The Mekong Delta Region (MDR) in Vietnam, located at the downstream end of the Mekong River, is highly affected by climate change and extreme weather events, such as floods, droughts, soil erosion, and salinization. Due to the specific characteristics of climate, topography, river systems, and population, water-related diseases (WRDs) have been a disease burden in the Mekong Delta. This article aims to critically review the evidence of existing studies on the association between climatic conditions and WRDs in the MDR. Dengue was found to be most sensitive to the changes in ambient temperatures, humidity, and rainfall at a lag of 2 months. The climate-based prediction model was recommended for an early warning system to enhance dengue prevention. Diarrheal diseases are highly correlated with extreme weather events such as high temperatures and floods, but the evidence on the association between climatic conditions and cause-specific WRDs is limited and inconclusive. Despite the preliminary evidence for the development of climate change adaptation strategies in the MDR, studies on other WRDs (i.e., water-washed, water-scarce, and water-contaminated diseases) should be conducted. In addition, future studies should investigate the effects of interaction between climatic factors and sociodemographic, household, and individual factors in predicting climate-sensitive diseases. How to translate and integrate the scientific evidence to the policy and practices that protect the MDR residents from the elevated extreme weather events due to climate change should be warranted.
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Article
Climate Change and Water-Related Diseases in the Mekong Delta Region
Nu Quy Linh Tran, Des Connell, Trung Hieu Nguyen, and Dung Phung
Article
Climate Change Impacts on Diarrheal Disease, From Epidemiological Association Research to Social Vulnerability Exploration
Junfeng Yu, Lianping Yang, Hung Chak Ho, and Cunrui Huang
Climate change has resulted in rising global average temperatures and an increase in the frequency and intensity of extreme weather events, which already has and will yield serious public health consequences, including the risk of diarrheal diseases. Sufficient evidence in the literature has highlighted the association between different meteorological variables and diarrhea incidence. Both low and high temperatures can increase the incidence of diarrheal disease, and heavy rainfall has also been associated with increased diarrhea cases. Extreme precipitation events and floods are often followed by diarrhea outbreaks. Research has also concluded that drought can concentrate pathogens in water sources, which makes it possible for diarrhea pathogens to distribute broadly when the first heavy rain happens. Substantial evidence underscores the important role social, behavioral, and environmental factors may have for the climate-diarrhea relationship. Meteorological factors may further influence the social vulnerability of populations to diarrhea through a variety of social and behavioral factors. Future research should focus on social factors, population vulnerability, and further understanding of how climate change affects diarrhea to contribute to the development of targeted adaptation strategies.
Article
Collective Health: Theory and Practice. Innovations From Latin America
Ligia Maria Vieira-da-Silva
Throughout history, knowledge and practices on the health of populations have had different names: medical police, public health, social medicine, community health, and preventive medicine. To what extent is the Brazilian collective health, established in the 1970s, identified with and differentiated from these diverse movements that preceded it? The analysis of the socio-genesis of a social field allows us to identify the historical conditions that made possible both theoretical formulations and the achievement of technical and social practices. Collective health, a product of transformations within the medical field, constituted a rupture in relation to preventive medicine and public health and hygiene, being part of a social medicine movement in Latin America that, in turn, had identification with European social medicine in the 19th century. Focused on the development of a social theory of health that would support the process of sanitary reform, collective health has been built as a space involving several fields: scientific, bureaucratic, and political. Thus, it brought together health professionals and social scientists from universities, health care services, and social movements. Its scientific subfield has developed, and the sanitary reform project has had several successes related to the organization of a unified health system, which has ensured universal coverage for the population in Brazil. It has incorporated into and dialogued with several reformist movements in international public health, such as health promotion and the pursuit of health equity. Its small relative autonomy stems from subordination to other dominant fields and its dependence on the state and governments. However, its consolidation corresponded to the strengthening of a pole focused on the collective and universal interest, where health is not understood as a commodity, but as a right of citizenship.
