Annual Review of Public Health - Volume 28, 2007

Policymakers are increasingly seeking to determine whether the federal government's recent investments in public health preparedness have left the public health system better prepared to respond to large-scale public health emergencies. Yet, there remain questions about how to define “public health emergency preparedness,” how much preparedness is enough, and how preparedness can be measured and assessed. This chapter identifies the key challenges associated with measuring public health preparedness and reviews approaches currently in use. We also identify some emerging measurement techniques that might help address some of these challenges.

Quality improvement (QI) methods have been used in many industries to improve performance and outcomes. This chapter reviews key QI concepts and their application to public health emergency preparedness (PHEP). We conclude that for QI to flourish and become standard practice, changes to the status quo are necessary. In particular, public health should build its capabilities in QI, enhance implementation, and align incentives to facilitate use of QI.

This review defines crisis risk communication, traces its origins to a number of applied fields, and then shows how basic principles have become incorporated into emergency preparedness and risk communication for public health. Literature from four different disciplines that inform crisis risk communications are reviewed. These are (a) environmental risk communication, (b) disaster management, (c) health promotion and communication, and (d) media and communication studies. Current curricula and training materials are briefly reviewed. Although this literature review suggests much progress has been made to incorporate and disseminate crisis risk communication principles into public health practice, and case studies suggest that public health workers have gained skills and experience, this emerging field still lacks in-depth evaluation of the effectiveness of event-specific crisis risk communication efforts.

First responders, including military health care workers, public health service workers, and state, local, and volunteer first responders serve an important role in protecting our nation's citizenry in the aftermath of disaster. Protecting our nation's health is a vital part of preserving national security and the continuity of critical national functions. However, public health and public safety workers experience a broad range of health and mental health consequences as a result of work-related exposures to natural or man-made disasters. This chapter reviews recent epidemiologic studies that broaden our understanding of the range of health and mental health consequences for first responders. Evidence-based psychopharmacologic and psychotherapeutic interventions for posttraumatic distress reactions and psychiatric disorders are outlined. Finally, the application of public health intervention models for the assessment and management of distress responses and mental disorders in first-responder communities is discussed.

Network analysis is an approach to research that is uniquely suited to describing, exploring, and understanding structural and relational aspects of health. It is both a methodological tool and a theoretical paradigm that allows us to pose and answer important ecological questions in public health. In this review we trace the history of network analysis, provide a methodological overview of network techniques, and discuss where and how network analysis has been used in public health. We show how network analysis has its roots in mathematics, statistics, sociology, anthropology, psychology, biology, physics, and computer science. In public health, network analysis has been used to study primarily disease transmission, especially for HIV/AIDS and other sexually transmitted diseases; information transmission, particularly for diffusion of innovations; the role of social support and social capital; the influence of personal and social networks on health behavior; and the interorganizational structure of health systems. We conclude with future directions for network analysis in public health.

Standard inference procedures for regression analysis make assumptions that are rarely satisfied in practice. Adjustments must be made to insure the validity of statistical inference. These adjustments, known for many years, are used routinely by some health researchers but not by others. We review some of these methods and give an example of their use in a health services study for a continuous and a count outcome. For the continuous outcome, we describe retransformation using the smear factor, accounting for missing cases via multiple imputation and attrition weights and improving results with bootstrap methods. For the count outcome, we describe zero inflated Poisson and negative binomial models and the two-part model to account for overabundance of zero values. Recent advances in computing and software development have produced user-friendly computer programs that enable the data analyst to improve prediction and inference based on regression analysis.

Telephone surveys are critical for examining cross-sectional characteristics of population subgroups, tracking trends in prevalence of conditions and risk behaviors over time, identifying risk factors associated with multiple health conditions, and assessing the effects of interventions. Technology has aided telephone research through advances such as computer-assisted telephone interviewing. However, technology such as answering machines and caller ID has contributed to declines in response rates and has increased costs of conducting telephone surveys. The exponential increase in cell phone utilization presents a challenge to the tradition of random digit dial (RDD) surveys of households. Because telephone surveys are used by other industries such as marketing and public opinion polling, the marketplace may help drive innovation and adaptation. Cell phones have made telephone communication an even greater part of the everyday culture and could make potential telephone survey respondents even more accessible to public health researchers.

