Rethinking and Decolonizing Theories, Policies, and Practice of Health from the Global South.

This article states the need to decolonize the theories, policies, and practices that dominate health, and reflects on the necessity for a new epistemology built from the Global South. This allows rethinking health with a new categorical framework, which incorporates socially determined health and life, with the optic of reaching the highest conceivable degree of living well/well-living. We put forth that the epistemic bases of epidemiology and the implementation of health systems tend to reproduce a coloniality of power and of established health knowledge. Health systems are viewed as an accumulation of reforms based on theories and policies of the Global North imposed on Latin America and the Caribbean. These systems have been built as bureaucratic, biomedicalized, treatment-oriented, and commercialized health systems that are perceived as external to societies and that reproduce mistreatment, violence, and racism. We make the argument to rethink, remake, and decolonize the theories and practices that govern both epidemiology and health systems, and, from the South, develop strategic processes for building health sovereignty as the vision for the reconstruction of hope and social justice.

Health Benefits of Strategies for Carbon Mitigation in US Transportation, 2017‒2050.

Objectives. To quantify health benefits and carbon emissions of 2 transportation scenarios that contrast optimum levels of physical activity from active travel and minimal air pollution from electric cars. Methods. We used data on burden of disease, travel, and vehicle emissions in the US population and a health impact model to assess health benefits and harms of physical activity from transportation-related walking and cycling, fine particulate pollution from car emissions, and road traffic injuries. We compared baseline travel with walking and cycling a median of 150 weekly minutes for physical activity, and with electric cars that minimized carbon pollution and fine particulates. Results. In 2050, the target year for carbon neutrality, the active travel scenario avoided 167 000 deaths and gained 2.5 million disability-adjusted life years, monetized at $1.6 trillion using the value of a statistical life. Carbon emissions were reduced by 24% from baseline. Electric cars avoided 1400 deaths and gained 16 400 disability-adjusted life years, monetized at $13 billion. Conclusions. To achieve carbon neutrality in transportation and maximize health benefits, active travel should have a prominent role along with electric vehicles in national blueprints. (Am J Public Health. 2022; 112(3):426-433. https://doi.org/10.2105/AJPH.2021.306600).

A Public Health Learning Collaborative on Climate Change for Urban Health Departments, 2016-2018.

OBJECTIVES: The objective of this project was to demonstrate and assess approaches of urban local health departments (LHDs) to simultaneously address climate change, health, and equity; incorporate climate change into program practice; and participate in their jurisdiction's climate change work. METHODS: From January 2016 through March 2018, the Center for Climate Change and Health created learning activities, networking and relationship-building opportunities, communication platforms, and information sharing for 12 urban LHDs in the United States. We used administrative data and conducted interviews with participants and key informants to assess success in meeting learning collaborative goals. RESULTS: LHDs developed diverse projects that incorporated internal capacity building, climate and health vulnerability assessments, surveillance, and community engagement. Projects fostered greater LHD engagement on climate change, broadened community partnerships, and furthered LHD integration into jurisdictions' climate planning. LHD engagement helped shift the dialogue in the community and jurisdiction about climate change to include public health. CONCLUSIONS: LHDs have skills and expertise to rapidly partner with other governmental agencies and community-based organizations and to help communities identify vulnerabilities, take action to reduce the health harms of climate change, and-through Health in All Policies approaches and community partnerships-to ensure that climate policies are optimized for positive health and equity outcomes.

California Healthy Places Index: Frames Matter.