Article
Community Directed Approaches for Health Improvement
William R. Brieger and Bright C. Orji
The community-directed intervention (CDI) strategy is an approach in which communities themselves direct the planning and implementation of intervention delivery fostered with support from the Special Programme for Research and Training in Tropical Diseases of the World Health Organization and partners. This approach grew out of the onchocerciasis control effort in Africa and has been piloted in several African countries, such as Nigeria and Kenya. The approach would become a stimulus for developing primary health care (PHC) services in remote and previously unreached rural villages. Empirical works across countries indicated that CDI is an accepted and effective strategy in the mass treatment of schistosomiasis and soil transmitted helminths (STH) infections. That will further support technical skill and institutional knowledge on mass treatment across countries using a standard approach. Staff orientation and training were needed to get programs off the ground since few staff had basic training in the benefits and procedures of organizing community participation. However, technical training to perform these health tasks did not guarantee that services would reach communities where participation was not the underlying value of the system. The team aimed to trace the development and evolution of CDI from community-directed treatment with ivermectin (CDTI), a focused disease control effort for onchocerciasis/river blindness; adapt the approach to address other health and development needs; and examine the challenges CDI has faced, which are not unlike those experienced by PHCs.
Article
Community Empowerment and Health Equity
Jennie Popay
Empowerment features prominently in public health and health promotion policy and practice aimed at improving the social determinants of health that impact communities and groups that are experiencing disadvantage and discrimination. This raises two important questions. How should empowerment be understood from the perspective of health and health equity and how can public health practitioners support empowerment for greater health equity?
Many contemporary definitions link empowerment to improvements in individual self-care and/or the adoption of “healthier” lifestyles. In contrast, from a health equity perspective community empowerment is understood as sociopolitical processes that engage with power dynamics and result in people bearing the brunt of social injustice exercising greater collective control over decisions and actions that impact their lives and health. There is growing evidence that increased collective control at the population level is associated with improved social determinants of health and population health outcomes. But alongside this, there is also evidence that many contemporary community interventions are not “empowering” for the people targeted and may actually be having negative impacts. To achieve more positive outcomes, existing frameworks need to be used to recenter power in the design, implementation, and evaluation of local community initiatives in the health field. In addition, health professionals and agencies must act to remove barriers to the empowerment of disadvantaged communities and groups. They can do this by taking experiential knowledge more seriously, by challenging processes that stigmatize disadvantaged groups, and by developing sustainable spaces for the authentic participation of lay communities of interest and place in decisions that have an impact on their lives.
Article
Community-Oriented Primary Health Care for Improving Maternal, Newborn, and Child Health
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.
Article
Community Resilience and Earthquakes: The Role of Neighborhood—A Case Study From Christchurch, Aotearoa New Zealand
Karen Banwell
It is well recognized that preexisting social connections and networks help people adapt and provide for more positive outcomes in the aftermath of a disaster. The role of place, of local neighborhood, in helping people to adapt and manage through the difficult times is developing. Neighborhood, the place where people live, can help facilitate the important informal response to disasters—where residents come together and provide mutual support. Features such as well-defined geography, intimate streets, walkable access to social infrastructure and natural spaces, and central meeting places all help to build the social connections that foster community resilience. Another important element is the community-focused groups that are already in place, especially ones with people who know their areas and who to support. Community resilience is a consequence of having good social connections, with social infrastructure helping to facilitate those connections; these are the same social and physical characteristics of neighborhoods that influence local health and well-being. The main message is that it is possible to develop urban environments in a way that provides multiple benefits. Social connections make people happier and healthier; they can learn from village life that can improve their future living environments, ones that are healthy and resilient. A vibrant well-connected neighborhood community with walkable access to natural spaces, to local shops and schools, and to places for locals to gather is healthy, self-reliant, and more resilient.
Article
Comprehensive Abortion Care
Nathalie Kapp, Mariana Romero, Shamala Dupte, Allison Shaber, and Daniel Grossman
Abortion is a common part of people’s reproductive lives, regardless of where they live in the world.
When using World Health Organization-recommended methods of either surgical or medical abortion, procedures are very safe and effective, and providers do not need a lot of information or testing to provide quality services. Both medical and surgical methods may be used to induce or to treat incomplete abortion. Although both methods are safe and effective, they have different characteristics and acceptability; therefore, clients should be given the choice of method in settings where it is possible.
Service delivery can include provision of surgical and medical abortion services by many cadres of providers, from nurses and midwives to physicians. Most people (generally around 90%) seek induced abortion before 12 weeks’ gestation, during which time medical abortion can be safely provided either through an in-person clinical encounter or through telemedicine, and there is emerging evidence of safe over-the-counter-like use.
