The bilingual program was culturally and linguistically appropriate and addressed risk factors for chronic conditions. Participants formed positive relationships with bilingual coaches who they preferred to interpreters. They felt the program promoted healthy eating, weight and physical activity. Although Chinese stakeholders had concerns about participants’ ability to goal set, participants said they met their health goals and were committed to the GHS program. Strategies to enhance the program included promoting the bilingual GHS to the communities and stakeholders. Factors to consider beyond language in adapting the program to the Australian Chinese communities include meeting the heterogenous needs of the older population, ensuring community engagement and addressing cultural beliefs and practices.
The aspects of the study that I found interesting were that:
translation alone definitely isn’t enough to make a program culturally appropriate and relevant (which we knew but was good to have confirmed)
there were a broad range of health beliefs, priorities and attitudes amongst participants, highlighting that even within a relatively narrowly defined population such as this pilot, there is considerable diversity
bilingual staff were clearly preferred to interpreters.
These points are all relevant to other bilingual and culturally targeted health programs. If you have any trouble accessing the article please let me know.
O’Callaghan, C., Tran, A., Tam, N., Wen, L. M., & Harris-Roxas. (2021). Promoting the get healthy information and coaching service (GHS) in Australian-Chinese communities: facilitators and barriers. Health Promotion International, daab129. https://doi.org/10.1093/heapro/daab129
As Prof Catherine Bennett points out, reducing the reproduction rate of the Delta variant to 1.2-1.3 has itself been a major achievement.
However, because COVID spreads based on inequalities – insecure work, where people live, housing conditions, inability to isolate – a targeted approach based on epidemiological data alone can lead to interventions that reinforce inequities. Interventions like curfews, limiting people to one hour outside the home, and increased policing are unlikely to have an influence on COVID transmission. If anything, they’re only likely to lead to increased criminal justice engagement and charges. They’re also not based on public health evidence.
Because these measures are only being imposed in the poorer parts of Sydney where COVID is circulating most, they’re entrenching determinants of health inequity.
Eighteen months ago, when I was still trying to figure what COVID was all about, I wrote:
There is likely to be a social gradient in transmission, i.e. the poor are more likely to get COVID-19, at least at first. This is a concern that some have already flagged in the U.S.
If there is a social gradient in the disease, there needs to be a social gradient in our response. The most affected locations and communities should be the focus of the health system’s initial response (we can’t just assume this will be the case). If antiviral therapies are found to be effective, or if a vaccine is eventually developed, consideration should be given to deploying them to poorer areas first.
If I reflect back on when I started in public health, most people were actively hostile to the concept of health equity and global heating was regarded as a fringe issue of marginal significance. How much things have changed when the US DHHS sets up an Office of Climate Change and Health Equity. Even if it’s a small, under-resourced unit, its very existence has meaning.
“The Secretary of Health and Human Services shall … establish an Office of Climate Change and Health Equity to address the impact of climate change on the health of the American people,” – Source
Important report from the Lowitja Institute , which outlines a call to action on the cultural determinants of health for Aboriginal and Torres Strait Islander people. It includes the comprehensive framework below.
Unfortunately, we are quick to respond when there is an urgent risk to our own safety or those we care about; and quick to forget when the crisis has passed and the only perceivable danger is to ‘others.’ Our tendency to distance ourselves from those we view as alien or intrinsically different from us puts everyone in danger. It is a fundamental misunderstanding of a risk that is always there and that can be mitigated only through effective contingency planning, requiring trust and a common denominator of commitment to our shared humanity.
— Read on blogs.bmj.com/bmj/2020/03/18/covid-19-the-painful-price-of-ignoring-health-inequities/
We know the rich look after their own, but these injustices are not acts of God or mere sad facts of life to be shrugged at with resignation. There will be many terrible lessons to learn from this pandemic: one is a lesson that should have been learned long ago, that inequality kills.
Models for organizational innovation give an idea of the dimensions that need to be considered to strengthen the integration of equity into organizations and to support the changes in practice that result from using the tool. They provide a reminder that a health equity tool cannot be the cornerstone of an organizational strategy to fight against SIH; rather, it must be incorporated as part of a systemic strategy of professional and organizational development.
— Read on academic.oup.com/heapro/advance-article-abstract/doi/10.1093/heapro/day047/5068642
A useful contribution, if perhaps self-evident. I don’t think many people arguing for the use of health equity decision support tools imagine their use alone will make the changes required to address inequities. Clearly related organisational and workforce development, resourcing, and leadership are all required as well.
This ebook describes the use and evolution of health impact assessment (HIA) and EFHIA internationally and in Australia, how it has been used in relation to health service plans, examines its effectiveness and impacts on decision-making and implementation and examines several EFHIAs using case study and interpretive description methodologies.
This research shows that EFHIA has the potential to have both direct and indirect impacts on health service planning. These impacts are influenced by a broad range of factors however. The case studies in this ebook show that engagement with the EFHIA process and the extent to which EFHIA is regarded as a broader learning process are important factors that mediate the extent to which EFHIAs influence subsequent activities.
This research suggests that it is not possible to adequately describe the full range of impacts of EFHIA on decision-making and implementation without looking at perceptions about EFHIA’s effectiveness, in particular the perceptions of those involved in the EFHIA and those responsible for acting on its recommendations. These perceptions change over time, suggesting that future research on the effectiveness of HIA should look at the mechanisms by which this change occurs.
The ebook makes two theoretical contributions in the form of (i) a typology for HIAs and (ii) a conceptual framework for evaluating the impact and effectiveness of HIAs. This conceptual framework is tested for its applicability and refined.
The ebook and the accompanying publications were written to fulfil the requirements for a Doctor of Philosophy in Public Health at the University of New South Wales.
I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.
Workshop 3: Review of Urban HEART guidance
There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn’t agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that’s familiar in the context of HIA and negotiating recommendations.
Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.
There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART’s role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.
An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn’t really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won’t necessarily result in inequities being better addressed.
The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They’re not readily comparable to other health interventions because they’re fundamentally different types of interventions.
The need for an online guide, repository and clearinghouse for evidence was discussed. We’re very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.
City case presentations
Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There’s a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.
Plenary discussion: Next steps
One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.
The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It’s intended to be both, but there’s a tension, which most HIA practitioners would have encountered as well.
There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won’t describe in detail here because I’m not able to do justice to the range of issues discussed. Some of the broad topics touched on included:
sharing best practice, particularly in the form of brief case studies focused on key learning
building Urban HEART into WHO and country-level work plans
linking to professional groups/associations
ensuring the health sector comes along the journey and that Urban HEART doesn’t become the sole responsibility of cities/other sectors
how often does Urban HEART need to be revisited/redone
how can we make Urban HEART sell itself, i.e. so it doesn’t need much ongoing support
compendiums of best practice and then thinking how some of these best practice cases might be synthesised
how to advance an equity agenda in settings where it’s not on the political agenda
These issues are all eerily familiar to people who’ve worked on HIA! It was an excellent Consultation with lots of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.