Nancy Edwards

Obesity, stigma and public health planning

Given the rise in obesity rates in North America, concerns about obesity-related costs to the health care system are being stressed in both the popular media and the scientific literature. With such constant calls to action, care must be taken not to increase stigmatization of obese people, particularly of children. While there is much written about stigma and how it is exacerbated, there are few guidelines for public health managers and practitioners who are attempting to design and implement obesity prevention programs that minimize stigma. We examine stigmatization of obese people and the consequences of this social process, and discuss how stigma is manifest in health service provision. We give suggestions for designing non-stigmatizing obesity prevention public health programs. Implications for practice and policy are discussed.

The Role of Nursing Best Practice Champions in Diffusing Practice Guidelines: A Mixed Methods Study

BACKGROUND While the importance of nursing best practice champions has been widely promoted in the diffusion of evidence-based practice, there has been little research about their role. By learning more about what champions do in guideline diffusion, the nursing profession can more proactively manage and facilitate the role of champions while capitalizing on their potential to be effective leaders of the health care system. AIM To determine how nursing best practice champions influence the diffusion of Best Practice Guideline recommendations. METHODS A mixed method sequential triangulation design was used involving two phases: (1) key informant interviews with 23 champions between February and July 2006 and (2) a survey of champions (N= 191) and administrators (N= 41) from September to October 2007. Qualitative findings informed the development of surveys and were used in interpreting quantitative information collected in phase 2. RESULTS Most interview and survey participants were female, employed full-time, and had worked in practice for over 20 years. Qualitative and quantitative findings suggest that champions influence the use of Best Practice Guideline recommendations most readily through: (1) dissemination of information about clinical practice guidelines, specifically through education and mentoring; (2) being persuasive practice leaders at interdisciplinary committees; and (3) tailoring the guideline implementation strategies to the organizational context. CONCLUSIONS AND IMPLICATIONS Our research suggests that nursing best practice champions have a multidimensional role that is well suited to navigating the complexities of a dynamic health system to create positive change. Understanding of this role can help service organizations and the nursing profession more fully capitalize on the potential of champions to influence and implement evidence-based practices to advance positive patient, organizational, and system outcomes.

Stigmatization as a Social Control Mechanism for Persons Living with HIV and AIDS

Stigmatization contributes to inequity by marginalizing persons living with HIV and AIDS (PHAs). In this study we examined the stigmatizing practices in health care settings from the perspectives of PHAs and health care providers (HCPs). A qualitative design, using a participatory action research approach, was used. Interviews and focus groups were completed with 16 aboriginal and 17 nonaboriginal individuals living with HIV (APHAs and PHAs) and 27 HCPs in Ottawa and Edmonton, Canada. We present findings to support the premise that stigmatization can be used as a social control mechanism with PHAs. Participants described both active and passive social control mechanisms: shunning and ostracizing, labeling, and disempowering health care practices. Forgiving behavior, balancing disclosure, practicing universal precautions, bending the rules, shifting services, and reducing labeling were strategies to manage, resist, and mitigate social control. The findings illustrate the urgent need for multilevel interventions to manage, resist, and mitigate stigma.

Increasing Capacity for Knowledge Translation: Understanding How Some Researchers Engage Policy-makers

The potential for research to influence policy, and for researchers to influence policy actors, is significant. The purpose of this qualitative study was to explore the experiences of health services researchers engaging in (or not able to engage in) policy-relevant research. Semistructured telephone interviews were completed with 23 experienced researchers.The results paint a complex and dynamic picture of the policy environment and the relationship between government officials and academic researchers. Elements of this complexity included diverse understandings of the nature of policy and how research relates to policy; dealing with multiple stakeholders in the policy-making process; and identifying strategies to manage the different cultures of government and academia.

Is reporting on interventions a weak link in understanding how and why they work? A preliminary exploration using community heart health exemplars.

BackgroundThe persistent gap between research and practice compromises the impact of multi-level and multi-strategy community health interventions. Part of the problem is a limited understanding of how and why interventions produce change in population health outcomes. Systematic investigation of these intervention processes across studies requires sufficient reporting about interventions. Guided by a set of best processes related to the design, implementation, and evaluation of community health interventions, this article presents preliminary findings of intervention reporting in the published literature using community heart health exemplars as case examples.MethodsThe process to assess intervention reporting involved three steps: selection of a sample of community health intervention studies and their publications; development of a data extraction tool; and data extraction from the publications. Publications from three well-resourced community heart health exemplars were included in the study: the North Karelia Project, the Minnesota Heart Health Program, and Heartbeat Wales.ResultsResults are organized according to six themes that reflect best intervention processes: integrating theory, creating synergy, achieving adequate implementation, creating enabling structures and conditions, modifying interventions during implementation, and facilitating sustainability. In the publications for the three heart health programs, reporting on the intervention processes was variable across studies and across processes.ConclusionStudy findings suggest that limited reporting on intervention processes is a weak link in research on multiple intervention programs in community health. While it would be premature to generalize these results to other programs, important next steps will be to develop a standard tool to guide systematic reporting of multiple intervention programs, and to explore reasons for limited reporting on intervention processes. It is our contention that a shift to more inclusive reporting of intervention processes would help lead to a better understanding of successful or unsuccessful features of multi-strategy and multi-level interventions, and thereby improve the potential for effective practice and outcomes.