INTRODUCTION: We describe the California Healthy Places Index (HPI) and its performance relative to other indexes for measuring community well-being at the census-tract level. The HPI arose from a need identified by health departments and community organizations for an index rooted in the social determinants of health for place-based policy making and program targeting. The index was geographically granular, validated against life expectancy at birth, and linked to policy actions. MATERIALS AND METHODS: Guided by literature, public health experts, and a positive asset frame, we developed a composite index of community well-being for California from publicly available census-tract data on place-based factors linked to health. The 25 HPI indicators spanned 8 domains; weights were derived from their empirical association with tract-level life expectancy using weighted quantile sums methods. RESULTS: The HPI's domains were aligned with the social determinants of health and policy action areas of economic resources, education, housing, transportation, clean environment, neighborhood conditions, social resources, and health care access. The overall HPI score was the sum of weighted domain scores, of which economy and education were highly influential (50% of total weights). The HPI was strongly associated with life expectancy at birth (r = 0.58). Compared with the HPI, a pollution-oriented index did not capture one-third of the most disadvantaged quartile of census tracts (representing 3 million Californians). Overlap of the HPI's most disadvantaged quartile of census tracts was greater for indexes of economic deprivation. We visualized the HPI percentile ranking as a web-based mapping tool that presented the HPI at multiple geographies and that linked indicators to an action-oriented policy guide. PRACTICE IMPLICATIONS: The framing of indexes and specifications such as domain weighting have substantial consequences for prioritizing disadvantaged populations. The HPI provides a model for tools and new methods that help prioritize investments and identify multisectoral opportunities for policy action.

Routine Assessment of Health Impacts of Local Transportation Plans: A Case Study From the City of Los Angeles.

OBJECTIVES: To determine the health impacts of three future scenarios of travel behavior by mode for the City of Los Angeles, California, and to provide specific recommendations for how to conduct health impact assessments of local transportation plans on a more routine basis. METHODS: We used the Integrated Transportation and Health Impact Model to assess the health impacts of the Los Angeles Mobility Plan 2035 by using environmental impact report data on miles traveled by mode under alternative implementation scenarios as inputs. The Integrated Transportation and Health Impact Model links region-wide changes in travel behavior to population exposures to physical activity, air pollution, and traffic collisions and associated health outcomes and costs. RESULTS: The largest impacts were on cardiovascular disease through increases in physical activity. Reductions in air pollution-related illnesses were more modest. Traffic injuries and deaths increased across all scenarios but were greatly reduced through targeted roadway safety enhancements accounted for outside the model. CONCLUSIONS: By establishing miles travelled as the metric for transportation impacts of statewide and regional plans, states can leverage existing data sources to more routinely consider health impacts as part of environmental impact reports. While not insurmountable, challenges remain regarding the incorporation of land use and roadway safety strategies into health impact estimates.

Health and greenhouse gas mitigation benefits of ambitious expansion of cycling, walking, and transit in California.

The purpose of this research was to quantify health co-benefits and carbon reductions of preferred scenarios of California regional transportation plans and alternatives with ambitious levels of active transport. The alternatives were designed to examine the efficacy of independent contributions of walking, bicycling, and transit at levels consistent with the U.S. Surgeon General recommendation for physical activity. Using data from travel and health surveys, vital statistics, collision databases, and outputs from regional and statewide travel models, the Integrated Transport and Health Impacts Model estimated the change in the population disease burden, as measured by deaths and disability adjusted life years (DALYs), due to a shift from a 2010 baseline travel pattern to an alternative. Health pathways modeled were physical activity and road traffic injuries. The preferred scenarios increased statewide active transport from 40.5 to 53.4 min person-1 w-1, which was associated with an annual decrease of 909 deaths and 16,089 DALYs. Sensitivity analyses that accounted for 2040 projected age- and sex-specific population characteristics and cause-specific mortality rates did not appreciably alter the annual change in deaths and DALYs on a population basis. The ambitious, maximal alternatives increased population mean travel duration to 283 min person-1 w-1 for walking, bicycling, or transit and were associated a reduction in deaths and DALYs from 2.5 to 12 times greater than the California preferred scenarios. The alternative with the largest health impact was bicycling 283 min person-1 w-1 which led to 8,543 fewer annual deaths and 194,003 fewer DALYs, despite an increase in bicyclist injuries. With anticipated population growth, no alternative achieved decreases in carbon emissions but bicycling had the greatest potential for slowing their growth. Alternatives that included transit similarly reduced carbon emissions, but with less health benefit. Aggressive expansion of active transport is an efficacious, but underutilized policy option with significant health co-benefits for mitigating greenhouse gases.

Cross-sectional analysis of two social determinants of health in California cities: racial/ethnic and geographic disparities.