Seasonality, a periodic surge in disease incidence corresponding to seasons or other calendar periods, characterizes many infectious diseases of public health importance. The recognition of seasonal patterns in infectious disease occurrence dates back at least as far as the Hippocratic era, but mechanisms underlying seasonality of person-to-person transmitted diseases are not well understood. Improved understanding will enhance understanding of host-pathogen interactions and will improve the accuracy of public health surveillance and forecasting systems. Insight into seasonal disease patterns may be gained through the use of autocorrelation methods or construction of periodograms, while seasonal oscillation of infectious diseases can be easily simulated using simple transmission models. Models demonstrate that small seasonal changes in host or pathogen factors may be sufficient to create large seasonal surges in disease incidence, which may be important particularly in the context of global climate change. Seasonality represents a rich area for future research.

This review discusses key findings and recommendations related to the role of physical activity in weight gain prevention, weight loss, and weight-loss maintenance across the lifespan. For weight gain prevention, epidemiological and clinical studies suggest that regular physical activity is critical, with increases above the recommended 30 min daily for health (e.g., to 45 to 60 min daily) potentially desirable for curtailing weight gain. For weight loss, clinical studies suggest that physical activity interventions alone usually produce only modest results. Combining physical activity with dietary interventions increases the chance of success, especially at higher levels of physical activity (e.g., 200 to 300 min or more weekly). For weight-loss maintenance, high levels of physical activity (e.g., 40 to 90 min daily) may be necessary. To manage weight across the lifespan, a comprehensive approach to physical activity is needed supported by public policy interventions that help make physical activity a part of daily life.

One in three adults worldwide (>1.1 billion people) smokes; 80% live in low- and middle-income countries. Tobacco use causes five million deaths each year and, if current smoking patterns continue, will kill 10 million persons annually by 2020. From 1970 to 2000, tobacco leaf production decreased by 36% in developed countries but more than doubled in developing countries. China is the world's leading producer and consumer of tobacco. Seven multinational tobacco companies dominate the world cigarette market, led by Altria, British American Tobacco, and Japan Tobacco, which collectively manufacture more than 2 trillion cigarettes per year. Extensive knowledge exists about effective tobacco control interventions. However, dissemination of best practices and adoption and implementation of recommended policies are fragmentary. The Framework Convention on Tobacco Control (ratified by 140 countries as of October 1, 2006) provides a template outlining the ingredients for a comprehensive tobacco control campaign.

Youth violence is recognized as a major public health problem in the United States and the world. Over the past ten years, progress has been made in documenting the factors that contribute to violent behavior. Emerging research is deepening our understanding of the individual and societal influences that contribute to and protect against youth violence. However, much work still remains to be done in this field, both in examining potential causes and in designing effective intervention strategies. This chapter highlights specific dimensions of youth violence prevention selected by the authors because these dimensions are the focus of public attention, are emerging as critical issues in the study of youth violence, or have a unique place in the current political and social context. We focus on the developmental pathways to violence, factors that mediate and moderate youth violence, the role of culture and media in youth violence, school-based violence such as school shootings and bullying, and the training of health care professionals.

Church-based health promotion (CBHP) interventions can reach broad populations and have great potential for reducing health disparities. From a socioecological perspective, churches and other religious organizations can influence members' behaviors at multiple levels of change. Formative research is essential to determine appropriate strategies and messages for diverse groups and denominations. A collaborative partnership approach utilizing principles of community-based participatory research, and involving churches in program design and delivery, is essential for recruitment, participation, and sustainability. For African Americans, health interventions that incorporate spiritual and cultural contextualization have been effective. Evidence indicates that CBHP programs have produced significant impacts on a variety of health behaviors. Key elements of CBHP are described with illustrations from the authors' research projects.

