Lawrence W. Green

How should we define health

The WHO definition of health as complete wellbeing is no longer fit for purpose given the rise of chronic disease. Machteld Huber and colleagues propose changing the emphasis towards the ability to adapt and self manage in the face of social, physical, and emotional challenges

Evaluating the Relevance, Generalization, and Applicability of Research: Issues in External Validation and Translation Methodology

Starting with the proposition that “if we want more evidence-based practice, we need more practice-based evidence,” this article (a) offers questions and guides that practitioners, program planners, and policy makers can use to determine the applicability of evidence to situations and populations other than those in which the evidence was produced (generalizability), (b) suggests criteria that reviewers can use to evaluate external validity and potential for generalization, and (c) recommends procedures that practitioners and program planners can use to adapt evidencebased interventions and integrate them with evidence on the population and setting characteristics, theory, and experience into locally appropriate programs. The development and application in tandem of such questions, guides, criteria, and procedures can be a step toward increasing the relevance of research for decision making and should support the creation and reporting of more practice-based research having high external validity.

Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project

The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 13-15 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey. In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes.

Ecological Foundations of Health Promotion

In this article, human ecology is defined; its historical and intellectual roots are traced through various disciplines to its applications in public health and health promotion today; its strengths and limitations are described; some potential contributions of systems theory are suggested; and some emerging ecological models of health promotion are anticipated.

Diffusion theory and knowledge dissemination, utilization, and integration in public health.

Legislators and their scientific beneficiaries express growing concerns that the fruits of their investment in health research are not reaching the public, policy makers, and practitioners with evidence-based practices. Practitioners and the public lament the lack of relevance and fit of evidence that reaches them and barriers to their implementation of it. Much has been written about this gap in medicine, much less in public health. We review the concepts that have guided or misguided public health in their attempts to bridge science and practice through dissemination and implementation. Beginning with diffusion theory, which inspired much of public healths work on dissemination, we compare diffusion, dissemination, and implementation with related notions that have served other fields in bridging science and practice. Finally, we suggest ways to blend diffusion with other theory and evidence in guiding a more decentralized approach to dissemination and implementation in public health, including changes in the ways we produce the science itself.

Public Health Asks of Systems Science: To Advance Our Evidence-Based Practice, Can You Help Us Get More Practice-Based Evidence?

Public health asks of systems science, as it did of sociology 40 years ago, that it help us unravel the complexity of causal forces in our varied populations and the ecologically layered community and societal circumstances of public health practice. We seek a more evidence-based public health practice, but too much of our evidence comes from artificially controlled research that does not fit the realities of practice. What can we learn from our experience with sociology in the past that might guide us in drawing effectively on systems science?

Five-year blood pressure control and mortality following health education for hypertensive patients

Three health education interventions for urban poor hypertensive patients were introduced sequentially in a randomized factorial design: 1) an exit interview to increase understanding of and compliance with the prescribed regimen; 2) a home visit to encourage a family member to provide support for the patients regimen; and 3) invitations to small group sessions to increase the patients confidence and ability to manage his/her problem. Previous evaluation of the initial two-year experience demonstrated a positive effect of the educational program on compliance with the medical treatment and blood pressure control. Data accumulated over an additional three years, including mortality analysis, are now presented. The study group consisted of the same cohort of 400 ambulatory hypertensive outpatients in the eight experimental and control groups. The five-year analysis shows a continuing positive effect on appointment keeping, weight control, and blood pressure control. All-cause life table mortality rate was 57.3 per cent less for the experimental group compared to the control group (12.9/100 vs 30.2/100, p less than .05), while the hypertension-related mortality rate was 53.2 per cent less (8.9/100 vs 19.0/100, p less than .01). The results from this longitudinal study provide evidence to encourage health practitioners to utilize such educational programs in the long-term management and control of high blood pressure.

