Water planners and policy analysts need to pay closer attention to the behavioral aspects of water use, including the use of nonprice measures such as norms, public communications, and intrinsic motivations. Empirical research has shown that people are motivated by normative as well as economic incentives when it comes to water. In fact, this research finds that after exposure to feedback about water use, adding an economic incentive (rebate) for reducing water use holds no additional power. In other cases, nonprice measures can be a way to increase the salience, and subsequently, effectiveness of any adopted pricing mechanisms. We review these empirical findings and locate them within more general literature on normative incentives for behavioral change. Given increasing water scarcity and decreasing water security in cities, policy planners need to make more room for normative incentives when designing rules for proenvironmental behavior.
Leong Ching and Swee Kiat Tay
Amira M. Khan, Zohra S. Lassi, and Zulfiqar A. Bhutta
Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings. Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
Joseph Cook and Daniel Brent
Water utilities commonly use complex, nonlinear tariff structures to balance multiple tariff objectives. When these tariffs change, how will customers respond? Do customers respond to the marginal volumetric prices embedded in each block, or do they respond to an average price? Because empirical demand estimation relies heavily on the answer to this question, it has been discussed in the water, electricity, and tax literatures for over 50 years. To optimize water consumption in an economically rational way, consumers must have knowledge of the tariff structure and their consumption. The former is challenging because of nonlinear tariffs and inadequate tariff information provided on bills; the latter is challenging because consumption is observed only once and with a lag (at the end of the period of consumption). A large number of empirical studies show that, when asked, consumers have poor knowledge about tariff structures, marginal prices, and (often) their water consumption. Several studies since 2010 have used methods with cleaner causal identification, namely regression discontinuity approaches that exploit natural experiments across changes in kinks in the tariff structure, changes in utility service area borders, changes in billing periods, or a combination. Three studies found clear evidence that consumers respond to average volumetric price. Two studies found evidence that consumers react to marginal prices, although in both studies the change in price may have been especially salient. One study did not explicitly rule out an average price response. Only one study examined responsiveness to average total price, which includes the fixed, nonvolumetric component of the bill. There are five messages for water professionals. First, inattention to complex tariff schedules and marginal prices should not be confused with inattention to all prices: customers do react to changes in prices, and prices should remain an important tool for managing scarcity and increasing economic efficiency. Second, there is substantial evidence that most customers do not understand complex tariffs and likely do not respond to changes in marginal price. Third, most studies have failed to clearly distinguish between average total price and average volumetric price, highlighting the importance of fixed charges in consumer perception. Fourth, evidence as of late 2020 pointed toward consumers’ responding to average volumetric price, but it may be that this simply better approximates average total price than marginal or expected marginal prices; no studies have explicitly tested this. Finally, although information treatments can likely increase customers’ understanding of complex tariffs (and hence marginal price), it is likely a better use of resources to simplify tariffs and pair increased volumetric charges with enhanced customer assistance programs to help poor customers, rather than relying on increasing block tariffs.
Susan B. Rifkin
In 1978, at an international conference in Kazakhstan, the World Health Organization (WHO) and the United Nations Children’s Fund put forward a policy proposal entitled “Primary Health Care” (PHC). Adopted by all the World Health Organization member states, the proposal catalyzed ideas and experiences by which governments and people began to change their views about how good health was obtained and sustained. The Declaration of Alma-Ata (as it is known, after the city in which the conference was held) committed member states to take action to achieve the WHO definition of health as “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Arguing that good health was not merely the result of biomedical advances, health-services provision, and professional care, the declaration stated that health was a human right, that the inequality of health status among the world’s populations was unacceptable, and that people had a right and duty to become involved in the planning and implementation of their own healthcare. It proposed that this policy be supported through collaboration with other government sectors to ensure that health was recognized as a key to development planning. Under the banner call “Health for All by the Year 2000,” WHO and the United Nations Children’s Fund set out to turn their vision for improving health into practice. They confronted a number of critical challenges. These included defining PHC and translating PHC into practice, developing frameworks to translate equity into action, experiencing both the potential and the limitations of community participation in helping to achieve the WHO definition of health, and seeking the necessary financing to support the transformation of health systems. These challenges were taken up by global, national, and nongovernmental organization programs in efforts to balance the PHC vision with the realities of health-service delivery. The implementation of these programs had varying degrees of success and failure. In the future, PHC will need to address to critical concerns, the first of which is how to address the pressing health issues of the early 21st century, including climate change, control of noncommunicable diseases, global health emergencies, and the cost and effectiveness of humanitarian aid in the light of increasing violent disturbances and issues around global governance. The second is how PHC will influence policies emerging from the increasing understanding that health interventions should be implemented in the context of complexity rather than as linear, predictable solutions.
