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Objectives. We sought to examine the utilization and impact of enabling services, such as interpretation and eligibility assistance, among underserved Asian American, Native Hawaiian, and other Pacific Islander (AANHOPI) patients served at 4 community health centers. Methods. For this project, we developed a uniform model for collecting data on enabling services and implemented it across 4 health centers that served primarily AANHOPI patients. We also examined differences in patient characteristics between users and nonusers of enabling services. Results. Health center patients used many enabling services, with eligibility assistance being the most used service. In addition, compared with nonusers, users of enabling services were more likely to be older, female, AANHOPI, and uninsured (P Conclusions. For underserved AANHOPI patients at community health centers, enabling services are critical for access to appropriate care. We were the first to examine uniform data on enabling services across multiple health centers serving underserved AANHOPI patients. More data on enabling services and evaluation are needed to develop interventions to improve the quality of care for underserved AANHOPI patients. (Am J Public Health. 2010;100:2199-2205. doi: 10.2105/AJPH.2009.172270)

Objectives. We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. Methods. We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. Results. Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. Conclusions. Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children. (Am J Public Health. 2010;100:742-749. doi: 10.2105/AJPH.2008.151472)

Reducing and eliminating disparities in health is a matter of life and death. Each year in the United States, thousands of individuals die unnecessarily from easily preventable diseases and conditions. It is critical that we approach this problem from a broad public health perspective, attacking all of the determinants of health: access to care, behavior, social and physical environments, and overriding policies of universal access to care, physical education in schools, and restricted exposure to toxic substances. We describe the historical background for recognizing and addressing disparities in health, various factors that contribute to disparities, how the public health approach addresses such challenges, and two successful programs that apply the public health approach to reducing disparities in health. Public health leaders must advocate for public health solutions to eliminate disparities in health.

Nuclear weapons pose a particularly destructive threat. Prevention of the proliferation and use of nuclear weapons is urgently important to public health. 'Horizontal' proliferation refers to nation-states or nonstate entities that do not have, but are acquiring, nuclear weapons or developing the capability and materials for producing them. 'Vertical' proliferation refers to nation-states that do possess nuclear weapons and are increasing their stockpiles of these weapons, improving the technical sophistication or reliability of their weapons, or developing new weapons. Because nation-states or other entities that wish to use or threaten to use nuclear weapons need methods for delivering those weapons, proliferation of delivery mechanisms must also be prevented. Controlling proliferation--and ultimately abolishing nuclear weapons--involves national governments, intergovernmental organizations, nongovernmental and professional organizations, and society at large. (Am J Public Health. 2007;97:1589-1594. doi:10.2105/AJPH.2006. 100602)

Objectives. Although a growing body of evidence demonstrates that availability and quality of essential public health services vary widely across communities, relatively little is known about the factors that give rise to these variations. We examined the association of institutional, financial, and community characteristics of local public health delivery systems and the performance of essential services. Methods. Performance measures were collected from local public health systems in 7 states and combined with secondary data sources. Multivariate, linear, and nonlinear regression models were used to estimate associations between system characteristics and the performance of essential services. Results. Performance varied significantly with the size, financial resources, and organizational structure of local public health systems, with some public health services appearing more sensitive to these characteristics than others. Staffing levels and community characteristics also appeared to be related to the performance of selected services. Conclusions. Reconfiguring the organization and financing of public health systems in some communities--such as through consolidation and enhanced intergovernmental coordination--may hold promise for improving the performance of essential services.

We propose cumulative meta-analysis as the procedure of completing a new meta-analysis at each successive wave in a research database. Two facets of cumulative knowledge are considered: the first, sufficiency, refers to whether the meta-analytic database adequately demonstrates that a public health intervention works. The second, stability, refers to the shifts over time in the accruing evidence about whether a public health intervention works. We used a hypothetical data set to develop the indicators of sufficiency and stability, and then applied them to existing, published datasets. Our discussion centers on the implications of the use of this procedure in evaluating public health interventions.

