented? (2) What were the outcomes of these projects? (3) What kinds of implementation strategies were used? (4) What are the implications of these findings? METHODS: 12 166 reports were identified through a search of articles in the National Library of Medicine database (PubMed). In addition, reports in the gray literature (available online but not published in a peer-reviewed journal) were also reviewed. Reports that describe the implementation of one or more community-based interventions or an integrated project in which an assessment of the effectiveness of the project was carried out qualified for inclusion in the review. Outcome measures that qualified for inclusion in the review were population-based indicators that defined some aspect of health status: changes in population coverage of evidence-based interventions or changes in serious morbidity, in nutritional status, or in mortality. RESULTS: 700 assessments qualified for inclusion in the review. Two independent reviewers completed a data extraction form for each assessment. A third reviewer compared the two data extraction forms and resolved any differences. The maternal interventions assessed concerned education about warning signs of pregnancy and safe delivery; promotion and/or provision of antenatal care; promotion and/or provision of safe delivery by a trained birth attendant, screening and treatment for HIV infection and other maternal infections; family planning, and; HIV prevention and treatment. The neonatal and child health interventions that were assessed concerned promotion or provision of good nutrition and immunizations; promotion of healthy household behaviors and appropriate utilization of health services, diagnosis and treatment of acute neonatal and child illness; and provision and/or promotion of safe water, sanitation and hygiene. Two-thirds of assessments (63.0%) were for projects implementing three or fewer interventions in relatively small populations for relatively brief periods; half of the assessments involved fewer than 5000 women or children, and 62.9% of the assessments were for projects lasting less than 3 years. One-quarter (26.6%) of the projects were from three countries in South Asia: India, Bangladesh and Nepal. The number of reports has grown markedly during the past decade. A small number of funders supported most of the assessments, led by the United States Agency for International Development. The reviewers judged the methodology for 90% of the assessments to be adequate. CONCLUSIONS: The evidence regarding the effectiveness of community-based interventions to improve the health of mothers, neonates, and children younger than 5 years of age is growing rapidly. The database created for this review serves as the basis for a series of articles that follow this one on the effectiveness of CBPHC in improving MNCH published in the Journal of Global Health. These findings, together with recommendations provided by an Expert Panel which has guided this review, that are included as the last paper in this series, will help to provide the rationale for building stronger community-based platforms for delivering evidence-based interventions in high-mortality, resource-constrained settings.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 3. neonatal health findings.

BACKGROUND: As the number of deaths among children younger than 5 years of age continues to decline globally through programs to address the health of older infants, neonatal mortality is becoming an increasingly large proportion of under-5 deaths. Lack of access to safe delivery care, emergency obstetric care and postnatal care continue to be challenges for reducing neonatal mortality. This article reviews the available evidence regarding the effectiveness of community-based primary health care (CBPHC) and common components of programs aiming to improve health during the first 28 days of life. METHODS: A database comprising evidence of the effectiveness of projects, programs and field research studies (referred to collectively as projects) in improving maternal, neonatal and child health through CBPHC has been assembled and described elsewhere in this series. From this larger database (N = 548), a subset was created from assessments specifically relating to newborn health (N = 93). Assessments were excluded if the primary project beneficiaries were more than 28 days of age, or if the assessment did not identify one of the following outcomes related to neonatal health: changes in knowledge about newborn illness, care seeking for newborn illness, utilization of postnatal care, nutritional status of neonates, neonatal morbidity, or neonatal mortality. Descriptive analyses were conducted based on study type and outcome variables. An equity assessment was also conducted on the articles included in the neonatal subset. RESULTS: There is strong evidence that CBPHC can be effective in improving neonatal health, and we present information about the common characteristics shared by effective programs. For projects that reported on health outcomes, twice as many reported an improvement in neonatal health as did those that reported no effect; only one study demonstrated a negative effect. Of those with the strongest experimental study design, almost three-quarters reported beneficial neonatal health outcomes. Many of the neonatal projects assessed in our database utilized community health workers (CHWs), home visits, and participatory women's groups. Several of the interventions used in these projects focused on health education (recognition of danger signs), and promotion of and support for exclusive breastfeeding (sometimes, but not always, including early breastfeeding). Almost all of the assessments that included a measurable equity component showed that CBPHC produced neonatal health benefits that favored the poorest segment of the project population. However, the studies were quite biased in geographic scope, with more than half conducted in South Asia, and many were pilot studies, rather than projects at scale. CONCLUSIONS: CBPHC can be effectively employed to improve neonatal health in high-mortality, resource-constrained settings. CBPHC is especially important for education and support for pregnant and postpartum mothers and for establishing community-facility linkages to facilitate referrals for obstetrical emergencies; however, the latter will only produce better health outcomes if facilities offer timely, high-quality care. Further research on this topic is needed in Africa and Latin America, as well as in urban and peri-urban areas. Additionally, more assessments are needed of integrated packages of neonatal interventions and of programs at scale.

Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 5. equity effects for neonates and children.

BACKGROUND: The degree to which investments in health programs improve the health of the most disadvantaged segments of the population-where utilization of health services and health status is often the worst-is a growing concern throughout the world. Therefore, questions about the degree to which community-based primary health care (CBPHC) can or actually does improve utilization of health services and the health status of the most disadvantaged children in a population is an important one. METHODS: Using a database containing information about the assessment of 548 interventions, projects or programs (referred to collectively as projects) that used CBPHC to improve child health, we extracted evidence related to equity from a sub-set of 42 projects, identified through a multi-step process, that included an equity analysis. We organized our findings conceptually around a logical framework matrix. RESULTS: Our analysis indicates that these CBPHC projects, all of which implemented child health interventions, achieved equitable effects. The vast majority (87%) of the 82 equity measurements carried out and reported for these 42 projects demonstrated "pro-equitable" or "equitable" effects, meaning that the project's equity indicator(s) improved to the same degree or more in the disadvantaged segments of the project population as in the more advantaged segments. Most (78%) of the all the measured equity effects were "pro-equitable," meaning that the equity criterion improved more in the most disadvantaged segment of the project population than in the other segments of the population. CONCLUSIONS: Based on the observation that CBPHC projects commonly provide services that are readily accessible to the entire project population and that even often reach down to all households, such projects are inherently likely to be more equitable than projects that strengthen services only at facilities, where utilization diminishes greatly with one's distance away. The decentralization of services and attention to and tracking of metrics across all phases of project implementation with attention to the underserved, as can be done in CBPHC projects, are important for reducing inequities in countries with a high burden of child mortality. Strengthening CBPHC is a necessary strategy for reducing inequities in child health and for achieving universal coverage of essential services for children.

The value of social support to encourage people with schizophrenia to engage in physical activity: an international insight from specialist mental health physiotherapists.

BACKGROUND: Research is needed to understand how mental health physiotherapists use social support when promoting physical activity. AIMS: The aim of this study was to establish which dimensions of social support are used within physiotherapy sessions for individuals with schizophrenia. METHOD: A cross sectional international survey design of specialist mental health physiotherapists was undertaken. RESULTS: Forty mental health physiotherapists provided in depth accounts of the four functional dimensions of social support (informational, tangible, esteem and emotional) and the one structural dimension (importance of group exercise). The results illustrate how these different dimensions of social support are used by physiotherapists to engage patients and identify the value of group work as a specific form of support. Specifically the importance of all types of support was reported and this helped to provide a detailed consideration to the skills that mental health physiotherapist have. CONCLUSION: Providing social support is a significant part of the rehabilitation professionals' role. The current results advance the current understanding of how social support is provided to individuals with schizophrenia in rehabilitation settings.

Hand washing among school children in Bogotá, Colombia.

OBJECTIVES: We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices. METHODS: Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted. RESULTS: Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR]=6.0; 95% confidence interval [CI]=4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR=0.8; 95% CI=0.6, 0.9) or previous-year school absenteeism (OR=0.7; 95% CI=0.6, 0.9). CONCLUSIONS: Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.