Malnutrition is caused by consuming a diet with either too little and/or too much of one or more nutrients, such that the body malfunctions. These nutrients can be the macronutrients, including proteins, carbohydrates, and fats that provide the body with its building blocks and energy, or the micronutrients including vitamins and minerals, that help the body to function. Infectious diseases, such as diarrhea, can also cause malnutrition through decreased nutrient absorption, decreased intake of food, increased metabolic requirements, and direct nutrient loss. A double burden of malnutrition (both overnutrition and undernutrition) often occurs across the life course of individuals and can also coexist in the same communities and even the same households. While about a quarter of the world’s children are stunted, due to both maternal and young child undernutrition, overweight and obesity affects about one in three adults and one in ten children. Anemia, most commonly due to iron deficiency, is also affecting about a third of women of reproductive age and almost half of preschool children. Around 90% of nations have a serious burden of either two or three of these different forms of malnutrition. Malnutrition is one of the principal and growing causes of global disease and mortality, affecting at least half of the world’s inhabitants. Programs for tackling maternal and child undernutrition have gained impetus in the last decade with a consensus developing around a package of effective interventions. The nutrition-specific interventions, mostly delivered through the health sector, are directed at immediate levels of causality, while nutrition-sensitive interventions, directed at the underlying and basic levels of causality are delivered through other sectors such as agriculture, education, social welfare, as well as water and sanitation. Less consensus exists around the interventions needed to reduce overnutrition and the associated non-communicable diseases (NCDs), including diabetes, high blood pressure, and coronary heart disease. Prevention is certainly better than cure, however, and creating enabling environments for healthy food choices seems to be the most promising approach. Achieving “healthy diets for all,” by reducing consumption of meat and ultra-processed foods, as well as increasing consumption of fruit and vegetables, would help control rising rates of obesity and reduce NCD mortality. Adopting such healthy diets would also greatly contribute to reducing greenhouse gas emissions: the agriculture sector is responsible for producing a third of emissions, and a reduction on livestock farming would contribute to reducing global warming. Public health nutrition capacity to manage such nutrition programs is still widely lacking, however, and much still needs to be done to improve these programs and their governance.
Funmilola M. OlaOlorun and Wen Shen
Menopause is the natural senescence of ovarian hormonal production, and it eventually occurs in every woman. The age at which menopause occurs varies between cultures and ethnicities. Menopause can also be the result of medical or surgical interventions, in which case it can occur at a much younger age. Primary symptoms, as well as attitudes toward menopause, also vary between cultures. Presently, the gold standard for treatment of menopause symptoms is hormone therapy; however, many other options have also been shown to be efficacious, and active research is ongoing to develop better and safer treatments. In a high-resource setting, the sequelae/physiologic changes associated with menopause can impact a woman’s physical and mental health for the rest of her life. In addition to “hot flashes,” other less well-known conditions include heart disease, osteoporosis, metabolic syndrome, depression, and cognitive decline. In the United States, cardiac disease is the leading cause of mortality in women over the age of 65. The growing understanding of the physiology of menopause is beginning to inform strategies either to prevent or to attenuate these common health conditions. As the baby boomers age, the distribution of age cohorts will increase the burden of disease toward post-reproductive women. In addition to providing appropriate medical care, public health efforts must focus on this population due to the financial impact of this age cohort of women.
Jeff Levin and Ellen Idler
Religion, in both its personal and institutional forms, is a significant force influencing the health of populations across the life course. Decades of research have documented that expressions of faith and the practice of spiritual pursuits exhibit significantly protective effects for physical and mental health, psychological well-being, and population rates of morbidity, mortality, and disability. This finding has been observed across sociodemographic categories, across nations and cultures, across specific disease outcomes, and regardless of one’s religious affiliation. A salutary religious effect on health and well-being is especially apparent among older adults, but is also observed across generations and age cohorts. Moreover, this association has been persistently found for various religious indicators, including attendance at worship services, prayer and other private practices, subjective feelings of religiosity, and numerous measures of religious behaviors, attitudes, beliefs, and experiences. Finally, a protective or primary preventive effect of religion has been observed in clinical, epidemiologic, social, and behavioral studies, regardless of research design or methodology. Faith-based organizations also have contributed to the health of populations, in partnerships or alliances with medical institutions and public health agencies, many of these dating back many decades. Examples include congregational health promotion and disease prevention programs and community-wide interventions, especially targeting the health and well-being of older congregants and those in less well-resourced communities, as well as faith–health partnerships in healthcare delivery, public health policymaking, and legislative advocacy for healthcare reform. Religious denominations and institutions also play a substantial role in global health development throughout the world, individually and in partnership with national health ministries, transnational medical mission organizations, and established nongovernmental agencies. These efforts focus on a wide range of goals and objectives, including building public health infrastructure, addressing ongoing environmental health needs, and responding to acute public health challenges and crises, such as infectious disease outbreaks. Constituencies include at-risk populations and cohorts throughout the life course, and programming ranges from perinatal care to maternal and child healthcare to geriatric medicine.
