'It doesn't happen any other way': relationship-building and reflexivity for equity-focused intersectoral practice (EquIP).

Intersectoral processes that bring together public institutions, civil society organizations and affected community members are essential to tackling complex health equity challenges. While conventional wisdom points to the importance of human relationships in fostering collaboration, there is a lack of practical guidance on how to do intersectoral work in ways that support authentic relationship-building and mitigate power differentials among people with diverse experiences and roles. This article presents the results of RentSafe EquIP, a community-based participatory research initiative conducted in Owen Sound, Canada, in the midst of a housing crisis. The research explored the potential utility of equity-focused intersectoral practice (EquIP), a novel approach that invests in human relationships and knowledge co-creation among professionals and affected members of the community. The three-phase EquIP methodology centred the grounded expertise of community members with lived/living experience of housing inadequacy to catalyze reflexive thinking by people in professional roles about the institutional gaps and barriers that prevent effective intersectoral response to housing-related inequities. The research demonstrated that EquIP can support agency professionals and community members to (i) engage in (re)problematization to redefine the problem statement to better include upstream drivers of inequity, (ii) support reflexivity among those in professional roles to identify institutional practices, policies and norms that perpetuate stigma and impede effective intersectoral response and (iii) spark individual and collective agency and commitment towards a more equity-focused intersectoral system. We conclude that the EquIP methodology is a promising approach for communities seeking to address persistent health equity and social justice challenges.

Salud, complejidad y enfermedades no transmisibles

La ciencia y la producción del saber científico están cambiando, las partes no son el objetivo, es el todo y sus interrelaciones. La salud enfrenta nuevos retos que no pueden ser explicados por concepciones reduccionistas. Se reconoce el intento de agrupar variadas afecciones en las enfermedades no transmisibles que ocasionan las tres cuartas partes de las muertes en el mundo y en Cuba, constituyen uno de los grandes retos del desarrollo sostenible. Muchas de ellas, a pesar de su heterogeneidad y multicausalidad, comparten factores de riesgo -y protectores- comunes, que pueden ser revertidos con acciones integradas. Se comenta la frecuente comorbilidad de estas enfermedades con otras entidades, la polimorbilidad y el rol del envejecimiento en su aparición. Se resalta la presencia del estado inflamatorio crónico del endotelio y la disfunción de este órgano como posible vía final común de la patogenia, evolución y posterior expresión clínica de muchas de las conocidas como enfermedades no transmisibles, verdaderos síndromes sistémicos. Se dan un grupo de recomendaciones para mejorar su prevención y su control, con énfasis en la participación comunitaria, donde las ciencias sociales pueden aportar mucho para lograr mejores resultados, sin olvidar la susceptibilidad individual o de grupos a padecer determinadas enfermedades no transmisibles. Se considera que directivos, profesionales sanitarios, líderes formales e informales, personas, grupos y comunidades, deben capacitarse y actualizarse, en los conceptos y los enfoques de estas enfermedades para lograr el propósito de revertir sus efectos nocivos para la salud.

Science and the production of scientific knowledge are changing, the parts are not the objective, it is the whole and its interrelationships. Health faces new challenges that cannot be explained by reductionist conceptions. The attempt to group various conditions in non-communicable diseases that cause three quarters of deaths in the world and in Cuba is recognized as one of the great challenges of sustainable development. Many of them, despite their heterogeneity and multi-causality, share common risk -and protective- factors, which can be reversed with integrated actions. The frequent comorbidity of these diseases with other entities, polymorbidity, and the role of aging in their appearance are discussed. The presence of the chronic inflammatory state of the endothelium and the dysfunction of this organ are highlighted as a possible final common path of the pathogenesis, evolution and subsequent clinical expression of many of the so-called non-communicable diseases, true systemic syndromes. A group of recommendations are given to improve its prevention and control, with emphasis on the community participation of all, where the social sciences can contribute a lot to achieve better results, without forgetting individual or group susceptibility to suffering certain non-communicable diseases. It is considered that managers, health professionals, formal and informal leaders, people, groups and communities must be trained and updated in concepts and approaches to these diseases to achieve their purposes.