The innovative practice that resulted from the Ottawa Charter challenges public health knowledge about programming and evaluation. Specifically, there is a need to formulate program theory that embraces social determinants of health and local actors' mobilization for social change. Likewise, it is imperative to develop a theory of evaluation that fosters reflexive understanding of public health programs engaged in social change. We believe advances in contemporary social theory that are founded on a critique of modernity and that articulate a coherent theory of practice should be considered when addressing these critical challenges.

From its origins, when public health was integral to societies' social structures, through the sanitary movement and contagion eras, when it evolved as a separate discipline, to the 'new public health' era, when health promotion projects like Healthy Cities appear to be steering the discipline back to society's social structure, public health seems to have come full circle. It is this observation that has led some to ask, 'What's new about the 'new public health'?' This article addresses the question by highlighting what is new about the health promotion era--including adapted components of previous eras that have been incorporated into its core activities--and its suitability in addressing established and emerging public health threats. (Am J Public Health. 2004;94:705-709)

An internationally influential model of population health was developed in Canada in the 1990s, shifting the research agenda beyond health care to the social and economic determinants of health. While agreeing that health has important social determinants, the authors believe that this model has serious shortcomings; they critique the model by focusing on its hidden assumptions. Assumptions about how knowledge is produced and an implicit interest group perspective exclude the sociopolitical and class contexts that shape interest group power and citizen health. Overly rationalist assumptions about change understate the role of agency. The authors review the policy and practice implications of the Canadian population health model and point to alternative ways of viewing the determinants of health. (Am J Public Health. 2003;93:392-396)

The origin of the population health approach is an historic debate over the relationship between economic growth and human health. In Britain and France, the Industrial Revolution disrupted population health and stimulated pioneering epidemiological studies, informing the early preventive public health movement. A century-long process of political adjustment between the forces of liberal democracy and propertied interests ensued. The 20th-century welfare states resulted as complex political mechanisms for converting economic growth into enhanced population health. However, the rise of a 'neoliberal' agenda, denigrating the role of government, has once again brought to the fore the importance of prevention and a population health approach to map and publicize the health impacts of this new phase of 'global' economic growth.

The September 11, 2001, attack on the World Trade Center had profound effects on the well-being of New York City. The authors describe and assess the strengths and weaknesses of the city's response to the public health, environmental/ occupational health, and mental health dimensions of the attack in the first 6 months after the event. They also examine the impact on the city's health care and social service system. The authors suggest lessons that can inform the development of a post-September 11th agenda for strengthening urban health infrastructures. (Am J Public Health. 2003;93:400-406)

Population health is a relatively new term that has not yet been precisely defined. Is it a concept of health or a field of study of health determinants? We propose that the definition be 'the health outcomes of a group of individuals, including the distribution of such outcomes within the group,' and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. We present a rationale for this definition and note its differentiation from public health, health promotion, and social epidemiology. We invite critiques and discussion that may lead to some consensus on this emerging concept. (Am J Public Health. 2003;93: 380-383)

Violence is a public health problem that can be understood and changed. Research over the past 2 decades has demonstrated that violence can be prevented and that, in some cases, prevention programs are more cost-effective than other policy options such as incarceration. The United States has much to contribute to--and stands to gain much from--global efforts to prevent violence. A new World Health Organization Initiative presents an opportunity for the United States to work with other nations to find cost-effective ways of preventing violence and reducing its enormous costs.

The author examines available evidence on the effects of exposure to joblessness on emotional well-being according to race and sex. The impact of racism on general health outcomes also is considered, particularly racism in the specific form of wage discrimination. Perceptions of racism and measured exposures to racism may be distinct triggers for adverse health outcomes. Whether the effects of racism are best evaluated on the basis of self-classification or social classification of racial identity is unclear. Some research sorts between the effects of race and socioeconomic status on health. The development of a new longitudinal database will facilitate more accurate identification of connections between racism and negative health effects.