Postabortion care includes the timely management of an unsafe or spontaneous abortion (spontaneous loss of pregnancy) that has happened or is in progress; it has been a global strategy to reduce the morbidity and mortality related to less safe abortions. For all people having an abortion, postabortion care includes information and voluntary provision of postabortion contraception or other desired reproductive health services.
Article
Comprehensive Sexuality Education
Ine Vanwesenbeeck
Comprehensive sexuality education (CSE) is increasingly accepted as the most preferred way of structurally enhancing young peoples’ sexual and reproductive well-being. A historical development can be seen from “conventional,” health-based programs to empowerment-directed, rights-based approaches. Notably the latter have an enormous potential to enable young people to develop accurate and age-appropriate sexual knowledge, attitudes, skills, intentions, and behaviors that contribute to safe, healthy, positive, and gender-equitable relationships. There is ample evidence of program effectiveness, provided basic principles are adhered to in terms of content (e.g., adoption of a broad curriculum, including gender and rights as core elements) and delivery (e.g., learner centeredness). Additional and crucial levers of success are appropriate teacher training, the availability of sexual health services and supplies, and an altogether enabling (school, cultural, and political) context. CSE’s potential extends far beyond individual sexual health outcomes toward, for instance, school social climates and countries’ socioeconomic development. CSE is gaining worldwide political commitment, but a huge gap remains between political frameworks and actual implementation. For CSE to reach scale and its full potential, multicomponent approaches are called for that also address social, ideological, and infrastructural barriers on international, national, and local levels. CSE is a work never done. Current unfinished business comprises, among others, fighting persevering opposition, advancing equitable international cooperation, and realizing ongoing innovation in specific content, delivery, and research-methodological areas.
Article
Conceptual and Practical Aspects of Water Regulation in Developing Countries
Sanford V. Berg
Organizations regulating the water sector have major impacts on public health and the sustainability of supply to households, industry, power generation, agriculture, and the environment. Access to affordable water is a human right, but it is costly to produce, as is wastewater treatment. Capital investments required for water supply and sanitation are substantial, and operating costs are significant as well. That means that there are trade-offs among access, affordability, and cost recovery. Political leaders prioritize goals and implement policy through a number of organizations: government ministries, municipalities, sector regulators, health agencies, and environmental regulators.
The economic regulators of the water sector set targets and quality standards for water operators and determine prices that promote the financial sustainability of those operators. Their decisions affect drinking water safety and sanitation. In developing countries with large rural populations, centralized water networks may not be feasible. Sector regulators often oversee how local organizations ensure water supply to citizens and address wastewater transport, treatment, and disposal, including non-networked sanitation systems. Both rural and urban situations present challenges for sector regulators.
The theoretical rationale for water-sector regulation address operator monopoly power (restricting output) and transparency, so customers have information regarding service quality and operator efficiency. Externalities (like pollution) are especially problematic in the water sector. In addition, water and sanitation enhance community health and personal dignity: they promote cohesion within a community. Regulatory systems attempt to address those issues. Of course, government intervention can actually be problematic if short-term political objectives dominate public policy or rules are established to benefit politically powerful groups. In such situations, the fair and efficient provision of water and sanitation services is not given priority.
Note that the governance of economic regulators (their organizational design, values or principles, functions, and processes) creates incentives (and disincentives) for operators to improve performance. Related ministries that provide oversight of the environment, health and safety, urban and housing issues, and water resource management also influence the long-term sustainability of the water sector and associated health impacts. Ministries formulate public policy for those areas under their jurisdiction and monitor its implementation by designated authorities. Ideally, water-sector regulators are somewhat insulated from day-to-day political pressures and have the expertise (and authority) to implement public policy and address emerging sector issues.
Many health issues related to water are caused or aggravated by lack of clean water supply or lack of effective sanitation. These problems can be attributed to lack of access or to lack of quality supplied if there is access. The economic regulation of utilities has an effect on public health through the setting of quality standards for water supply and sanitation, the incentives provided for productive efficiency (encouraging least-cost provision of quality services), setting tariffs to provide cash flows to fund supply and network expansion, and providing incentives and monitoring so that investments translate into system expansion and better quality service. Thus, although water-sector regulators tend not to focus directly on health outcomes, their regulatory decisions determine access to safe water and sanitation.