Our Healthy Community Conceptual Framework and Intervention Model for Health Promotion and Disease Prevention in Municipalities.

This paper introduces the conceptual framework and intervention model of Our Healthy Community (OHC), a new, coordinated, and integrated approach towards health promotion and disease prevention in municipalities. The model is inspired by systems-based approaches and employs a supersetting approach for engaging stakeholders across sectors in the development and implementation of interventions to increase health and well-being among citizens. The conceptual model includes a combination of a bottom-up approach emphasizing involvement of citizens and other community-based stakeholders combined with a top-down approach emphasizing political, legal, administrative, and technical support from a variety of councils and departments in local municipality government. The model operates bidirectionally: (1) by pushing political and administrative processes to promote the establishment of conducive structural environments for making healthy choices, and (2) by involving citizens and professional stakeholders at all levels in co-creating processes of shaping their own community and municipality. An operational intervention model was further developed by the OHC project while working with the OHC in two Danish municipalities. The operational intervention model of OHC comprises three main phases and key actions to be implemented at the levels of local government and community: (1) Local government: Situational analysis, dialogue, and political priorities; (2) Community: Thematic co-creation among professional stakeholders; and (3) Target area: Intervention development and implementation. The OHC model will provide municipalities with new tools to improve the citizens' health and well-being with available resources. Health promotion and disease prevention interventions are developed, implemented, and anchored in the local community by citizens and local stakeholders at municipal and local community levels using collaboration and partnerships as leverage points.

Examining Intersectoral Action as an Approach to Implementing Multistakeholder Collaborations to Achieve the Sustainable Development Goals.

Objectives: The Sustainable Development Goals (SDGs) re-orient action towards improving the social and ecological determinants of health and equity. SDG 17 calls for enhanced policy and institutional coherence and strong multi-stakeholder partnerships. Intersectoral action (IA) has a promising history in public health, including health promotion and global health. Some experts see IA as crucial to the SDGs. Yet less is known about how IA is conceptualized and what promising models exist with relevance to the SDGs. We sought to investigate how IA is understood conceptually and empirically. Methods: We conducted a narrative review of global public health and political science literatures and grey literature on the SDGs to identify theoretical models, case studies and reviews of IA research. Results: Multiple competing conceptualizations of IA exist. Research has focused on case studies in high-income countries. More conceptual clarity, analyses of applications in LMICs, and explorations of political and institutional factors affecting IA are needed, as is attention to power dynamics between sectors. Conclusion: IA is required to collaborate on the SDGs and address equity. New models for successful implementation merit exploration.

Three Growth Spurts in Global Physical Activity Policies between 2000 and 2019: A Policy Document Analysis.

Non-communicable diseases (NCDs) contribute significantly to global mortality and are of particular concern in growing urban populations of low- and-middle income countries (LMICs). Physical inactivity is a key NCD determinant and requires urgent addressing. Laudable global and regional efforts to promote physical activity are being made, but the links between physical activity (PA), NCD reduction, and integrated intersectoral approaches to reducing obesogenic environments are not consistently made. This study applied a document analysis approach to global PA and NCD policies to better understand the current global policy environment and how this may facilitate integrated PA promotion. A total of 34 global policies related to PA, from different sectors, were analyzed. PA policy in mitigation of NCDs has evolved exponentially, with a progression towards addressing structural determinants alongside individual behavior change. The global PA agenda is primarily driven by the World Health Organization. Intersectoral collaboration is importantly regarded, but the contributions of other sectors, outside of health, education, transport, and urban planning, are less clear. Improving PA among key sub-populations-women, girls, and adolescents-requires greater policy consideration. It is imperative for PA-relevant sectors at all levels to recognize the links with NCDs and work towards integrated policy and practice in mitigation of the rising NCD pandemic.

Theory-based capacity building intervention for intersectoral action for health at local governments: An exploratory pilot study.