The authors invoke a population health perspective to assess the distribution of environmental hazards according to race/ethnicity, social class, age, gender, and sexuality and the implications of these hazards for health. The unequal burden of environmental hazards borne by African American, Native American, Latino, and Asian American/Pacific Islander communities and their relationship to well-documented racial/ethnic disparities in health have not been critically examined across all population groups, regions of the United States, and ages. The determinants of existing environmental inequities also require critical research attention. To ensure inclusiveness and fill important gaps, scientific evidence is needed on the health effects of the built environment as well as the natural environment, cities and suburbs as well as rural areas, and indoor as well as outdoor pollutants.

The authors review the available empirical evidence from population-based studies of the association between perceptions of racial/ethnic discrimination and health. This research indicates that discrimination is associated with multiple indicators of poorer physical and, especially, mental health status. However, the extant research does not adequately address whether and how exposure to discrimination leads to increased risk of disease. Gaps in the literature include limitations linked to measurement of discrimination, research designs, and inattention to the way in which the association between discrimination and health unfolds over the life course. Research on stress points to important directions for the future assessment of discrimination and the testing of the underlying processes and mechanisms by which discrimination can lead to changes in health.

Research on racism as a harmful determinant of population health is in its infancy. Explicitly naming a long-standing problem long recognized by those affected, this work has the potential to galvanize inquiry and action, much as the 1962 publication of the Kempe et al. scientific article on the 'battered child syndrome' dramatically increased attention to--and prompted new research on--the myriad consequences of child abuse, a known yet neglected social phenomenon. To further work on connections between racism and health, the author addresses 3 interrelated issues: (1)links between racism, biology, and health; (2) methodological controversies over how to study the impact of racism on health; and (3) debates over whether racism or class underlies racial/ethnic disparities in health.

Objectives. Whether community-wide education changed cardiovascular risk factors and disease risk in Pawtucket, RI, relative to a comparison community was assessed. Methods. Random-sample, cross-sectional surveys were done of people aged 18 through 64 years at baseline, during, and after education. Baseline cohorts were reexamined. Pawtucket citizens of all ages participated in multilevel education, screening, and counseling programs. Results. The downward trend in smoking was slightly greater in the comparison city. Small, insignificant differences favored Pawtucket in blood cholesterol and blood pressure. In the cross-sectional surveys, body mass index increased significantly in the comparison community; a similar change was not seen in cohort surveys. Projected cardiovascular disease rates were significantly (16%) less in Pawtucket during the education program. This difference lessened to 8% posteducation. Conclusions. The hypothesis that projected cardiovascular disease risk can be altered by community-based education gains limited support from these data. Achieving cardiovascular risk reduction at the community level was feasible, but maintaining statistically significant differences between cities was not. Accelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs. (Am J Public Health. 1995; 85:777-785), Community programs in education about cardiovascular disease risk may have little long term impact on reducing risks factors. From 1984 to 1991, various Pawtucket, RI, community groups, grocery stores, and educational institutions ran a program to educate and change residents' behavior with regard to cardiovascular disease. Disease risk factors were assessed in a total of 15,261 people in Pawtucket and in a parallel control city without an education program. Participants were surveyed every 2 years from 1981 to 1993. Blood pressure and cholesterol levels dropped slightly more in Pawtucket than in the control city. Cigarette smoking decreased slightly more in the control city than in Pawtucket. Body mass index rose significantly more in the control city than in Pawtucket. The relative risk rate of cardiovascular disease in Pawtucket decreased by 20% during the program, but 3 years later the decrease was only 8%. People were receptive to the program, but it had a significant impact only when it was operating.

