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Article

Research in diverse fields has examined how social and gender norms, broadly defined as informal rules of acceptable behavior in a given group or society, may influence sexual and reproductive health outcomes. One set of conceptual and empirical approaches has focused on perceptions of how commonly others perform a behavior and the extent to which others support or approve of the behavior. Another set of approaches has focused on how social norms emerge from structures of gender and power that characterize the social institutions within which individuals are embedded. Interventions intended to improve sexual and reproductive health outcomes by shifting social and gender norms have been applied across a wide range of populations and settings and to a diverse set of behaviors, including female genital mutilation/cutting, the use of modern contraceptive methods, and behavioral risk reduction for HIV. Norms-based intervention strategies have been implemented at multiple socioecological levels and have taken a variety of forms, including leveraging the influence of prominent individuals, using community activities or mass media to shift attitudes, and introducing legislation or policies that facilitate the changing of social norms. Recent advances in social and gender norms scholarship include the integration of previously disparate conceptual and empirical approaches into a unified multilevel framework. Although challenges remain in measuring social and gender norms and studying their impacts on sexual and reproductive health-related behaviors across cultures, the research will continue to shape policies and programs that impact sexual and reproductive health globally.

Article

Maya Chandrasekaran, Joseph Cook, and Marc Jeuland

Improved access to safe and reliable water, sanitation, and hygiene (WASH) services in the developing world has many positive health and economic impacts. Two of the key channels through which such impacts manifest are (a) the reduced time burden for the household members, usually women, who are responsible for water collection and transportation, and (b) time saved from not having to defecate in the open, far away from living areas. WASH interventions can produce time savings for low-income households via several specific pathways—for example, through access to closer, more convenient, better quality water and sanitation sources; reduced cost of water delivery to the home; direct conveyance of water via reliable piped supply; or improvements that reduce the time costs of coping with unreliable supply. In existing studies, time savings arising from WASH interventions have primarily been elicited using one of three methods. The first is the time diary approach, which aims to reconstruct an individual’s time use on a recent or typical day. A second approach is direct questioning, where the time spent on a specific activity in a recent (or typical) time period—in this case water collection and WASH management—is recorded. Finally, researchers have begun to use the Global Positioning System and smartphones to track information related to individuals’ movements throughout the day and to determine how those locations map to community water and sanitation facilities. The time savings estimated in published works vary greatly, which may be due to differences in intervention evaluation methods, time elicitation strategies, geographical context, households’ baseline water situation, and the type of improved technology considered. Then, the value of time saved by individuals from use of improved WASH services depends on the opportunity cost of time—that is, the value of the next best use of that time. From a development perspective, alternative time uses for education or income generation may be of particular interest, but other time use (e.g., for leisure, other domestic work, or rest) may also contribute to enhanced household and individual welfare. Unfortunately, in contrast to a fairly robust time valuation literature, especially regarding transportation choices, there is relatively sparse literature on the reallocation of time savings, and its value, from WASH interventions. Many economic analyses therefore fall back on “rule-of-thumb” methods that assume that time savings are worth some fraction, typically approximately 50%, of the prevailing market wage rate. Two methods for time valuation could be used more extensively for valuing WASH-related time savings and burdens in middle- and low-income countries: (a) revealed preference methods based on choices made by individuals between time and other burdens and (b) structured stated preference trade-offs that yield time values based on respondents choices in hypothetical games. Given the shortcomings of the literature, researchers working in this domain should devote greater attention to reporting the nature of the pre-intervention WASH situation in their study setting, describing and validating time use elicitation methods, including, when possible, with objective measures, and more thoroughly considering how time savings are reallocated or contribute to household well-being and reduced poverty. Finally, when conducting cost–benefit analysis of WASH interventions, analysts should use their judgment and knowledge about the specifics of a particular water project when specifying time savings; however, 60% of baseline time spent appears to be a reasonable base case estimate for water supply improvements. For sanitation improvements, the evidence base is thin, but per person time savings of 5–10 minutes per day appears reasonable as a starting point. In each case, sensitivity analysis is recommended around these base case values. Specifically, the value of that time is unlikely to be worth 100% of the household after-tax wage in the policy site, so the analyst should test whether the outcome of a project appraisal would change if time is valued between 25% and 75% of the average after-tax wage rate or, absent that data, the local unskilled wage rate. If the project recommendation changes within this range, the analyst should consider investing in primary research in the policy site, most likely using a stated preference approach. Primary research may also be warranted if distributional consequences of the project (e.g., on women or on the poor) are a central focus of the intervention.