AIM: To design, implement and evaluate a nurse-led capacity building intervention (PromoGOB) for intersectoral action for health at local governments. DESIGN: The programme was based on theories of the policy process and organizational change and facilitated by a nurse developing a health broker role. A complex intervention perspective was adopted in carrying out the study. The intervention was evaluated using a mixed method embedded design. METHODS: Quantitative component relied on a specific questionnaire. This tool, designed and piloted ad hoc, measured the capacity in terms of knowledge, awareness, resources, skills, and commitment, both at sectoral and government levels. For the qualitative component, semi-structured interviews were conducted. These explored the perceived capacity and feasibility and acceptability issues. The programme was initiated at the end of October 2019, and it lasted a total of 5 weeks. Nineteen individuals representing various sectors at a local government in northern Spain participated in the study. The data analysis was concluded by the end of March 2020. FINDINGS: PromoGOB positively influenced participants' capacity for addressing health promotion. Awareness component, intersectoral work and the nurse as health broker were essential in the programme. The necessity of political participation was identified as an issue to be prioritized in future studies. CONCLUSION: This study highlights the relevance of capacity building at local governments and the role that nurses can play in it. Further work should be undertaken to continue developing Health in All Policies approach at local level. IMPACT: This study offers a starting point for nurses to get involved in the policy process of health promotion, performing a specific role as health brokers, building capacity at local governments for addressing social determinants of health, and delving into theories and concepts of the Health in All Policies field.

Brazilian Public Policies for Assistance to Women in Situations of Violence: Contributions from Culturo-Behavioral Science.

Brazilian public policies establish that the assistance to women in situations of violence should be carried out by networks comprising health, social assistance, public safety, and justice services. To solve intersectoral problems faced by the networks, the government suggests the creation of units of the Brazilian Woman's House (BWH) - an organization that concentrates the principal services. The objective of this study was to analyze the strategy of the BWH in the context of the networks from a culturo-behavioral science perspective. Toward this objective, national laws, statistical data, and public information related to BWH were analyzed. The analysis of the macrosystem indicates that the existence of a BWH places the services that compose it under the control of a common set of external variables, which can make the effects of legislation and funding more predictable. The organization's Total Performance System shows that reports constitute an essential aggregate product for stakeholders to exercise social control over this public policy. The process level analysis endorses the advantages of implementing BWH units. Some suggestions are made for changes in the wording of BWH legislation that might make BWH's products and the social control of this policy more likely. The recommendations presented should only be considered as a starting point for a broad discussion and future action. It is hoped that this study will support further analysis of the actual BWHs and inform reformulations of this public policy.

Current issues and options for improving influenza vaccination rates in rural areas / Enjeux actuels et pistes de solution pour améliorer les couvertures vaccinales antigrippales dans les milieux ruraux

INTRODUCTION: Despite the positive impact of vaccination on health, influenza vaccination rates worldwide remain low for certain population groups. In Quebec, vaccination rates among populations with chronic diseases remain below what is expected by public health. Since this situation is also noticeable in rural areas, it is necessary to reflect on the current issues associated with low vaccination rates in the rural population. PURPOSE OF RESEARCH: The purpose of this commentary is to explore the importance of obtaining a multifactorial understanding of the problem raised in order to propose possible solutions to increase influenza vaccination rates among people living in rural areas.

Introduction: Malgré l'impact positif de la vaccination sur la santé, les couvertures vaccinales antigrippales au niveau mondial demeurent faibles pour certains groupes de population. Au Québec, les couvertures vaccinales chez les populations atteintes de maladies chroniques demeurent en deçà de ce qui est attendu par la santé publique. Cette situation étant aussi perceptible en région rurale, il s'avère nécessaire de réfléchir sur les enjeux actuels associés aux faibles couvertures vaccinales au sein de cette population spécifique. But de l'étude: Ce commentaire a pour but d'explorer l'importance d'obtenir une compréhension multifactorielle du problème soulevé afin de proposer des pistes de solution visant à augmenter les couvertures vaccinales antigrippales auprès des personnes vivant en région rurale.