OBJECTIVE: To study the magnitude and direction of city-level racial and ethnic differences in poverty and education to characterise health equity and social determinants of health in California cities. DESIGN: We used data from the American Community Survey, United States Census Bureau, 2006-2010, and calculated differences in the prevalence of poverty and low educational attainment in adults by race/ethnicity and by census tracts within California cities. For race/ethnicity comparisons, when the referent group (p2) to calculate the difference (p1-p2) was the non-Hispanic White population (considered a historically advantaged group), a positive difference was considered a health inequity. Differences with a non-White reference group were considered health disparities. SETTING: Cities of the State of California, USA. RESULTS: Within-city differences in the prevalence of poverty and low educational attainment disfavoured Black and Latinos compared with Whites in over 78% of the cities. Compared with Whites, the median within-city poverty difference was 7.0% for Latinos and 6.2% for Blacks. For education, median within-city difference was 26.6% for Latinos compared with Whites. In a small, but not negligible proportion of cities, historically disadvantaged race/ethnicity groups had better social determinants of health outcomes than Whites. The median difference between the highest and lowest census tracts within cities was 14.3% for poverty and 15.7% for low educational attainment. Overall city poverty rate was weakly, but positively correlated with within-city racial/ethnic differences. CONCLUSIONS: Disparities and inequities are widespread in California. Local health departments can use these findings to partner with cities in their jurisdiction and design strategies to reduce racial, ethnic and geographic differences in economic and educational outcomes. These analytic methods could be used in an ongoing surveillance system to monitor these determinants of health.

The Integrated Transport and Health Impact Modeling Tool in Nashville, Tennessee, USA: Implementation Steps and Lessons Learned.

The Integrated Transport and Health Impact Model (ITHIM) is a comprehensive tool that estimates the hypothetical health effects of transportation mode shifts through changes to physical activity, air pollution, and injuries. The purpose of this paper is to describe the implementation of ITHIM in greater Nashville, Tennessee (USA), describe important lessons learned, and serve as an implementation guide for other practitioners and researchers interested in running ITHIM. As might be expected in other metropolitan areas in the US, not all the required calibration data was available locally. We utilized data from local, state, and federal sources to fulfill the 14 ITHIM calibration items, which include disease burdens, travel habits, physical activity participation, air pollution levels, and traffic injuries and fatalities. Three scenarios were developed that modeled stepwise increases in walking and bicycling, and one that modeled reductions in car travel. Cost savings estimates were calculated by scaling national-level, disease-specific direct treatment costs and indirect lost productivity costs to the greater Nashville population of approximately 1.5 million. Implementation required approximately one year of intermittent, part-time work. Across the range of scenarios, results suggested that 24 to 123 deaths per year could be averted in the region through a 1%-5% reduction in the burden of several chronic diseases. This translated into $10-$63 million in estimated direct and indirect cost savings per year. Implementing ITHIM in greater Nashville has provided local decision makers with important information on the potential health effects of transportation choices. Other jurisdictions interested in ITHIM might find the Nashville example as a useful guide to streamline the effort required to calibrate and run the model.

Contrasts in active transport behaviour across four countries: how do they translate into public health benefits?

OBJECTIVE: Countries and regions vary substantially in transport related physical activity that people gain from walking and cycling and in how this varies by age and gender. This study aims to quantify the population health impacts of differences between four settings. METHOD: The Integrated Transport and Health Model (ITHIM) was used to estimate health impacts from changes to physical activity that would arise if adults in urban areas in England and Wales adopted travel patterns of Switzerland, the Netherlands, and California. The model was parameterised with data from travel surveys from each setting and estimated using Monte Carlo simulation. Two types of scenarios were created, one in which the total travel time budget was assumed to be fixed and one where total travel times varied. RESULTS: Substantial population health benefits would accrue if people in England and Wales gained as much transport related physical activity as people in Switzerland or the Netherlands, whilst smaller but still considerable harms would occur if active travel fell to the level seen in California. The benefits from achieving the travel patterns of the high cycling Netherlands or high walking Switzerland were similar. CONCLUSION: Differences between high income countries in how people travel have important implications for population health.

Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area.

