public health problems

public health problems

Public Health Problems: Addressing the Challenges

1. Introduction

Let us engage you with some recently collected data; studies that force us to rethink the concepts of global health. To illustrate, one group of researchers recently undertook to apply the latest techniques in the field of global burden of disease to the rich countries of the Organization for Economic Cooperation and Development (OECD). Their findings are disquieting. Injuries are one of the most important public health problems in the developed world, ranking third behind only cardiovascular and neoplastic diseases. The burden from neuropsychiatric conditions, substance abuse, and the diseases of young adults largely due to higher rates of injury accounts for a significant proportion of disability adjusted life years in countries like the United States and Canada. Combined, these conditions represent a paradox, in that citizens of OECD countries enjoy among the longest life expectancies in the world but new evidence suggests the quality and functionality of those extra years is poor. High income is clearly no longer an inoculation against great health, although it is this association between wealth, prosperity, and health status that has been the focus of public health and epidemiology at the global level. Ironically, this research moves the spotlight on to developed countries most of whom have at best rudimentary national Public Health capacity. This represents a large and growing gap between what we know and what we are willing to do about it. With the world’s population aged 60 and over predicted to hit 2 billion by 2050, public health issues have never been more important to address than now when people are living longer than ever before.

2. Understanding the Scope of Public Health Problems

Clearly, mental health is pervasive and affects many people. Lastly, because mental health is so integral to overall health, prevention and treatment of mental disorders is of the utmost importance in improving public health. A comprehensive understanding of the epidemiology of mental health issues is the first step in addressing this component of the broader field of public health.

The majority of work in public health has concentrated on physical health problems, but mental health is quite integral to overall wellbeing. Mental disorders represent a major portion of the disease burden of the entire United States and they are prevalent in every aspect of the human lifecycle. According to the Surgeon General’s report on mental health (2000), mental disorders are the leading cause of disability in the U.S. and Canada for ages 15-44. In both countries, anxiety disorders are the most common. The U.S. and Canada are not alone in this trend; the World Health Report 2001 states that mental disorders constitute 15% of the global burden of disease – a figure that matches the burden of disease due to cardiovascular disorders and surpasses the burden of disease due to all cancers.

Fundamentals

3. Identifying the Root Causes

Third, pinpointing the root causes of problems often encounters resistance from individuals or groups which prosper from the present state of affairs. This is particularly true when the investigator is trying to understand disparities in the distribution of health and disease between social groups. It is important to recognize that the differential distribution of disease is itself a problem to be explained. Efforts to examine the causes of health disparities are unlikely to be well received by those who perceive such inquiries as a threat to their interests. Available evidence and common beliefs tend to be scrutinized more critically when they challenge self-interest. This resistance increases the likelihood that political factors will influence what is studied and how it is interpreted. The implication of this is not that epidemiologists should become political advocates. Rather, it is that politically naive understandings of the causes of health problems are more likely to reflect the status quo and will therefore have less relevance to the development of effective interventions.

Second, identifying the root causes of problems often entails the development of alternative framings of problems and their etiologies. This is a sound strategy, in that problems and their causes are viewed as patterns of events which are inferred from the behavior and conditions observed. Changes in these patterns are thought to be modifications of present patterns or to be replacements of one set of conditions or events with another. Discovery of causal relationships is thus central to the development of effective interventions to alter the course of events and prevent the recurrence of the problem. An implicit or explicit theory of cause is the necessary foundation for effective action. Underlying causes are constructs which are derived from theories. Therefore, to identify underlying causes, sound theory and careful logic are required.

First, direct consideration of root causes requires a shift in the orientation of the field from apolitical or ahistorical assessment of health problems to one which explicitly recognizes the ways in which health is influenced by social, economic, and political structures and processes. Root causes are seldom the result of a single factor. More commonly, they are produced by a convergence of circumstances which create the conditions that lead to the problem. Analysis of root causes requires investigators to ask a sequence of “why” questions to illuminate the multiple levels and types of factors that have contributed to the problem. Asking these questions is deceptively difficult because we are conditioned to think in terms of simple cause-and-effect. Consequently, we often stop the casual chain with the first answer that is provided, which usually identifies the factor that is most obvious, accessible, and amenable to change, but may have little bearing on the incidence of the problem. Failure to systematically investigate the underlying causes of problems is a major source of ineffectiveness in public health interventions.