Revisitando definições e naturezas da intersetorialidade: um ensaio teórico / Revisiting definitions and natures of intersectoriality: a theoretical essay

Resumo Este ensaio teórico aborda definições e características centrais das ações intersetoriais para a saúde. Tem como objetivo, portanto, refletir sobre o conhecimento produzido a respeito das concepções e da natureza das ações intersetoriais para a saúde. Para a construção das análises, realizou-se uma revisão integrativa a partir de publicações referentes ao período de 2000 a 2019 identificadas nas bases de dados Lilacs, SciELO, Web of Science e Science Direct. O corpus contemplou 12 artigos, sendo analisados os aspectos relacionados com a finalidade, o propósito ou o método da ação intersetorial, sendo possível traçar similaridades e contrastes entre as definições. Diante da opacidade na construção de definições, coube situar que existe uma construção sócio-histórica dos conceitos, mas as definições provisórias expressam certo borramento ou apagamento que se encontram em disputa no interior do campo da saúde e que podem direcionar a distintos pontos de vista e constituir barreiras para incluir a implementação das ações intersetoriais relacionadas à promoção da saúde nas práticas cotidianas. De tais reflexões derivaram um conjunto de proposições acerca das naturezas das ações intersetoriais para a saúde, com vistas a contribuir para o debate sobre a temática.

Abstract This theoretical essay addresses definitions and central characteristics of intersectoral actions for health. It aims, therefore, to reflect on the knowledge produced about the conceptions and nature of health intersectoral actions. An integrative review was conducted for the construction of the analyses from publications referring to the 2000-2019 period identified in the Lilacs, SciELO, Web of Science, and Science Direct databases. The corpus included 12 papers, with aspects related to the aim, purpose or method of intersectoral action under analysis, outlining similarities and contrasts between definitions. Given the opacity in the construction of definitions, we had to point out a socio-historical construction of the concepts, and that the provisional definitions express a certain blurring or erasure in dispute within the field of health that can lead to different viewpoints and are barriers to include the implementation of intersectoral actions related to health promotion in daily practices. Such reflections derived a set of propositions about the nature of intersectoral health actions that aim to contribute to the debate on the theme.

Analysis of Cameroon's Sectoral Policies on Physical Activity for Noncommunicable Disease Prevention.

Physical inactivity is increasing in low- and middle-income countries (LMICs), where noncommunicable diseases (NCDs), urbanisation and sedentary living are rapidly growing in tandem. Increasing active living requires the participation of multiple sectors, yet it is unclear whether physical activity (PA)-relevant sectors in LMICs are prioritising PA. We investigated to what extent sectors that influence PA explicitly integrate it in their policies in an LMIC such as Cameroon. We systematically identified policy documents relevant to PA and NCD prevention in Cameroon; and using the Walt and Gilson policy triangle we described, analysed, and interpreted the policy contexts, contents, processes, and actors. We found 17 PA and NCD policy documents spanning from 1974 to 2019 across seven ministries. Thirteen (13/17) policies targeted infrastructure improvement, and four (4/17) targeted communication for behaviour change, all aiming to enhance leisure domain PA. Only the health sector explicitly acknowledged the role of PA in NCD prevention. Notably, no policy from the transport sector mentioned PA. Our findings highlight the need for intersectoral action to integrate PA into policies in all relevant sectors. These actions will need to encompass the breadth of PA domains, including transport, while emphasising the multiple health benefits of PA for the population.

Learning from intersectoral action beyond health: a meta-narrative review.