Article

Anna Jarkiewicz and Mariusz Granosik

Defining global citizenship (GC) depends on the perspective undertaken. The academic literature on GC is divided into two theoretical approaches: normative and interpretative. The first of these can also be called the attributive approach, because it refers to specific attributes that indicate whether someone is, or is not, a global citizen. This approach emphasizes the importance of education, during the course of which appropriate skills, competencies, and attitudes characterizing a global citizen are shaped. In contrast, representatives of the interpretative approach do not concentrate on creating a list of attributes through the prism of which the concept of GC can be identified but, rather, try to recognize what meaning individuals and language users ascribe to the concept. Understanding what GC is and what meaning actors ascribe to it is crucial in this view. The adopted theoretical perspective also determines who is and who can be a (global) citizen. The education emphasized in the normative approach, and the related course of acquiring specific attributes, means that only adults are recognized as (global) citizens. Young people are only citizens in the making. Consequently, full citizenship is an exclusive social category that is acquired on reaching the age of majority. In the interpretative approach, both adolescents and adults are considered equally as citizens. This approach stands in opposition to the age-determined order and seeks to broaden analysis by breaking from a transitional life-stage paradigm that works to divide childhood from adolescence and adolescence from adulthood. In this approach, we do not become citizens but are citizens from the very beginning of our lives. Within this concept, shifting young people’s understanding of life by applying “citizenship” as an inclusive social category is necessary. Depending on what theoretical perspective is used, a diverse range of educational practices will be employed—global citizenship education (GCE). The normative approach is related to the idea of GCE and practical notions about how GC could be taught in educational institutions or learned in other settings. In the interpretive approach, the emphasis is on cooperation in creation, joint and democratic decision-making, from which no one is excluded, regardless of age, race, religion, gender, and so on. In the same way that globalization became the target of criticism, the idea of GC and GCE is generating increasingly more discussion. Some of its aspects refer to the neoliberal foundation of GC; in that context, GCE can be understood as a system of influencing individuals to adjust them to the economic expectations of contemporary markets. Also, the expansion of the GC idea to other continents forced educators to take into account the achievements of cultural anthropology and academics to conduct international comparative research. What in the normative conceptualization was considered a universal norm in light of intercultural studies began to be perceived as a neocolonial expansion of Euro-American culture. This raises a fundamental question about a better (less colonializing) variant of global education. One of many answers is critical global learning, focused on demystification of dominant global discourses, mapping local discourses to recognize their statuses, tracing individual or institutional narratives to collective “root” meta-narratives, and emancipation of those who are discriminated against or not recognized in their formal civil rights.

Article

Danuta Wasserman

Around 700,000 people take their lives each year worldwide. Suicide accounts for approximately 1.3% of all deaths and therefore represents a major public health problem. The global age-standardized suicide rate is 9 per 100,000 population, yet there are large variations among genders, ages, countries, and world regions. The stress–vulnerability model of suicidal behaviors has been proposed to explain how a diathesis, developed through the influence of genetic and neurodevelopmental factors in relation to perinatal, postnatal, and life experiences, interacts with different risk and protective factors that either decrease or enhance the individual’s level of resilience to stress and suicidal risk. Public health suicide prevention strategies include suicide means restriction, reducing harmful substance use, promoting responsible media reporting, public-awareness campaigns, gatekeeper trainings, school-based interventions, crisis helplines, and postvention. Mental health strategies comprise identification, treatment, and rehabilitation of persons in distress and at risk for suicide. Multicomponent strategies that use a combination of evidence-based methods from public and mental health sectors are recommended. Future work should aim at enhancing the quality of epidemiological data, improving the research on protective and ideation-to-action factors, expanding the quantity and quality of data coming from low- and middle-income countries, and evaluating the cost-effectiveness of different suicide prevention strategies.

Article

In many countries, Traditional Chinese Medicine has acquired a status similar to other historical healthcare systems that are not at all or only partially legitimated by modern science, such as Ayurveda and homeopathy. They all contribute in one way or another to the health of the public. And yet, Chinese medicine eludes inclusion in modern, global public health concepts. Its focus on the individual patient-healer relationship, its diverse non-Chinese terminologies, often developed by individuals regardless of the historical meaning of the original Chinese terms, and an increasingly uncoordinated development of TCM in China and the rest of the world, with heterogenous educational standards resulting in very different skill levels of practitioners, make it impossible to draw far-reaching conclusions and contribute generalizable suggestions for the continued improvement of global public health.