4. Implementing Effective Solutions

A commitment to combat specific diseases has also been seen through increased aid and purchasing power of international leaders. An example is the initiative to eradicate polio through the formation of The Global Polio Eradication Initiative, which has strengthened the performance of its partners through large grants to conduct activities in endemic countries.

Governance reforms and the development of a global health framework can be seen through many recent global health initiatives, one being the formation of the Global Alliance for Vaccines and Immunizations. This was created with the goal to immunize children and protect the health of future generations. The GAVI alliance has brought together public and private sectors with the shared goal of creating equal access to new and underused vaccines for children living in the world’s poorest regions.

Additional strategies to create system changes involve partnership development and strengthening of global governance on health issues. A study of successful health partnerships to improve health equity in Europe identified that these partnerships were successful because they implement concrete actions, make changes in agendas and power dynamics, engage in joint advocacy initiatives, and use resources effectively to influence policy.

Social advocacy involves understanding the values, beliefs, and attitudes of those in a community or population and creating a positive change on a health issue. As obesity has become a significant health issue in the United States, corresponding prevalence data has shown an increase in legislation and community initiatives to combat it. A study done by the Rudd Center of Yale University and published in Health Affairs explored public opinion on government involvement in the regulation of fast food restaurants in schools and found that the majority of Americans and parents were supportive of government intervention to limit high-calorie, low-nutrition foods.

Another example of system advocacy is an evaluation of the fight against AIDS in resource-poor countries. Research showed that it was strong forms of international activism directed to specific targets, namely the US government and the pharmaceutical industry, that resulted in a policy change to expand global access to HIV/AIDS medicines.

System advocacy is a more complex approach involving many strategies to address policymakers or administrators at the federal, state, or local levels and their beliefs and actions that affect the level of funding and regulation to a particular health issue. A national policy addressing tobacco use has been established in many countries which have ratified the WHO Framework Convention on Tobacco Control. Countries that have ratified this agreement are now obligated to follow efforts to reduce tobacco use. This is a significant step in changing a major risk factor that leads to the development of chronic diseases in many regions.

Individual advocacy can be as simple as brief interactions to defeat nutrition standards changes that would have allowed the sale of soft drinks in schools. Several physicians and school board members expressed their beliefs that soda should not be sold in schools due to its contribution to obesity.

Changes in political, economic, social, and technological environments are necessary to translate public health problems and alternative solutions into policies and programs. Advocacy has been defined as a combination of individual and social actions designed to gain political commitment, policy support, social acceptance, and systems support for a particular health goal or program.

Enacting Solutions

5. Collaboration for a Healthier Future

Much of the literature on partnership working in health promotes a normative view, arguing that collaboration between organizations is vital in order to maximize resources, avoid duplication of effort, and maximize the utilization of scarce resources. The Black Report and the subsequent Acheson Inquiry into health inequalities identified the need to develop initiatives to involve ‘opinion leaders’ and develop community resources to bring about change, and echoed an earlier statement from WHO that “the most important social and political step that would relieve people from impoverishment, hardship, and deprivation and promote their health would be a coordinated strategy to raise the living standard of the poor.” It is often implied that initiatives to build healthier communities and reduce health disparities will most effectively be brought about by partnership working between a wide range of statutory, voluntary, and community organizations, and there is a large body of literature which is underpinned by this logic. This normative stance assumes that health improvement can be brought about by simply increasing the level of collaboration between organizations. In contrast, critical realist perspectives drawn from research conclude that collaboration is just one of many mechanisms by which partnerships may impact on health. These perspectives argue that partnership impacts on health will be contingent upon the particular activities undertaken by the partners, which in turn will be influenced by wider contextual factors and the resources available to the partners. A realist evaluation of partnerships may therefore be necessary in order to determine the circumstances under which collaboration is most likely to result in better health.

In 1988, the Ottawa Charter for Health Promotion acknowledged the need to build and sustain partnerships between public, private, and voluntary sector organizations, as well as with communities to progress towards better health. Over the past 20 years, numerous international declarations and national health strategies have highlighted the critical importance of collaboration and partnership working in improving health status and tackling health inequities. A theory of partnership working has emerged that identifies the conditions necessary for successful partnerships, as well as the potential challenges and limitations that partnerships may face. This theory stems from a recognition that collaboration is not an end in itself but a means of proactively engaging with other organizations to work towards shared goals, and one that is worthy of empirical investigation.