Intersectoral action (ISA) is considered pivotal for achieving health and societal goals but remains difficult to achieve as it requires complex efforts, resources and coordinated responses from multiple sectors and organizations. While ISA in health is often desired, its potential can be better informed by the advanced theory-building and empirical application in real-world contexts from political science, public administration and environmental sciences. Considering the importance and the associated challenges in achieving ISA, we have conducted a meta-narrative review, in the research domains of political science, public administration, environmental and health. The review aims to identify theory, theoretical concepts and empirical applications of ISA in these identified research traditions and draw learning for health. Using the multidisciplinary database of SCOPUS from 1996 to 2017, 5535 records were identified, 155 full-text articles were reviewed and 57 papers met our final inclusion criteria. In our findings, we trace the theoretical roots of ISA across all research domains, describing the main focus and motivation to pursue collaborative work. The literature synthesis is organized around the following: implementation instruments, formal mechanisms and informal networks, enabling institutional environments involving the interplay of hardware (i.e. resources, management systems, structures) and software (more specifically the realms of ideas, values, power); and the important role of leaders who can work across boundaries in promoting ISA, political mobilization and the essential role of hybrid accountability mechanisms. Overall, our review reaffirms affirms that ISA has both technical and political dimensions. In addition to technical concerns for strengthening capacities and providing support instruments and mechanisms, future research must carefully consider power and inter-organizational dynamics in order to develop a more fulsome understanding and improve the implementation of intersectoral initiatives, as well as to ensure their sustainability. This also shows the need for continued attention to emergent knowledge bases across different research domains including health.

Lessons from a rural housing crisis: grounded insights for intersectoral action on health inequities.

Local communities are struggling with persistent health inequities driven by income disparity, housing inadequacy, and other intersecting factors that constrain individual and community well-being. Increasingly, intersectoral approaches are recognized as essential to tackle such challenges, given their intersecting nature. This paper describes Equity-focused Intersectoral Practice (EquIP), a novel methodology that merges participatory research principles with the purposeful positioning of grounded expertise (lived experience) to shift the gaze of intersectoral actors towards the contextual factors that contribute to health inequities. The EquIP methodology creates uncommon spaces for intersectoral encounter that support critical reflexivity and relationship-building among institutional and community-based intersectoral actors. A case example of the EquIP methodology, implemented in a small, rural Canadian city in the context of a regional housing crisis, illustrates how investment in reflexivity and relational praxis among diverse intersectoral actors supports the identification of existing structures, beliefs, and practices within institutional settings that constrain effective intersectoral response to health inequities.

A multilevel transition perspective on embedding intersectoral action in local health policies.

Intersectoral action is advocated as a social practice that can effectively address health inequalities and related social issues. Existing knowledge provides insight into factors that may facilitate or hinder successful intersectoral action, but not much is known about how intersectoral action evolves and becomes embedded in local health policies. This is where this study aims to make its contribution, by adopting the multilevel perspective on transitions, which is increasingly used to study social innovation in sustainability transitions but has not yet been applied to public health and health promotion. Through this perspective, it was unravelled how intersectoral action between youth-care organizations and community sports clubs became embedded in local health policies of Rotterdam, a large city in the Netherlands. A single explorative case study was conducted based on content analysis of policy documents and 15 in-depth interviews with policy officers, managers and field workers operating in the fields of youth and sports in Rotterdam. The findings showed that intersectoral action between community organizations and policymakers evolves through congruent processes at different levels that changed institutional logics. Moreover, it emerged that policymakers and other actors that advocate novel social practices and act as boundary spanners can adopt multiple strategies to embed these practices in local health policy. The multi-level perspective adds value to earlier approaches to research intersectoral collaboration for health promotion as it allows to better capture the politics involved in the social innovation processes. However, further sharpening and more comprehensive application of transition concepts to study transitions in public health and health promotion is needed.

Relato de Experiência: Percurso e desafios para adesão municipal ao Sistema Nacional de Segurança Alimentar e Nutricional / Experience Report: Paths and challenges of a municipality to join the National Food and Nutrition Security System

