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--> Health Care Health care has a limited but not negligible role as a determinant of health. Approximately 5 years of the 30-year increase in life expectancy achieved this century can be attributed to improved health services (Bunker et al., 1994). Of these 5 years, it has been estimated that curative services contribute about 3.5 and clinical preventive services about 1.5 years. The greatest share of this gain from health care can be attributed to diagnosis and treatment of coronary heart disease, which contributes 1 to 2 of these additional years of life. Linking the Determinants According to the presenter, the Evans and Stoddart field model helps in conceptualizing factors affecting health. Substantial evidence is available to support the relationship that many of these factors have with health. Currently incomplete, however, are descriptions of mechanisms underlying the linkages among the various determinants and full characterizations of the interactions among factors. Some evidence is available to demonstrate that these interactions exist. For example, high socioeconomic status is a buffer against the negative impact of perinatal stress on developmental outcomes in children at age 20 months (Werner, 1989). Similarly, high socioeconomic status reduces the negative impact of high umbilical lead levels on mental development (Bellinger et al., 1993). What is not yet available is an understanding of why the interactions occur. Interventions to Improve Health Many factors can influence the impact of interventions to improve health. It is possible to target various determinants of health to produce change at an individual level, a community level, or both. All aspects of each broad determinant of health are not equally amenable to intervention, however. For example, the social environment of isolated senior citizens can be improved by increasing contact with others, but their genetic endowment is not changeable. Time frames for change following interventions can vary widely, from days to decades. Some successful interventions will produce observable results within a year or two, but others may be followed by long latency periods before significant changes can be observed in health status. The impact of an intervention may also be influenced by when it reaches an individual because there appear to be "critical periods" in human development. Certain interventions in childhood, for example, may have long-delayed yet long-lasting results. In addition, the population effects of interventions are important to
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--> consider. Small changes at the individual level may have important ramifications when applied to a whole community (Rose, 1992). Community Interventions The literature on community interventions is diffuse and difficult to summarize. A few observations based on that literature were shared with the committee. For example, the Healthy Cities–Healthy Communities activities demonstrate that a high level of interest in community interventions exists, but these activities have not yet generated a body of evidence that will allow them to be replicated in other settings. Study designs rarely meet high scientific standards. Although literature on advocacy and the process of community change abounds, validation through outcomes research is often lacking. Information linking process with outcome is inadequate, as are details describing implementation of interventions. It was suggested that evidence that interventions have had a positive impact on the population is more likely to emerge in narrowly defined areas such as increasing immunization rates or decreasing workplace smoking. Similarly, one-time accomplishments are easier to document than what is needed to sustain activities. Literature examining the difference between attaining goals and maintaining them is lacking, and this issue requires more attention. Targets for Intervention The traditional targets for intervention have been specific diseases or behaviors. The field model of the determinants of health suggests consideration of a wider array of targets. For example, if adolescents' sense of well-being can be improved by reducing their feelings of alienation and hopelessness, can unintended pregnancies, alcohol and other drug use, crime, and the school dropout rate all be reduced? A multidimensional approach would be required, focusing on education, social and community involvement, family preservation, and improved social networks for teens and their parents. Community-level interventions might include after-school programs, athletics (e.g., midnight basketball), and church-based programs. The multidimensional approach may be unfamiliar to health professionals because it is new and relies on partnerships with people from fields beyond those traditionally encompassed by a medical model. It is, however, consistent with the field model and may provide expanded opportunities for performance monitoring and improving the community's health. The variety of ways in which community can be defined, such as geography, politics, or social networks, was also noted (Patrick and Wickizer, 1995). The committee was
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--> encouraged to consider all kinds of communities in seeking solutions to health needs. Implications for Performance Monitoring Performance monitoring should make use of measures of inputs, process, and outcomes so that their interrelationships can be studied.5 It was suggested that key determinants of health should be monitored, regardless of whether they are amenable to change at the local level, so that communities can understand the range of important factors. The value of both individual- and community level data was emphasized. Subjective individual level data may contribute important information about community needs. For example, information on social support, perceived barriers to service utilization, and attitudes toward the community and its resources is all relevant to health and to performance monitoring and can be obtained from community surveys. The quality of cooperation among organizations is an often-neglected consideration for which community level measures might be developed. The success of multiple organizations serving a particular community may depend on how well their services are coordinated. For example, senior citizens may be served by separate programs providing meals, transportation, outreach, and mental health services. Each program may be meeting its own goals, but if they are not working together, their overall impact may be diminished. It was suggested to the committee that an initial step in performance monitoring is to determine which organizations and institutions in a community can affect health and disease. Those institutions can then be described with respect to goals and objectives, resources, and activities. What problems are being addressed? How effectively? What other activities might be added? Are these institutions educating the community about the problems and their responses? Although organizations themselves can benefit from internal monitoring systems to determine their efficiency in resource utilization and whether desired outcomes are being achieved, they often lack the tools to adequately monitor 5 In the context of the committee's work, outcome measures describe a state of health or well-being (e.g., immunization rates) that is the product of factors that can be characterized on the basis of the field model. To monitor outcomes that change slowly, intermediate outcome measures may be used (e.g., monitoring changes in prevalence of smoking rather than changes in incidence of lung cancer). Process measures describe activities that are being performed in connection with efforts to achieve a desired outcome. Input measures (also referred to as measures of structure or capacity) describe the characteristics of resources (e.g., funds, personnel, equipment, time, policies) available or in use (e.g., number of doses of vaccine available).
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--> their activities. If available, however, such tools may contribute to performance monitoring activities in the community. Important measures include units of services delivered, costs of services, proportion of need met, percentage of resources used to meet objectives, and impact. Community members can provide feedback, measuring how well individuals external to an organization rate the organization's efforts. In addition, an organization should consider how well its programs and services compare with "best practices." It was noted that efforts to identify best practice in developing and using community report cards are under way. Performance monitoring provides an opportunity for a community to define and articulate expectations for organizations' contributions to the population's health. Although organizations might disagree with the appropriateness of the expectations, a useful dialogue may ensue. It was suggested that communities may want to focus special attention on expectations regarding managed care organizations (MCOs) and business. MCOs have improved provider education efforts and information tools such as clinical records, but "community" is often defined as their enrollees. Historically, MCOs have not considered the entire community or public health as their area of concern. A community expectation that part of their corporate and social responsibility is the health of the entire local population could encourage their broader involvement in public health activities. Businesses, including MCOs, that have strong historical ties with a city or region may have greater interest in local health issues. However, as corporations expand to multiple regions, they may be less involved in the local communities where they have a presence. It was suggested that larger corporations operating in many locations should be encouraged to be involved in those communities. At the same time, smaller businesses with strong local bases should be educated and encouraged to become involved in community health efforts. The presentation concluded with mention of another framework for assessing the community and health that translates the determinants of the field model into community terms (see Figure 2). Community social and physical environments are affected by cultural, political, policy, and economic systems and in turn, influence community response, activation, and social support, and ultimately community outcomes including social behaviors, community health, and quality of life (Patrick and Wickizer, 1995). Therefore, performance monitoring might also benefit from attention to the underlying cultural, political, and economic forces represented in this framework.
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