Autism spectrum disorders (ASDs) are complex, lifelong, neurodevelopmental conditions of largely unknown cause. They are much more common than previously believed, second in frequency only to mental retardation among the serious developmental disorders. Although a heritable component has been demonstrated in ASD etiology, putative risk genes have yet to be identified. Environmental risk factors may also play a role, perhaps via complex gene-environment interactions, but no specific exposures with significant population effects are known. A number of endogenous biomarkers associated with autism risk have been investigated, and these may help identify significant biologic pathways that, in turn, will aid in the discovery of specific genes and exposures. Future epidemiologic research should focus on expanding population-based descriptive data on ASDs, exploring candidate risk factors in large well-designed studies incorporating both genetic and environmental exposure data and addressing possible etiologic heterogeneity in studies that can stratify case groups and consider alternate endophenotypes.

Beryllium exposure can cause a granulomatous lung disease in workers who develop a lymphocyte-mediated sensitization to the metal. Workers in diverse industries are at risk because beryllium's properties are critical to nuclear, aerospace, telecommunications, electronic, metal alloy, biomedical, and semiconductor industries. The occupational air concentration standard's failure to protect beryllium workers is driving many scientific and occupational health advances. These developments include study of bioavailability of different physicochemical forms of beryllium, medical surveillance to show effectiveness of skin protection in preventing sensitization in high-risk processes, gene-environment interaction, transgenic mice for use in experimental research, and risk-based management of industrial exposures in the absence of effective exposure-response information. Beryllium sensitization and disease prevention are paradigms for much broader public health action in both occupational and general population settings.

More than 12,000 newly diagnosed cases of cancer occur each year in the United States among children ages 20 years or younger, and the current 5-year survival rate is near 80%. An estimated 228,000 among adults 47 years or younger and currently living in the United States had a diagnosis of cancer during childhood or adolescence. Here, we review long-term adverse effects of childhood cancer and its treatment with an emphasis on physical performance and health. We also briefly review existing guidelines that may be used to develop appropriate exercise and diet interventions for childhood cancer survivors. We suggest that there is a need for development of evidence-based, risk-based guidelines and interventions for health promotion among long-term childhood cancer survivors, particularly for those whose physical activity limitations interfere with chances for optimizing their bodies' potential in today's society.

As the managed behavioral health care market has matured, behavioral health carve-outs have solved many problems facing the delivery of behavioral health services; at the same time, they have exacerbated existing difficulties or created new problems. Carve-outs developed to address rising inpatient behavioral health costs and limited insurance coverage. They are based on the economic principles of economies of specialization, economies of scale, price negotiation, and selection. Literature shows that carve-outs have been successful in lowering costs and maintaining or improving access, but results on their impact on quality of care are mixed. In recent years, carve-outs have evolved to take on new roles within the health system, such as coordinating mental and physical health, addressing fragmented public financing systems, and using market power to implement quality improvement. Although not perfect, carve-outs have been instrumental in addressing long-standing challenges in utilization, access, and cost of behavioral health care.

The definition of disease is central to the practice of medicine and to public health policy. Practice guidelines set standards for disease identification and treatment. Quality care is often defined as adherence to these guidelines. Over the past few years, the diagnostic thresholds for several common medical conditions have been lowered, resulting in a substantial expansion in the market for health care. The most recent guidelines for high blood pressure, high cholesterol, and impaired fasting glucose each define a high percentage of the adult population as in need of regular medical attention. Under the latest proposed thresholds, virtually the entire adult population qualifies for a chronic condition diagnosis. We evaluate the health and financial outcomes associated with changes in diagnostic thresholds for the prevention of three risk factors for cardiovascular disease and stroke: blood pressure, serum cholesterol, and fasting plasma glucose. Estimates of the numbers of people affected, the cost implications, and the overall public health consequences are offered.