Introdução: O Sistema Nacional de Segurança Alimentar e Nutricional possibilita a gestão intersetorial e participativa, e a articulação entre os entes federados para a implementação das políticas promotoras de Segurança Alimentar e Nutricional. Objetivos: Relatar a experiência municipal de Duque de Caxias-RJ para adesão ao Sistema Nacional de Segurança Alimentar e Nutricional e as principais perspectivas e desafios após essa conquista. Métodos e Resultados: No percurso para adesão ao sistema, os técnicos do Departamento de Segurança Alimentar e Nutricional Sustentável realizaram ações para efetivação da Política de Segurança Alimentar e Nutricional desde 2009, quando foi realizado o primeiro encontro com gestores municipais para mapear as ações, até 2015, quando foram publicadas a Lei Orgânica de Segurança Alimentar e Nutricional e a Lei do Conselho de Segurança Alimentar e Nutricional do município de Duque de Caxias revisadas. Além disso, foi realizado um encontro com secretários municipais visando criar a Câmara Intersetorial de Segurança Alimentar e Nutricional, instância responsável pela elaboração do Plano Municipal de Segurança Alimentar e Nutricional. Após árduo trabalho, Duque de Caxias formalizou a criação da Câmara e instituiu os membros de dez secretarias afetas ao tema. Em 2016, após esse longo percurso, o município obteve a adesão ao Sistema Nacional de Segurança Alimentar e Nutricional de forma pioneira no Estado do Rio de Janeiro. Alcançada essa etapa, as principais expectativas foram o fomento à participação social, o fortalecimento da intersetorialidade juntamente com debate sobre a alocação de recursos municipais, e o acesso aos recursos federais. Conclusão: O cenário nacional mudou o que se refletiu nos demais entes federados. Mesmo diante de tantos desafios, ter (e manter) todas as instâncias que compõem o Sistema Nacional de Segurança Alimentar e Nutricional em nível municipal é de extrema importância para a efetivação do Direito Humano à Alimentação Adequada. (AU)

Introduction: The National Food and Nutrition Security System permits intersectoral and participatory management, and the articulation between the affiliated entities to implement and promote its policies. Objectives: To report the experience of the municipality of Duque de Caxias/RJ to join the National Food and Nutrition Security System and the main subsequent prospects and challenges. Methods and Results: Since 2009, towards adhering to the system, technicians of the Department of Sustainable Food and Nutrition Security carried out actions to establish the Food and Nutrition Security Policy. These continued from the first meeting held with municipal managers to map the actions, up to 2015 when the Organic Law on Food and Nutrition Security and the Law of the Security Council of the municipality of Duque de Caxias on Food and Nutrition were published. In addition, a meeting was held with municipal secretariats to create the Intersectoral Chamber of Food and Nutrition Security, the body responsible for the preparation of the Municipal Plan for Food and Nutrition Security. After hard work, Duque de Caxias formalised the creation of the Chamber and instated the members of ten secretariats associated to the plan. After such a long journey, in 2016, the municipality pioneered the affiliation to the National System of Food and Nutritional Security in the State of Rio de Janeiro. Conclusion: The main aspirations were the promotion of social participation, the strengthening of intersectoral work along with a debate on the allocation of municipal resources, and access to federal resources. The national scenario changed also affecting federated entities. Even in the face of so many challenges, to forge and maintain all the rankings of the National System of Food and Nutrition Security at the municipal level is extremely important for the fulfillment of the Human Right to Adequate Food. (AU)

Recommendations for Effective Intersectoral Collaboration in Health Promotion Interventions: Results from Joint Action CHRODIS-PLUS Work Package 5 Activities.

The burden of chronic disease in Europe continues to grow. A major challenge facing national governments is how to tackle the risk factors of sedentary lifestyle, alcohol abuse, smoking, and unhealthy diet. These factors are complex and necessitate intersectoral collaboration to strengthen health promotion, counter-act the social determinants of health, and reduce the prevalence of chronic disease. European countries have diverse intersectoral collaboration to encourage health promotion activities. In the Joint Action CHRODIS-PLUS success factors for intersectoral collaboration within and outside healthcare which strengthen health promotion activities were identified with a mixed method design via a survey of 22 project partners in 14 countries and 2 workshops. In six semi-structured interviews, the mechanisms underlying these success factors were examined. These mechanisms can be very context-specific but do give more insight into how they can be replicated. In this paper, 20 health promotion interventions from national programs in CHRODIS PLUS are explored. This includes community interventions, policy actions, integrated approaches, capacity building, and training activities. The interventions involved collaboration across three to more than six sectors. The conclusion is a set of seven recommendations that are considered to be essential for fostering intersectoral collaboration to improve health-promoting activities.