Article
Contraceptive Technology
Timothee Fruhauf and Holly A. Rankin
Contraceptive technology refers to tools that are used to delay or prevent pregnancy. Modern contraceptive technology encompasses female or male sterilization, intrauterine devices, contraceptive implants, contraceptive pills, contraceptive patches, intravaginal rings, diaphragms, external or internal condoms, emergency contraception, and certain fertility awareness–based methods. Duration of these methods’ effects varies from permanent and irreversible to long-lasting and reversible to short term with day-to-day reversibility. The efficacy of modern contraceptive technologies at preventing pregnancy ranges between 76% and 99.95% during the first year of typical use. Mechanisms of action vary from physically impeding meeting of sperm and oocyte to use of exogenous reproductive hormones to alter fertility. Contraceptive counseling for the selection of a method should adopt a shared decision-making framework and can consider advantages, disadvantages, contraindications, and side effects of a method to align with a patient’s contraceptive use goals. Certain clinical contexts, such as post-abortion, postpartum, adolescent patients, and patients with elevated body mass index have contraceptive nuances that are important to consider. Finally, contraceptive technology has many non-contraceptive benefits that provide additional indications for their use.
Article
Convergence Theory and the Salmon Effect in Migrant Health
Yudit Namer and Oliver Razum
For decades, researchers have been puzzled by the finding that despite low socioeconomic status, fewer social mobility opportunities, and access barriers to health care, some migrant groups appear to experience lower mortality than the majority population of the respective host country (and possibly also of the country of origin). This phenomenon has been acknowledged as a paradox, and in turn, researchers attempted to explain this paradox through theoretical interpretations, innovative research designs, and methodological speculations.
Specific focus on the salmon effect/bias and the convergence theory may help characterize the past and current tendencies in migrant health research to explain the paradox of healthy migrants: the first examines whether the paradox reveals a real effect or is a reflection of methodological error, and the second suggests that even if migrants indeed have a mortality advantage, it may soon disappear due to acculturation. These discussions should encompass mental health in addition to physical health.
It is impossible to forecast the future trajectories of migration patterns and equally impossible to always accurately predict the physical and mental health outcomes migrants/refugees who cannot return to the country of origin in times of war, political conflict, and severe climate change. However, following individuals on their path to becoming acculturated to new societies will not only enrich our understanding of the relationship between migration and health but also contribute to the acculturation process by generating advocacy for inclusive health care.
Article
Customer Assistance Programs and Affordability Issues in Water Supply and Sanitation
Joseph Cook
Concerns about water affordability have centered on access to networked services in low-income countries, but have grown in high-income countries as water, sewer, and stormwater tariffs, which fund replacement of aging infrastructure and management of demand, have risen. The political context includes a UN-recognized human right to water and a set of Sustainable Development Goals that explicitly reference affordable services in water, sanitation, and other sectors. Affordability has traditionally been measured as the ratio of combined water and sewer bills divided by total income or expenditures. Subjective decisions are then made about what constitutes an “affordable” ratio, and the fraction paying more than this is calculated. This measurement approach typically omits the coping costs associated with poor supply, notably the time costs of carrying water home. Three less commonly used approaches include calculating (a) the expenditure related to procuring a “lifeline” quantity of water as a percent of income or expenditures, (b) the amount of income left for other needs after water and sewer expenditures are subtracted, and (c) the number of hours of minimum wage work needed to purchase an essential quantity of water.
Lowering water rates for all customers does not necessarily help those in need in low- and middle-income countries. This includes tariff structures that subsidize the price of water in the lowest block or tier (i.e., lifeline blocks) for all customers, not just the poor. Affordability programs that do not operate through tariffs can be characterized by (a) how they are administered and funded, (b) how they target the poor, and (c) how they deliver subsidies to the poor. Common types of delivery mechanisms include subsidizing public taps for unconnected households, subsidizing or financing the fees associated with obtaining a connection to the piped network, and subsidizing monthly bills for poor households. Means-tested consumption subsidies are most common in industrialized countries, whereas subsidizing public taps and connection fees are more common in low- and middle-income countries.
A final challenge is directing subsidies to renters who are more likely to be poor and who do not have a direct relationship with a water utility because they pay for water through their landlord, either included as part of their rent or as a separate water payment. Based on data from the 2013 American Housing Survey, approximately 21% of all housing units in the United States are occupied by this type of “hard to reach” customer, although not all of them would be considered poor or eligible for an assistance program. This ratio is as high as 74% of all housing units in metropolitan areas like New York City. Because of data limitations, there are no similar estimates in low-income countries.