Article

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.

Article

Regulating quality is challenging because in public utilities such as water and sanitation, quality is multidimensional, is not always objectively measurable, and can be hard to verify, both ex ante and ex post. It is therefore useful to review the main insights from the New Economics of Regulation theoretical literature on quality provision to guide public policy. Focusing on formal utilities, this normative approach emphasizes the asymmetry of information between a regulator and the regulated companies. The analysis shows that when quality is verifiable, it can be included in a contract exactly like a quantity variable. Its provision, however, will be distorted as a result of regulated quantities also being distorted due to asymmetric information. When quality and quantity are complements, service quality ends up being lower because in the optimal regulatory contract, quantities are distorted downward for rent extraction. If quality is not verifiable but is observable by the users, the operator freely chooses its quality investment. It tends to underprovide quality when an improvement in quality raises the gross consumer surplus more than it increases the gross profit of sales because it does not take into account the nonmonetary benefit generated by its investment. It tends to overprovide quality otherwise. In order to correct these distortions, the regulator has to use a production allocation rule to simultaneously lower the informational rent and boost quality. The regulator has a single instrument to achieve the conflicting goals of rent extraction and quality provision. Quantities can be higher or lower than the first-best optimal levels depending on the correction needed to control quality. Finally, when quality is neither verifiable nor observable by consumers, as is typically the case with credence attributes such as those concerning process of production impacting security or pollution, the optimal level of quality investment from the firm’s perspective is zero. In this case, the easiest solution is often to impose a minimum standard and either rely on certification agencies to ensure that this minimum target is met or directly audit the quality investments made by the regulator. Finally, when improving the quality of water and sanitation services requires the creation of new infrastructure or institution, the high opportunity cost of public funds in developing countries raises the question of whether it is optimal to commit public funds for such investments. The analysis illuminates the trade-off between financing those investments with private funds and protecting consumer surplus.

Article

Paul Dalziel and Trudi Cameron

A strong social gradient in the experience of health means that a person’s health tends to reflect social position. There is strong evidence that average health outcomes in a country tend to be poorer when income inequality is greater. Consequently, public health policy is influenced by a country’s economic situation. Adopting principles in the Helsinki Statement on Health in All Policies, this means governments should pay attention to the public health implications of its economic policies, moving beyond simple analyses of how policy might support growth in gross domestic product. Since 2009, a global movement has aimed to shift the emphasis of economic policy evaluation from measuring economic production to measuring people’s well-being. This approach is known as well-being economics. Many countries have engaged with citizens to create their own national well-being framework of statistical indicators. Some countries have passed legislation or designed new institutions to focus specific policy areas on promoting the well-being of current and future generations. A small number of countries are attempting to embed well-being in their core economic policies. Further policy work and research are required for the vision of a well-being economy to be realized.

Article

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.

Article

Luiz Augusto Cassanha Galvao, Volney Câmara, and Daniel Buss

The relationship between environment and health is part of the history of medicine and has always been important to any study of human health and to public-health interventions. In Latin America many health improvements are related to environmental interventions, such as the provision of better water and sanitation services. Latin America’s development, industrialization, and sweeping urbanization have brought many improvements to the well-being of its populations; they have also inaugurated new societies, with new patterns of consumption. The region’s basic environmental-health interventions have needed to be updated and upgraded to include disciplines such as toxicology, environmental epidemiology, environmental engineering, and many others. Multidisciplinary and inter-sector approaches are paramount to understanding new profiles of health and well-being, and to promoting effective public-health interventions. The new social, economic, labor, and consumption aspects of modern Latin American society have become more and more relevant to understanding the complex interactions in the region’s social, biological, and physical environment, which are essential to explaining some of the emerging and re-emerging public-health problems. Environmental health, as concept and as intervention, is simple and easily understood, but no longer sufficient to achieve the levels of health and well-being expected and required by these new realities. Many global changes such as climate change, biodiversity loss, and mass migrations has been identified as main cause of ill health and are at the center of the sustainable development challenges in general, and many are critical and specific public health. To face this development, other frameworks have emerged, such as planetary health and environmental and social determinants of health. Public health remains central to some, such as the improved environmental-health agenda, while others assign public health a relative position in a variety of overarching frameworks.