Responsabilidad personal con la salud. Conocimientos y percepciones de diferentes actores sociales / Personal Responsibility with Health. Differents Social Actors Knowledges and Perceptions

RESUMEN Fundamento el proceso de actualización del modelo económico y social cubano refrenda la necesidad de asegurar el adecuado equilibrio entre las responsabilidades que competen al Estado y al Gobierno y las correspondientes a los individuos. Se ha producido un reposicionamiento del tema de la responsabilidad personal con la salud a nivel nacional, pero se desconoce la representación social de este término en diferentes actores sociales que intervienen en la gobernanza para la salud en el nivel comunitario y local. Objetivo: explorar los conocimientos y percepciones que poseen diferentes actores sociales de la comunidad sobre la responsabilidad personal con la salud. Método: se seleccionó una muestra de 385 sujetos del área de salud Andrés Ortiz del municipio Guanabacoa en La Habana mediante criterios probabilísticos y discrecionales, compuesta por profesionales y técnicos del sector de la salud, miembros de organizaciones no gubernamentales, de organizaciones políticas, del gobierno local y de la ciudadanía pertenecientes a tres consultorios de la atención primaria de salud. Se construyeron y validaron instrumentos para la recogida de datos. Se obtuvo la información mediante entrevistas semiestructuradas y encuestas. Se realizó análisis de contenido del discurso y análisis descriptivo de los datos utilizando frecuencias absolutas y relativas. Resultados: el 100 % de los profesionales y técnicos del sector de la salud, de los miembros del gobierno local, de las organizaciones políticas y de las organizaciones no gubernamentales poseía referencias previas sobre el término, pero solo el 45 % de la ciudadanía había escuchado acerca de él. Las fuentes del conocimiento previo sobre el término difirieron entre los actores sociales. La percepción de que la responsabilidad personal con la salud debe restringirse al autocuidado individual fue mayoritaria principalmente entre la ciudadanía (83,4 %), los representantes de las organizaciones no gubernamentales (78 %), los miembros del gobierno local y dirigentes del sector salud (62,5 %), los técnicos y profesionales de la salud (59 %) y en menor proporción los profesores de ese sector (50 %). El 100 % de los representantes de las organizaciones políticas percibieron que esta responsabilidad debía tener una visión individual. Conclusiones: existen divergencias en el campo representacional de la responsabilidad personal con la salud entre los diferentes actores sociales consultados. Predominó el entorno discursivo y representacional relacionado con una responsabilidad personal limitada a la salud individual.

ABSTRACT Background: the updating process of the Cuban economic and social model support the need to ensure the proper balance between the responsibilities that concern the State and the Government and those corresponding to individuals. There has been a repositioning of the issue of personal responsibility with health at the national level, but the social representation of this term in different social actors that intervene in health governance at the community level, community and local level, is unknown. Objective: to explore the knowledge and perceptions that different social actors in the community have on personal responsibility with health. Method: a sample of 385 subjects from the Andrés Ortiz health area of ​​the Guanabacoa municipality in Havana was selected using probabilistic and discretionary criteria, composed of professionals and technicians from the health sector, members of non-governmental organizations, political organizations, and the government local and citizens belonging to three clinics of primary health care. Instruments for data collection were built and validated. The information was obtained through semi-structured interviews and surveys. Discourse content analysis and descriptive data analysis were performed using absolute and relative frequencies. Results: the 100 % of professionals and technicians from the health sector, members of local government, political organizations and non-governmental organizations had previous references to the term, but only the 45 % of the public had heard about him. The sources of prior knowledge about the term differed among social actors. The perception that personal responsibility for health should be restricted to individual self-care was the majority mainly among citizens (83.4 %), representatives of non-governmental organizations (78 %), members of the local government and leaders of the health sector (62.5 %), technicians and health professionals (59 %) and, to a lesser proportion teachers in this sector (50 %). The 100 % of the representatives of the political organizations perceived that this responsibility should have an individual vision. Conclusions: there are differences of opinion in the representational field of personal responsibility with health among the different social actors consulted. The discursive and representational environment predominated, related to personal responsibility limited to individual health.

Equality and poverty: views from managers and professionals from public services and household heads in the Belo Horizonte Metropolitan Area, Brazil.