Instead of sector-by-sector affordability policies, governments might do better to think about the entire package of services a poor person has a perceived right to consume. Direct income support, calculated to cover a package of basic services, could then be delivered to the poor, preserving their autonomy to make spending decisions and preserving the appropriate signals about resource scarcity.
Article
Dementia Caregiver Interventions
Laura N. Gitlin
The number of people living with dementia worldwide is estimated to be 55 million and is expected to increase to 78 million by 2030 andover 150 million by 2050. Families—defined broadly as relatives, fictive kin, neighbors, friends, relatives, and spouses—provide most of the long-term care throughout the disease trajectory. Family caregiving is a global phenomenon. Low- to middle-income countries in Latin America, Africa, and Asia are experiencing the most rapid increases in dementia, with the burden of care being particularly acute for extremely low-resourced families in these regions of the world.
Compared to caregiving for individuals with serious illnesses but who are not cognitively impaired, caregivers of people living with dementia provide more assistance with all aspects of care, oversee complex clinical symptoms, and must at some point in the disease process provide constant vigilance and extensive hands-on and physical care. The economic outlay of dementia caregiving is another differentiator, with families incurring approximately 70% of care costs. As care responsibilities increase with disease progression, caregivers need a wide range of supportive services to help them stay healthy themselves and also manage the complexities of the disease process and their elongated care responsibilities.
In response, a robust body of intervention studies has evolved during the past half-century. Although most research has emanated from the United States, research is emerging from other countries that either adapt and test existing evidence-based U.S. programs or develop and evaluate new intervention approaches tailored to the specific country and cultural group.
An appraisal of this expansive and growing research offers a “glass half full” and “glass half empty” perspective as to the level and depth of the evidence. On one hand and taken as a whole, this vast corpus of research has yielded evidence for a wide range of strategies, approaches, interventions, and programs demonstrating varying levels of effectiveness in supporting caregivers by increasing mastery and reducing depressive symptoms and care burdens. On the other hand, more methodological rigor in studies is needed along with the testing of interventions with diverse family caregivers that considers strength-based approaches (vs. symptom reduction only) and a wider range of outcomes such as supporting resilience, adaptation, and positive affect.
Despite evidence for many supportive approaches for caregivers, interventions with some level of evidence have not been widely disseminated, embedded in practice settings, nor sustained. Few families worldwide have access to proven supportive programs; few health professionals are aware of the evidence base; and most agencies, community-based programs, and health care systems do not have the infrastructure, staff capacities, or both to identify caregivers and provide disease education, support, care coordination, skills training, and other needed strategies shown to be helpful to families. This persistent “family care gap” between what is known to be effective and what is practiced in health care systems is one of the defining characteristics of this field of inquiry.
Article
Demographic Transition in India: Insights Into Population Growth, Composition, and Its Major Drivers
Usha Ram and Faujdar Ram
Globally, countries have followed demographic transition theory and transitioned from high levels of fertility and mortality to lower levels. These changes have resulted in the improved health and well-being of people in the form of extended longevity and considerable improvements in survival at all ages, specifically among children and through lower fertility, which empowers women. India, the second most populous country after China, covers 2.4% of the global surface area and holds 18% of the world’s population. The United Nations 2019 medium variant population estimates revealed that India would surpass China in the year 2030 and would maintain the first rank after 2030. The population of India would peak at 1.65 billion in 2061 and would begin to decline thereafter and reach 1.44 billion in the year 2100. Thus, India’s experience will pose significant challenges for the global community, which has expressed its concern about India’s rising population size and persistent higher fertility and mortality levels. India is a country of wide socioeconomic and demographic diversity across its states. The four large states of Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan accounted for 37% of the country’s total population in 2011 and continue to exhibit above replacement fertility (that is, the total fertility rate, TFR, of greater than 2.1 children per woman) and higher mortality levels and thus have great potential for future population growth. For example, nationally, the life expectancy at birth in India is below 70 years (lagging by more than 3 years when compared to the world average), but the states of Uttar Pradesh and Rajasthan have an average life expectancy of around 65–66 years.