OBJECTIVES: We quantified health benefits of transportation strategies to reduce greenhouse gas emissions (GHGE). METHODS: Statistics on travel patterns and injuries, physical activity, fine particulate matter, and GHGE in the San Francisco Bay Area, California, were input to a model that calculated the health impacts of walking and bicycling short distances usually traveled by car or driving low-emission automobiles. We measured the change in disease burden in disability-adjusted life years (DALYs) based on dose-response relationships and the distributions of physical activity, particulate matter, and traffic injuries. RESULTS: Increasing median daily walking and bicycling from 4 to 22 minutes reduced the burden of cardiovascular disease and diabetes by 14% (32,466 DALYs), increased the traffic injury burden by 39% (5907 DALYS), and decreased GHGE by 14%. Low-carbon driving reduced GHGE by 33.5% and cardiorespiratory disease burden by less than 1%. CONCLUSIONS: Increased physical activity associated with active transport could generate a large net improvement in population health. Measures would be needed to minimize pedestrian and bicyclist injuries. Together, active transport and low-carbon driving could achieve GHGE reductions sufficient for California to meet legislative mandates.

A systems-based intervention to promote smoking as a vital sign in patients served by community health centers.

The frequency of asking and advising adult patients about tobacco use was measured after an intervention to adopt smoking as a vital sign at 7 community health centers. The intervention consisted of training staff, revising forms and vital sign stamps, and disseminating educational materials. Documentation in medical charts was reviewed for 1,571 randomly sampled patients in 2002 and 2003. The point prevalence (last encounter) and period prevalence (any annual encounter) of asking patients about smoking increased significantly from 2002 to 2003 (59% to 85%, and 71% to 97%, respectively) overall and at each health center. On advising smokers to quit, 4 health centers improved, but the overall point prevalence, 26%, and period prevalence, 46%, were unchanged over time. An intervention using multiple strategies may have contributed to improving the rates of asking but did not have as large or consistent an impact on rates of advising smokers to quit.

Race/ethnicity in medical charts and administrative databases of patients served by community health centers.

OBJECTIVE: The objective of this study was to measure the agreement in classification of patients' race/ethnicity in the medical charts and the automated practice management systems (PMSs) of seven community health centers. SETTING: Community health centers are on the frontlines of providing primary care to the under-served and racial/ethnic minorities. Public and private investments in information technology and the increasing use of automated disease registries hold promise to improve care and reduce ethnic and racial disparities. However, data quality may limit the accuracy of race/ethnicity classification and the ability to measure the effect of population-based clinical quality improvements. DESIGN/PARTICIPANTS: In a cross-sectional study, a probability sample of 947 patients with encounters in 2002 was selected from 79,119 patients. Each PMS used a single data field with a pick list that combined ethnicity and race. Race/ethnicity on registration forms completed by patients was abstracted from medical charts. Race/ethnicity classifications were aggregated into seven major categories: Asian/Pacific Islander, Black/African-American, Native American, White, Hispanic/Latino, Other, Missing/Unknown. OUTCOME MEASURES: The sensitivity, positive predictive value, and proportion of agreement were outcome measures of agreement between information in the medical chart and PMS. RESULTS: The overall proportion of agreement (PA) between the medical chart (reference) and PMS was 87%. The PA varied significantly by health center (95%-74%). Hispanic/Latino had the highest sensitivity (91%) and positive predictive value (95%) and White the lowest (84% and 80%, respectively). CONCLUSIONS: In broad categories, correspondence of race/ethnicity classifications in medical charts and PMS was good, although health centers varied. A careful appraisal of data quality of race/ethnicity is warranted before administrative databases are used in clinical quality improvement programs or research to assess health disparities.

A record linkage protocol for a diabetes registry at ethnically diverse community health centers.

Community health centers serve ethnically diverse populations that may pose challenges for record linkage based on name and date of birth. The objective was to identify an optimal deterministic algorithm to link patient encounters and laboratory results for hemoglobin A1c testing and examine its variability by health center site, patient ethnicity, and other variables. Based on data elements of last name, first name, date of birth, gender, and health center site, matches with >/=50% to < 100% of a maximum score were manually reviewed for true matches. Match keys based on combinations of name substrings, date of birth, gender, and health center were used to link encounter and laboratory files. The optimal match key was the first two letters of the last name and date of birth, which had a sensitivity of 92.7% and a positive predictive value of 99.5%. Sensitivity marginally varied by health center, age, gender, but not by ethnicity. An algorithm that was inexpensive, accurate, and easy to implement was found to be well suited for population-based measurement of clinical quality.

Glycemic control in diabetic patients served by community health centers.