Uncovering the Benefits of Participatory Research: Implications of a Realist Review for Health Research and Practice

Context Participatory research (PR) is the co-construction of research through partnerships between researchers and people affected by and/or responsible for action on the issues under study. Evaluating the benefits of PR is challenging for a number of reasons: the research topics, methods, and study designs are heterogeneous; the extent of collaborative involvement may vary over the duration of a project and from one project to the next; and partnership activities may generate a complex array of both short- and long-term outcomes. Methods Our review team consisted of a collaboration among researchers and decision makers in public health, research funding, ethics review, and community-engaged scholarship. We identified, selected, and appraised a large-variety sample of primary studies describing PR partnerships, and in each stage, two team members independently reviewed and coded the literature. We used key realist review concepts (middle-range theory, demi-regularity, and context-mechanism-outcome configurations [CMO]) to analyze and synthesize the data, using the PR partnership as the main unit of analysis. Findings From 7,167 abstracts and 591 full-text papers, we distilled for synthesis a final sample of twenty-three PR partnerships described in 276 publications. The link between process and outcome in these partnerships was best explained using the middle-range theory of partnership synergy, which demonstrates how PR can (1) ensure culturally and logistically appropriate research, (2) enhance recruitment capacity, (3) generate professional capacity and competence in stakeholder groups, (4) result in productive conflicts followed by useful negotiation, (5) increase the quality of outputs and outcomes over time, (6) increase the sustainability of project goals beyond funded time frames and during gaps in external funding, and (7) create system changes and new unanticipated projects and activities. Negative examples illustrated why these outcomes were not a guaranteed product of PR partnerships but were contingent on key aspects of context. Conclusions We used a realist approach to embrace the heterogeneity and complexity of the PR literature. This theory-driven synthesis identified mechanisms by which PR may add value to the research process. Using the middle-range theory of partnership synergy, our review confirmed findings from previous PR reviews, documented and explained some negative outcomes, and generated new insights into the benefits of PR regarding conflicts and negotiation between stakeholders, program sustainability and advancement, unanticipated project activity, and the generation of systemic change.

Clinical trials of patient education for chronic conditions: A comparative meta-analysis of intervention types☆

Results are reported of a quantitative synthesis of 70 published evaluations of educational programs for people with long-term health problems and regimens that include drugs. Study methods and interventions are rated according to methodological and educational principles, respectively. The differential effects achieved by seven types of educational techniques are compared. The largest effect-size values (in standard deviation units) for knowledge were in three empirically distinct and homogeneous groups of studies--those testing one-to-one counseling, group education, and one or both of these strategies in combination with audiovisual materials (range = 0.73-1.13). Homogeneous subgroups of behavioral studies (grouped according to type of intervention) were found within the studies measuring drug utilization errors, but the overall group was homogeneous. The absence of significant differences among the subgroups precluded subgroup comparison. The overall effect size was 0.37, indicating substantially decreased drug errors. Analyses of study and other intervention characteristics found the educational rating score to be the strongest predictor of effect size for both knowledge and drug errors. Patient package inserts were predictors of lower effect sizes.

Assessment of the integration of the ecological approach in health promotion programs.

Purpose. This article proposes a model of the ecological approach in health promotion programs. Based on system theory, the model identifies intervention settings and targets as two independent dimensions for assessing the integration of this approach in programs. Additional objectives are to present and pretest an analytical procedure that allows the assessment of integration of the ecological approach in programs. Design. This was a descriptive study of the integration of the ecological approach in a sample of health promotion programs. Subjects. Subjects were 44 health promotion programs drawn from the population of Canadian federally funded programs. Measures. Descriptions of programs were obtained by telephone interviews. A coding scheme was applied to the data to identify intervention settings and targets for each program. Using this information, a summative score of the integration of the ecological approach was estimated for each program. Results. Singh-setting programs were the dominant pattern in the sample. Individuals whose health was of concern were very frequently the direct targets of the programs. However, organizational and interpersonal environments were also often directly targeted. Single-setting or single-intervention strategy programs outnumbered ecological programs. Conclusion. The proposed model and analytical procedure is a useful framework for the assessment of integration of the ecological approach in health promotion programs. The pilot test having been conducted on a convenience sample, future work should replicate the study in a representative sample of programs.