The spatial distribution of India’s population would have a more significant influence on its future political and economic scenario. The population growth rate in Kerala may turn negative around 2036, in Andhra Pradesh (including the newly created state of Telangana) around 2041, and in Karnataka and Tamil Nadu around 2046. Conversely, Uttar Pradesh, Bihar, Madhya Pradesh, and Rajasthan would have 764 million people in 2061 (45% of the national total) by the time India’s population reaches around 1.65 billion. Nationally, the total fertility rate declined from about 6.5 in early 1960 to 2.3 children per woman in 2016, a result of the massive efforts to improve comprehensive maternal and child health programs and nationwide implementation of the national health mission with a greater focus on social determinants of health. However, childhood mortality rates continue to be unacceptably high in Uttar Pradesh, Bihar, Rajasthan, and Madhya Pradesh (for every 1,000 live births, 43 to 55 children die in these states before celebrating their 5th birthday). Intertwined programmatic interventions that focus on female education and child survival are essential to yield desired fertility and mortality in several states that have experienced higher levels. These changes would be crucial for India to stabilize its population before reaching 1.65 billion. India’s demographic journey through the path of the classical demographic transition suggests that India is very close to achieving replacement fertility.
Article
Diabetes in South Asians
Sara Garduño‐Diaz and Santosh Khokhar
As of 2023, it is estimated that Type 2 diabetes (T2D) affects approximately 783 million people worldwide, with South Asians presenting the highest age-adjusted comparative diabetes prevalence among adults (90,204.5 people). Ethnicity has been highlighted as a major risk factor for the development of T2D with central adiposity, insulin resistance, and unfavorable lipid profile identified as predominant signals of alarm. Leading databases, including Web of Science, Medline, PubMed, Google Scholar, and ScienceDirect, were consulted, and manual searches were carried out for cited references in leading diabetes-related journals. Genetic predisposition, central adiposity, and unfavorable lifestyles, including physical inactivity and an unhealthy diet, have been found to be associated with the prevalence of T2D in migrant South Asians. Additionally, “Westernization,” acculturation, socioeconomic factors, and lack of awareness regarding seriousness and consequences of the disease have also been identified as contributors to the development of T2D in this population. However, the higher prevalence of T2D in migrant South Asians may not be entirely attributed to genetic predisposition; hence, ethnicity and associated modifiable risk factors warrant further investigation. Preventive measures and appropriate interventions are limited by the lack of ethnic-specific cut-off points for anthropometric and biological markers, as well as by the absence of reliable methods for dietary and physical activity assessment.
Article
Digital Public Health: Quality, Interoperability and Capability Maturity
Siaw-Teng Liaw
Digitalization was accelerated to address the access, safety and quality needs of health professionals and citizens during care provision in the presence of human, animal and environmental vectors of pandemic infections. Digital transformation will harness cloud computing, artificial intelligence (AI), data networks and personalized digital agents, sensors, and visualization tools to monitor and enhance the care of individuals, populations and communities. A sociotechnical, multidisciplinary, and enterprise-wide approach is essential to improve the quintuple aims of cost-effectiveness, provider and patient well-being, and equity. Digitally competent health professionals and digitally mature health organizations are necessary to produce and use high-quality interoperable digital data and technologies to improve decisions and practice. The maturity of five essential digital health foundations (infrastructure, tools/agents, readiness to share information, enablers of trust and adoption, and quality improvement) is assessed across the micro–meso–macro continuum. The Digital Health Profile and Maturity Assessment Toolkit Maturity Model illustrates a sociotechnical capability maturity approach to assess how organizations manage, govern, improve, and sustain the ethical and safe production, use and sharing of digital health tools and data in the real world. The linkage and convergence of real-word data (RWD) from public health, clinical and managerial practice highlights potential cost-efficiencies in integrated data collection, reporting, aggregation, analysis, and use. Challenges include access, quality, and interoperability of RWD and tools. AI-driven data analytics is increasingly being used, despite misgivings about trustworthiness, biases and fairness of software agents, algorithms, and training data sets. The sociotechnical approach emphasizes leadership, inclusive governance, mutual trust, and reciprocity within a cocreation paradigm; communities of learning and practice operating within regulatory frameworks that promote quality, safety, and equitable access to digital tools and data; quality improvement and professional development programs aimed to improve digital health maturity; and science and digital health diplomacy to harmonize the multiplicity of actors and technology in digital public health ecosystems and global supply chains. Learning organizations that “think small and big simultaneously” within a standards-based cocreation paradigm will create the digital assets and social capital necessary for the national and global digital public health enterprise.