Rachel Baffsky, Lynn Kemp, and Anne Bunde-Birouste
Sports-based positive youth development (SB-PYD) programs are health promotion programs that intentionally use sports to build life skills and leadership capacity among young people at risk of social exclusion. The defining characteristics of SB-PYD programs are that they are strengths-based, holistic, and use sports as a vehicle to maximize young people’s health, social, and educational outcomes. SB-PYD programs aim to enhance modifiable social determinants of health (such as social inclusion) by explicitly addressing three Ottawa charter action areas; strengthening community action, developing personal skills, and creating supportive environments. These programs have been increasingly implemented since the early 2000s to address the United Nations’ sustainable development goals. Despite their growth, research indicates that SB-PYD programs are often designed, implemented, and evaluated without evidence-based theories of change. An evidence-based theory of change is a visual depiction of a program’s assumptions, activities, contextual factors, and outcomes supported by scientific findings. A lack of evidence-based theory of change becomes problematic at the implementation phase when practitioners are trying to determine if their programs should be adapted or fixed. Without an evidence-based theory of change, practitioners are making changes based on their intuition, which limits program outcomes. However, the process of developing a theory of change is time-consuming and resource intensive. Multiple calls to action have been made for SB-PYD practitioners who have successfully developed evidence-based theories of change to share their process with others in the field. This will provide a blueprint for other SB-PYD practitioners to develop and articulate their own theories of change to optimize program development and adaptation. Traditional translational research models assume the development of an evidence-based theory of change is the first step in a linear process of developing a sustainable health promotion program. However, in the 2010s, researchers started to observe that the development and adaptation of health promotion programs was rarely a linear process in reality, and that case studies are needed to provide empirical support for this claim. It is valuable for SB-PYD practitioners to consider the benefits of using translational research to develop and revise evidence-based theories of change for programs at any stage of implementation to maximize their public health impact.
Ravi Narayan, Claudio Schuftan, Brendan Donegan, Thelma Narayan, and Rajeev B. R.
The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels. The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM. Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.
Eve Dubé and Noni E. MacDonald
Vaccination is one of the greatest public health successes. With sanitation and clean water, vaccines are estimated to have saved more lives over the past 100 years than any other health intervention. Vaccination not only protects the individual, but also, in many instances, provides community protection against vaccine-preventable diseases through herd immunity. To reduce the risk of vaccine-preventable diseases, vaccination programs rely upon reaching and sustaining high coverage rates, but paradoxically, because of the success of vaccination, new generations are often unaware of the risks of these serious diseases and their concerns now concentrate on the perceived risk of individual vaccines. Over the past decades, several vaccine controversies have occurred worldwide, generating concerns about vaccine adverse effects and eroding trust in health authorities, experts, and science. Gaps in vaccination coverage can, in part, be attributed to vaccine hesitancy and not just to “supply side issues” such as access to vaccination services and affordability. The concept of vaccine hesitancy is now commonly used in the discourse around vaccine acceptance. The World Health Organization defines vaccine hesitancy as “lack of acceptance of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines.” A vaccine-hesitant person can delay, be reluctant but still accept, or refuse one, some, or all vaccines. Technical, psychological, sociocultural, political, and economic factors can contribute to vaccine hesitancy. At the individual level, recent reviews have focused on factors associated with vaccination acceptance or refusal, identifying determinants such as fear of side effects, perceptions around health and prevention of disease and a preference for “natural” health, low perception of the efficacy and usefulness of vaccines, negative past experiences with vaccination services, and lack of awareness or knowledge about vaccination. Very few interventions have been shown to be effective in reducing vaccine hesitancy. Most of the studies have only focused on metrics of vaccine uptake and refusal to evaluate interventions aimed at enhancing vaccine acceptance, which makes it difficult to assess their potential effectiveness to address vaccine hesitancy. In addition, despite the complex nature of vaccination decision-making, the majority of public health interventions to promote vaccination are designed with the assumption that vaccine hesitancy is due to lack or inadequate knowledge about vaccines (the “knowledge-deficit” or “knowledge gap” approach). A key predictor of acceptance of a vaccine by a vaccine-hesitant person remains the recommendation for vaccination by a trusted healthcare provider. When providers communicate effectively about the value and need for vaccinations and vaccine safety, people are more confident in their decisions. However, to do this well, healthcare providers must be confident themselves about the safety, effectiveness, and importance of vaccination, and recent research has shown that a proportion of healthcare providers are vaccine-hesitant in their professional and personal lives. Effective strategies to address vaccine hesitancy among these hesitant providers have yet to be identified. A better understanding of the dynamics of the underlying determinants of vaccine hesitancy is critical for effective tailored interventions to be designed for both the public and healthcare providers.