Indicators at the interface: managing policymaker-researcher collaboration

The knowledge transfer literature encourages partnerships between researchers and policymakers for the purposes of policy-relevant knowledge creation. Consequently, research findings are more likely to be used by policymakers during policy development. This paper presents a set of practice-based indicators that can be used to manage the collaborative knowledge creation process or assess the performance of a partnership between researchers and policymakers. Indicators for partnership success were developed from 16 qualitative interviews with health policymakers and researchers involved with eight research transfer partnerships with government. These process and outcomes indicators were refined through a focus group. Resulting qualitative and quantitative indicators were judged to be clear, relevant, credible, and feasible. New findings included the need to have different indicators to evaluate new vs mature partnerships, as well as specific indicators common to researcher-policymaker partnerships in general.

Barriers to Physical Activity and Restorative Care for Residents in Long-Term Care: A Review of the Literature

Despite the benefits of physical activity, residents living in long-term care (LTC) are relatively sedentary. Designing successful physical activity and restorative care programs requires a good understanding of implementation barriers. A database search (2002-2013) yielded seven studies (nine articles) that met our inclusion criteria. We also reviewed 31 randomized controlled trials (RCTs) to determine if the authors explicitly discussed the barriers encountered while implementing their interventions. Eleven RCTs (13 articles) included a discussion of the barriers. Hence, a total of 18 studies (22 articles) were included in this review. Barriers occurred at resident (e.g., health status), environmental (e.g., lack of space for physical activity), and organizational (e.g., staffing and funding constraints) levels. These barriers intersect to adversely affect the physical activity of older people living in LTC. Future studies targeting physical activity interventions for residents living in LTC are needed to address these multiple levels of influence.

Demographic and Clinical Determinants of Moderate to Vigorous Physical Activity During Home-Based Cardiac Rehabilitation: THE HOME-BASED DETERMINANTS OF EXERCISE (HOME) STUDY

PURPOSE: Little is known concerning moderate to vigorous physical activity (MVPA) levels in patients attending home-based cardiac rehabilitation (CR) programs and whether demographic/clinical characteristics moderate these levels. METHODS: Patients (N = 280, 77 female) who were referred to home-based CR, mainly because of myocardial infarction (34%), coronary artery bypass graft (17%), and percutaneous coronary intervention/ stent/atherectomy (32%), completed a questionnaire assessing demographic and clinical characteristics as well as MVPA, measured at the beginning and end of a 3-month home-based CR program. Charts were reviewed for blood work, blood pressure, stress tests, and diagnosis. RESULTS: Patients averaged 88.5 minutes per week of MVPA before starting home-based CR, which increased to 191.1 minutes during the program. Multiple regression analyses showed that patients who were male (&bgr; = −.11), did not have metabolic syndrome (&bgr; = −.14), and were meeting the MVPA guideline before starting home-based CR (&bgr; = .25) engaged in significantly more MVPA during home-based CR than their counterparts. Furthermore, the increase in MVPA was significantly larger for males (&bgr; = −.20), patients without metabolic syndrome (&bgr; = −.13), and patients who did not meet the MVPA guideline at baseline (&bgr; = −.29) than their counterparts. CONCLUSIONS: The MVPA levels of patients attending home-based CR tend to vary depending on gender, whether or not metabolic syndrome was present, and prior MVPA levels, suggesting the need to potentially target these particular groups in future behavioral interventions aimed at increasing MVPA.

Exploring which context matters in the study of health inequities and their mitigation

Aim: This commentary argues that contextual influences on health inequities need to be more thoroughly interrogated in future studies of population health interventions. Methods: Case examples were chosen to illustrate several aspects of context: its historical, global, and dynamic nature; its multidimensional character; and its macro- and micro-level influences. These criteria were selected based on findings from an extensive literature review undertaken for the Public Health Agency of Canada and from two invitational symposia on multiple intervention programmes, one with a focus on equity, the other with a focus on context. Findings: Contextual influences are pervasive yet specific, and diffuse yet structurally embedded. Historical contexts that have produced inequities have contemporary influences. The global forces of context cross jurisdictional boundaries. A complex set of social actors intersect with socio-political structures to dynamically co-create contextual influences. Conclusions: These contextual influences raise critical challenges for the field of population health intervention research. These challenges must be addressed if we are going to succeed in the calls for action to reduce health inequities. Implications for future public health research and research-funding agencies must be carefully considered.

An Integrated Framework for Risk Management and Population Health

ABSTRACT The traditional medical model of health and health policy development has focused on individuals and the role of medical care in preventing and treating disease and injury. Recent attention to health inequities and social determinants of health has raised the profile of population heath and evidence-based strategies for improving the health of whole populations. At the same time, risk science has emerged as an important new discipline for the assessment and management of risks to health. This article reviews historical developments in the fields of risk management and population health and proposes a joint population health risk management framework that integrates the key elements of both fields. Applying this integrated approach to managing population health risks will facilitate the development of evidence-based health policy. It will encourage a more systematic and comprehensive evaluation of population health issues and promote the use of a broader suite of interventions to reduce health risks and enhance population health status.