BACKGROUND: Tackling poverty requires reconsideration of quantitative factors related to "who" is poor and by "how much" and qualitative factors addressing "what poverty means in these individuals' lives". Greater understanding is required concerning the types of access actually used by families in poverty in attempts to meet their basic needs. Poverty must be addressed based on the question: "Inequality of what?" It is in reflecting on the realities of such groups when their basic needs are not met that public policies can be improved and implemented with legitimate priorities. OBJECTIVE: Describe coverage and access to public health, education and social assistance services and the related effects on the quality of life of families in extreme poverty. METHODS: An exploratory mixed methods study was conducted applying Amartya Sen's "Basic Capability Equality" framework, with: 1) 27 interviews with managers and professionals from public services serving territories with extreme poverty; 2) Survey with a systematic proportionate stratified sample of 336 heads of households in extreme poverty from a total 2605 families. The resulting data was analyzed with thematic content analysis and descriptive statistics, respectively. RESULTS: The managers and professionals described the lives of families in extreme poverty with phrases such as, "These people suffer. Sadness weighs on their lives!" and "Depression is the most common illness". Their precarious circumstances and inadequate access were cited as causes. Quality of life was considered bad or very bad by 41.4% of heads of households. A total income of less than one-third of the minimum wage was received by 56.9% of the sample. One or more people were unemployed in the family in 55.8% of cases. For 53.3% of heads of households, public services "did not meet any or few of their needs". The main social determinants of health were described as: alcohol and drugs (68.8%); lack of good health care (60.7%); and absence of income/work (37.5%). The following were identified as solutions to improve their quality of life: (1) health (40.5%); (2) education (37.8%); and (3) employment (44.6%). CONCLUSIONS: The social determinants of poverty and health must be addressed jointly through intersectoral public policies and egalitarian mechanisms that promote investment in social protection.

Health Impact Assessments in Spain: Have They Been Effective?

BACKGROUND: Health impact assessment (HIA) has scarcely been developed in Spain, in comparison with other European countries. Moreover, little is known about the effectiveness of HIA, taking into account direct impacts-changes on the decision-making process-as well as indirect impacts or those related to the process outcomes. From this broad perspective of HIA usefulness, the purpose was to assess the effectiveness of five HIAs carried out in Spain at the local level, and the role played by context and process factors on these impacts. METHODS: We carried out a qualitative study based on 14 interviews to HIAs participants from different sectors. A documentary review and nonparticipant observation techniques were implemented for an in depth understanding. RESULTS: The direct effectiveness of the HIAs was partial, but they had indirect effectiveness in all cases. The institutional and socio-political context, however, was not favorable to effectiveness. The elements of the process were largely determined by the context, although their influence, mediated by the role of proactive individuals, favored the effectiveness of the HIAs. CONCLUSIONS: When assessing HIA effectiveness, it is important to take into account a broad perspective on the nature of impacts and those factors influencing direct and indirect effectiveness. In Spain, the institutional and sociopolitical context was less favorable to HIA effectiveness than process-related factors. In order to implement the Health in All Policies strategy, will be necessary to improve context-related factors, such as institutional facilitators for HIA and democratic quality.

Health intersectoralism in the Sustainable Development Goal era: from theory to practice.

In 2015, the United Nations' (UN) Member States adopted a bold and holistic agenda of the Sustainable Development Goals (SDGs), integrating a vision of peace and prosperity for people and planet. Extensive work within, between, across sectors is required for this bold and holistic agenda to be implemented. It is in this context that this special article collection showcases multisectoral approaches to achieving SDG 3-Good Health and Well-Being-which, though focused explicitly on health, is connected to almost all other goals. A confluence of social and health inequities, within a context of widespread environmental degradation demands systems thinking and intersectoral action. Articles in this issue focus on the SDGs as a stimulus for renewed multisectoral action: processes, policies, and programs primarily outside the health sector, that have health implications through social, commercial, economic, environmental, and political determinants of health. Case studies offer critical lessons on effectively engaging other sectors to enhance their health outputs, identifying co-benefits and 'win-wins' that enhance human health.