The Community Health Center Network measured the prevalence of glycemic control in diabetic patients at 7 community health centers as part of its clinical quality improvement program. A cross-sectional survey was carried out in a random sample of 1817 diabetic patients having 1 or more encounters from October 1, 2000 to September 30, 2001. Computerized laboratory results for hemoglobin A1c (HbA1c) tests were available for half the sample. Manual review of medical charts was carried out for the rest. The proportion of diabetic patients with 1 or more HbA1c tests in the measurement year was 91% (CI95%: 90-93%) and poor glycemic control (HbA1c > 9%) occurred in 27% (CIM%: 25-30%). The mean of the most recent test was 7.8%. The frequency of testing varied significantly by clinic from 79% to 94% and increased with the number of encounters. Poor glycemic control also varied significantly by clinic (17-48%) and was significantly better in females and older patients. Measures of glycemic control were not associated with ethnicity or insurance status in multivariate analyses. A high proportion of diabetic patients received appropriate care, and this care was not associated with ethnicity or insurance status. The data warehouse was an essential tool for the clinical quality improvement program.

Lumbalgia ocupacional en enfermeras venezolanas / Occupational low back pain in Venezuelan nurses

Para examinar y verificar si los factores de riesgo ocupacionales presentes en el trabajo de enfermería hospitalario, operan sobre la aparición de la lumbalgia, se realizó un estudio de prevalencia en una muestra de 302 trabajadoras de la enfermería de dos hospitales de Venezuela.En un cuestionario sobre trastornos menstruales y otros síntomas perimenstruales, se hicieron 2 preguntas específicas sobre lumbalgia, basadas en la percepción del dolor de las trabajadoras: (1) ¿Hoy, al momento de esta entrevista, siente dolor a nivel de espalda baja? (si/no). (2) ¿Durante los últimos 12 meses, con qué frecuencia ha experimentado dolor a nivel de espalda baja? (nunca, de vez en cuando, frecuentemente y/o casi siempre). Como factores de riesgo ocupacionales, se examinaron diferentes actividades de manipulación de los pacientes e indicadores de intensidad del ritmo de trabajo. La asociación de la lumbalgia con cada uno de los factores ocupacionales fue analizada mediante un modelo de regresión logística múltiple ajustado por edad, obesidad, consumo de alcohol, cigarrillo, y la menstruación. La prevalencia de la lumbalgia al momento de la entrevista fue de un 28 por ciento y la prevalencia de este síntoma percibido frecuentemente o casi siempre durante el último año fue de un 48 por ciento. Se encontraron asociaciones estadísticamente significativas de la lumbalgia con diferentes tareas que implican posiciones incómodas del tronco y el levantamiento de cargas, p.ej.: Bañar pacientes, ORaj=1.09(IC 95 por ciento=1.01-1.16), así como con varios indicadores de intensidad de ritmo de trabajo, p.ej.: Percepción del ritmo de trabajo intenso, ORaj=1.58(IC 95 por ciento=1.24-2.02). Dentro de los factores de riesgo no ocupacionales, la menstruación y el cigarrillo resultaron estadísticamente asociados: Menstruación, RR=1.96(IC 95 por ciento=1.31-2.92); consumo de cigarrillos, RR=1.68 (IC 95 por ciento=1.16-2.43). Los resultados confirman que los factores de riesgo ocupacionales son condiciones determinantes para la aparición del dolor de espalda baja en el grupo de trabajadoras de la enfermería

What do injured workers think about their medical care and outcomes after work injury?

Patient satisfaction is an important aspect of quality of care. Little information about injured workers' satisfaction is available. A survey instrument was developed to assess "What Do Injured Workers Think About Their Medical Care?" Survey domains included access, satisfaction, reports of physician behaviors, and outcomes after work injury. Descriptive analyses were performed on more than 800 responses. Approximately 25% of respondents reported dissatisfaction with care. Satisfaction with choice of provider, interpersonal care, claims handling, and outcomes were major predictors of overall satisfaction. Spanish-speakers were more likely to be dissatisfied with physician communications. Months after injury, many workers reported significant pain and impact on job ability and daily function. Routine evaluation of patient satisfaction with occupational medical care could facilitate quality improvement efforts and informed purchaser and worker choice of occupational health services.