Article
Digital Solutions to Public Health Issues
Si Ying Tan and Jeremy Fung Yen Lim
Digital health technology has been adopted rapidly by countries as tools to promote good public health outcomes over the last decade. The COVID-19 pandemic that occurred since November 2019 has further accelerated the salience and relevance of digital health technology in tackling public health issues as countries start to implement movement restriction policies that pose a challenge to the physical delivery of healthcare services. Unarguably, the pandemic has elevated the significances of digital solutions to public health issues, which include improving access to an increased range of health services and the potential of cost-saving, maximizing population-wide health impacts through behavioral modifications, and controlling and managing public health emergencies. In general, digital technology in public health has three major applications—monitoring, decision support, and education. Monitoring is especially relevant in the context of effective disease screening and pandemic surveillance, decision support applies to the promotion of behavior modifications and resource optimization, while education serves to improve population-level health awareness and knowledge. Despite the promises of digital solutions to address various public health issues, there are unintended consequences that could arise consequent to their widespread applications, resulting in governance challenges and ethical issues in their applications, such as data privacy and erosion of trust, safety, cybersecurity, algorithmic bias, liability, autonomy, and social justice. To reap tangible benefits and positive impacts from large-scale deployment of various digital health solutions, countries need to anchor their national digital health policies or strategies by considering not only their benefits and applications, but also various governance challenges and ethical issues that could ensue during their implementations.
Article
Disability and Rural Health
Rayna Sage, Genna Mashinchi, and Craig Ravesloot
The ways in which disability impacts people and their health in rural places are a result of the interaction between the person and the rural environment in which they live. Disability is defined as ongoing difficulties engaging in daily activities and social roles due to physical or mental conditions. The United Nations Convention on the Rights of People with Disabilities (UN-CRPD) implemented policy in 2008 that recognized that disabled people are worthy of autonomy and dignity. The social and physical environment are constructed in ableist ways that make it difficult for people with disabilities to realize their independence and this is particularly true in many rural places. Person–environment fit and urbanormativity (the favoring of urban spaces at the expense of rural ones) are important concepts in understanding the experiences of rural disabled people. There is little existing research regarding the epidemiology of disability and rural health, but rural people report higher and earlier rates of disability than urban people and rural places have higher rates of older adults with higher rates of disability. Furthermore, rural people with disabilities experience various secondary health conditions and higher rates of mortality compared to urban people with disabilties. The lack of access to health care and advocacy help explain some of the differences in health outcomes when comparing rural and urban people. The disability rights movement led to the creation of different types of advocacy and service organizations across the globe to address these disparities. An important way to improve the experiences and health of rural people with disabilities is to ensure they have access to quality and dependable in-home services and community-based rehabilitation, which currently tend to be under-funded with dramatic worker shortages in many rural places. A final promising approach to improving the health of rural disabled people is through evidence-based health promotion programming that targets early indicators of health problemsand recovery and health-sustaining efforts following a health problem.
Article
Disability Inclusion in Sexual and Reproductive Health in the United States
Linda Long-Bellil
Despite the passage of the Americans with Disabilities Act (ADA) more than 30 years ago, people with disabilities experience significant barriers to exercising their right to sexual and reproductive health throughout their life course. The historical segregation and stigmatization of disabled individuals has created the conditions in which members of this population experience persistent disparities in the prevalence of adverse health conditions and inadequate attention to care, along with disparities in preventive care, health promotion, and access to health care services. These disparities manifest in social services and health care generally and also in the sphere of sexual and reproductive health.
Among many direct care workers, health care providers, and family members, assumptions persist that individuals with disabilities are asexual, unable to exercise informed consent to sexual activity, and unable to carry a pregnancy to term or to parent successfully. These assumptions adversely affect the ability of individuals with disabilities to access basic information about their sexual health and function in order to make informed decisions about their sexual activity, and also impact their access to preventive health screening, contraception, and perinatal care. Inadequate transportation and physically inaccessible environments and equipment such as examination tables pose additional barriers for some disabled individuals. A lack of training in disability-competent care among health care professionals is a pervasive problem and presents yet another challenge to obtaining appropriate and necessary information and care. Despite these barriers, the research shows that more and more women with disabilities are having children, and there is an increasing recognition that people with disabilities have a right to sexual expression and appropriate sexual and reproductive health care , accompanied by a gradual evolution among social services and health care providers to provide the necessary information and support.