Although it has been demonstrated that poor infant and child feeding practices, frequent infections, and diarrhea contribute to poor growth and malnutrition in developing countries, little attention has been paid to the behavioral aspects of these problems. During episodes of diarrhea, health care workers have emphasized the importance of oral rehydration therapy, while vaguely advising mothers to ''continue feeding during diarrhea''. With no data to support this supposition, public health workers have assumed that mothers in almost all cultures withhold food during diarrhea. They have ignored the possibility that decreased appetite may cause reduced caloric intake. In a year-long study of 118 children in a Peruvian mountain village, it was observed that the mothers, who normally do not push their children to eat, encouraged eating during episodes of diarrhea. However, the children had poor appetites, and often rejected food. Mothers expressed concern that their children had little appetite when they were sick. In Nigeria, mothers often force-feed their sick children; in India, specific anti-diarrheal foods are given, while other foods are avoided. The importance of this and similar studies is that the same behavior has been observed in several countries, suggesting that vague exhortations to feed children during episodes of diarrhea are useless because the mothers are already doing so. During convalescence, when children's appetites return, mothers often stop urging their children to eat. Effective public health messages should tell mothers to continue urging their children to eat during convalescence so that they ''catch up'' on nutrients lost while they were ill. Food recommendations should be specific for both periods, and should consider cultural preferences. Simply measuring caloric intake without understanding how people behave leads to useless advice, and ineffective public health measures. (Consumer Summary produced by Reliance Medical Information, Inc.)

Worldwide, 600 million people live with disability, 80% of whom live in developing countries (World Health Organization, 2005). But the idea of disability is controversial, influenced by culture and competing [...]

The British government is recently struggling to meet the financial and health needs of the aged, as the number of ageing people continue to grow exponentially. Between 1971 to 1991, the number of aged people increased from 8 million to 9 million. The situation is further aggravated by recent efforts of the government to cut financial support rendered to social and health care services. In order to address the problem government regulators are considering the adoption of a rationing scheme, so as to distribute social services evenly.

The purpose of this study was to evaluate the impact of anonymous testing availability on human immunodeficiency virus (HIV) test demand in Arizona. Testing patterns before and after the introduction of anonymous testing were compared, Client knowledge of new test policy and delay in testing until an anonymous option was available were assessed. Test numbers among men who have sex with men showed a statistically significant increase after introduction of an anonymous testing option. Arizona continues to maintain anonymous testing availability. Public health agencies should consider how test policy may influence people's HIV test decisions. (Am J Public Health. 1994;84:2008-2010), Homosexual men may be more likely to undergo HIV testing if they can remain anonymous. County health departments in Arizona experienced a significant increase of 16.1% in HIV tests during the five months following a policy change to anonymous testing. Men who have sex with other men appeared more likely to wait until confidential testing was available than other groups, such as injection drug users. This testing increase continued over a 20-month period. Persons at high risk for HIV infection may be more likely to seek anonymous testing for privacy reasons. However, in order to secure public funding for HIV care and to continue communication with an infected patient, named reporting also needs to be integrated into a comprehensive health policy.

A program to evaluate satisfaction with local health and human services agencies may allow residents to play a more active role in health promotion. In Jan 1990, a program sponsored by the University of Kansas Work Group on Health Promotion was implemented in Lawrence, KS. A consumer working group comprised of low-income residents developed a survey to assess the health concerns of other residents. Local health and human services agencies distributed the questionnaire. Responses were evaluated to determine the importance of issues and the satisfaction with the way issues were handled. The results were distributed to city officials, social service agencies and other community organizations. Possible solutions to areas of high dissatisfaction were discussed at a public meeting. A microgrant program was established to fund both formal and informal organizations proposing solutions to community health concerns. Self-help projects received priority funding.

Byline: Gustavo Angeles, Antonio J. Trujillo, Alexandra Lastra This paper uses a benefit incidence analysis (BIA) to evaluate whether public health expenditure in Ecuador is regressive or progressive. This paper overcomes several limitations of previous BIA analyses in developing countries: a) it develops a framework to allocate the operational and administrative government expenditures among providers at a centralised level according to their level of activity; b) it uses a household health survey in which an individual's consumption of medical care can be tied to a specific health provider. We rank the economic status of medical care users according to the consumption per adult equivalent, and using an index obtained from the availability of durable goods in the household. The findings suggest that the Ministry of Public Health expenditure is progressive, while the Ecuadorian Social Security Institute expenditure is regressive. We offer policy suggestions to increase the efficiency and equity of public health expenditures in Ecuador.

The need to demonstrate that health care has an influence on health status is increasingly pressing. Such demonstrations require tools of measurement which are unfortunately not available. Development of instruments has been hampered by a lack of consensus on appropriate frames of reference, and there appears to be little agreement on what should be measured and what relative importance should be ascribed to different dimensions of health status. An approach that does not require the assignment of numerical values or weights to various aspects of health status and is applicable to all age groups within the population and to the whole spectrum of health problems rather than to specific medical diagnoses would seem desirable. A scheme that is based upon the development of a 'profile' rather than a single 'index' for describing health status is proposed in this paper. The model is a conceptual framework whose usefulness will depend upon efforts of a large number of researchers from many disciplines to develop instruments which can be incorporated in it. Although the problems in development of the scheme are complex, I hope that it will focus attention on the relevant dimensions and facilitate improved coordination of efforts to produce ways to demonstrate what health care contributes to health.

The article, originally published in the journal in 1977, posits that the medical accomplishments of the last four decades have not improved public health but have worsened it by enabling chronic illness to survive and perpetuate.

The article, originally published in the journal in 1958, assesses the successes and challenges of the Health Insurance Plan of Greater New York (HIP) for developing and improving future medical care plans. Topics covered include enrollment, services, and patient outcomes.

The importance of national spirit, and effectively enhanced propaganda and ideological work to prevent and treat atypical pneumonia or severe acute respiratory syndrome (SARS), was discussed in the Sixteenth Chinese Communist Party (CCP). The need for correct direction of public opinion, and to work hard to create a good atmosphere for preventing and treating this disease are discussed.

Progress in public health and community-based interventions has been hampered by the lack of a comprehensive evaluation framework appropriate to such programs. Multilevel interventions that incorporate policy, environmental, and individual components should be evaluated with measurements suited to their settings, goals, and purpose. In this commentary, the authors propose a model (termed the RE-AIM model) for evaluating public health interventions that assesses 5 dimensions: reach, efficacy, adoption, implementation, and maintenance. These dimensions occur at multiple levels (e.g., individual, clinic or organization, community) and interact to determine the public health or population-based impact of a program or policy. The authors discuss issues in evaluating each of these dimensions and combining them to determine overall public health impact. Failure to adequately evaluate programs on all 5 dimensions can lead to a waste of resources, discontinuities between stages of research, and failure to improve public health to the limits of our capacity. The authors summarize strengths and limitations of the RE-AIM model and recommend areas for future research and application. (Am J Public Health. 1999;89:1322-1327)

Canadian proposals for a public health approach to cannabis are welcome and have a substantial history. (1,2) Prior research with Canadian survey data has grappled with the empirical difficulties of [...]

The Labour government of the UK should know that health prevention and promotion may be more effectively done by the private sector in alliance with the National Health Service. The government can help financial services and retailers place their products at the center of public health by guaranteeing that competition agencies do not bar partnerships, and that data protection regulations are obeyed.

Surveillance of occupational disease is the ongoing process of counting cases, evaluating data, and taking preventive action when increases in illness are suspected. The occupational health hazards typically monitored include exposure to toxic chemicals and carcinogens (cancer causing agents), and work-related injuries. Surveillance is necessary so that health officials will know whether hazards are increasing or decreasing, which workers are affected, and if prevention efforts are succeeding. The information gathered and its implications should be distributed to employees and industry managers as well as to occupational physicians and nurses. According to the author, existing surveillance systems in the US are extremely inadequate. Better occupational disease surveillance is achieved by other nations, particularly in western Europe. The most basic step in surveillance, accurate counting of cases, does not occur in the US for such conditions as asbestos exposure and lead poisoning. Yet the author applauds the efforts of the National Institute for Occupational Safety and Health (NIOSH); this organization is attempting to maintain quality programs despite massive budget cuts. Federal funds for NIOSH were slashed by over 50 percent since 1981, and the White House Office of Management and Budget has weakened research projects by censoring questionnaires. Other impediments to effective occupational disease surveillance in the US are that the toxic effects of many industrial products are not known, and physicians have minimal training in recognizing occupational exposure. The author concludes by urging public health professionals to give their loyal support to NIOSH.