Learning to be (L2B) aims to propose a comprehensive model of the assessment and development of social and emotional competences that bring together policymakers, researchers, teachers, school authorities and learners from different participating countries: Finland, Italy, Latvia, Lithuania, Portugal, Slovenia, and Spain. The project attempts to create an international framework for regulating activities and supporting teachers working on the social and emotional competences of the students and to provide tools which can be used across countries. The aim of the paper is to describe how L2B has been developed in Spain by analyzing the contributions of the international framework and extracting the specific needs in the Spanish context. Specifically, we describe two products of the project: (a) the process for creating a toolkit, a tool focused on creating activities and materials for helping teachers develop social and emotional competences of students and (b) the results of an exploratory study in Spain in which social and emotional competences are assessed and compared to the international framework. First, we explain the definition of social and emotional competences used for creating the toolkit. Second, we analyze responses of Spanish students to questionnaires administered before applying the toolkit in the schools. The paper describes social and emotional competences in Spain and evaluates the overlap between relevant variables in Spain and those used for developing the toolkit, the international tool. Specific needs in Spain are discussed, as well as the contribution of the project for promoting the improved development of students’ social and emotional competences, improving learning outcomes and stronger social cohesion in schools and local communities, as well as the utility of the results for creating new educational policies.Critical aspects in the field of education are currently related to low levels of socioemotional competences and high rates of school dropouts. However, there are no standard practices or guidelines for helping countries to assess and train social and emotional competences. To overcome this limitation, the project  The construction of safe and effective educational environments is achieved through holistic contributions that improve the effectiveness of social and emotional learning (SEL) initiatives. As previous studies have shown, the importance of SEL lies on the impact it has on relevant issues such as youth development. For instance, According to the study by The teaching staff is, thus, a key element for the promotion and dissemination of practices at both classroom and school levels, by coordinating actions focused on developing children in their own environments, such as their community or families. This idea implies that social and emotional skills must be exercised in the same way as other skills such as reading, writing or mathematical thinking.The Collaborative for Academic, Social and Emotional Learning (CASEL) identifies a list of closely related competences that should be considered in school programs focused on children’s holistic development. These competences are those related to cognitive, affective and behavioral fields. CASEL groups them into five key domains :(a)Self-awareness: This domain allows recognizing one’s own emotions, strengths and self-efficacy elements, while, at the same time, favoring an adequate self-perception and confidence in one’s own abilities.(b)Self-management: This domain is focused on the control of impulse and stress through the establishment of objectives that favor self-discipline, self-motivation and the development of organizational skills.(c)Social awareness: This domain focuses on the ability to develop empathy involves taking perspective, appreciating diversity and respecting others and their differences.(d)Social management: This domain focuses on establishing and maintaining positive relationships, developing active listening and empathic communication, and seeking and offering help if necessary, which are all necessary skills to effectively develop the group work so important in modern society.(e)Responsible decision-making: This domain implies that the student must go beyond identifying the problem, analyzing and evaluating the situation or solving the problem; this competence also involves doing everything with a social conscience and acting with ethical responsibility.These competences can be developed and trained in all areas of student life. This fact is the reason why students largely internalize competences when strategies, practices and policies of SEL are intentionally developed throughout these contexts. Systemic SEL, according to CASEL, involves a coordinated strategy across classrooms, schools, households, and communities. The degree of quality in the relationships and interactions between these areas determines the success of SEL development.In response to the scope of the classroom, CASEL found that the interactions between peers and the teacher are presented as a fundamental part of students’ social and emotional development. In this way, a relationship characterized by support and trust leads to an improvement in social competence, positive active commitment and academic improvement. Furthermore, students extend beyond the classroom itself, learning in informal environments in the school. It is therefore necessary to establish a culture of care at school, encouraging ethical values and expectations related to social relationships and behavior, and promoting respect and kindness toward others; this is the relevant role that educational leadership plays. Previous research also indicates that those schools where the educational leadership prioritizes SEL obtain successful implementation .In addition, the family school partnership is crucial for the successful development of SEL. Those programs in which both families and schools are focused on authentic relationships and based on active participation, listening and respect, are those that present the most effective programs . LikewisThe last key element discussed by CASEL (2015) is the importance of establishing strong relationships between community partners and organizations that unify efforts and contribute to the development of SEL through the generation of educational initiatives that give students the opportunity to apply acquired skills . In thatIn terms of effective SEL practices and their integration in the school curriculum, previous reviews and meta-analyses  highlighCommon options for developing SEL are discussed. For instance, What previous research undoubtedly underlines is that strategies habitually adopt partial and segmented implementation of SEL, without temporal continuity or an evaluation of the results, thus leading to ineffective outcomes for students . ConsequFinally, looking at trends in the development of educational policies from a global perspective, training on SEL promotes economic growth and social cohesion in Europe. The individuals with a balanced set of cognitive as well as social, emotional and health (SEH) skills are more likely to cope with difficult situations in life, perform well in the labor market, and achieve personal and professional goals .In the specific case of Spain, The Organic Law 2/2006 of Education (LOE) made special emphasis on social and emotional education and learning. The preamble itself states that education is the most appropriate way to build students’ personality and “to help them develop their abilities to the maximum, to shape their own personal identity and to contribute to their understanding of reality, integrating the cognitive, affective and axiological dimension.” Thus, the aim of education is to ensure that all citizens “achieve the maximum development of all their capacities: individual and social, intellectual, cultural and emotional, for what they need to receive a quality education adapted to their needs.” Specifically, article 71 states that “educational administrations shall provide the necessary means for all students to achieve maximum personal, intellectual, social and emotional development, as well as the objectives established in general terms in this Law.”The educational system in Spain is decentralized, so the educational authorities  are transferred to autonomous administrations. These autonomous governments have a certain degree of autonomy for concretizing and extending the national policies. In this sense, and in the case of social and emotional learning, each autonomous community has marked its own statements, within the margins allowed by central administrations.Responsible Education program, which has been already implemented in more than 100 educational centers in different parts of Spain and has shown improvements in academic performance, as well as in a reduction of students’ anxiety levels. This initiative consists of different programs specific to social and emotional development, i.e., Reading and emotions, Choir of emotions, and Literature, Emotions and Creativity. In Catalonia, the GROP research team (Grop de Recerca en Orientació Psicopedagògica) focuses both its research and training activities on emotional education at different levels of education, as well as for teachers’ learning  in line with what is already done in other countries.Learning to be (L2B) attempts to assemble previous experiences when conducting SEL programs, as well as unifying the approaches of professionals from different countries. Specifically, the perspectives of policymakers, researchers, teachers, school authorities and learners have been combined in order to capture needs at different levels.The project L2B targets low levels of socioemotional skill development and high rates of school dropouts in Europe, factors that lead to a negative influence on the social, academic and professional lives of young people and their personal fulfillment. Because of this, one of the goals of the project is to develop an “SEL Skills Assessment Toolkit” for teachers, which could assist schools in promoting positive relationships, developing understanding, and fostering social inclusion and respect for diversity. In addition, L2B aims to overcome previous limitations due to a lack of pre- and postprogram assessments of SEL levels. With this policy measure, the project proposes to widen the set of skills to be assessed and recognized in formal and non-formal education settings for a variety of purposes, including school and university admission, career prospects, and the implementation of other social roles; this will also bring together policymakers, researchers, teachers, school authorities, and learners from seven different participant countries. To do that, some issues are pursued:(a)A comprehensive model for assessing social, emotional, and health-related competences for schools will serve as a theoretical and methodological basis for social-emotional learning and assessment in primary and secondary schools.(b)toolkit for educators and learners for classroom use will include (self-)assessment tools for teachers, non-formal learning, and students.A practical assessment (c)An institutional self-assessment instrument for schools that will help them to evaluate their own social-emotional-health learning situation.(d)A set of recommendations for reviewing policy on SEH skills which will initiate the analysis of educational policies and national curricula in order to better support and facilitate positive policy reforms in Europe.To summarize, L2B is not an intervention program as previous SEL programs, L2B is a European project that aims to develop assessment methods and tools for the development of SEH -related competences in general education schools. L2B pretends to overcome limitations of previous studies in terms of evaluation by proposing formal and informal procedures for extracting evidence on the improvement of SEL between different time points. The tools will facilitate the recognition of SEH skills within the education system and would form a basis for further development of education policies and practices in the national curricula, improving the quality of SEH skills in education and fostering social cohesion and fundamental values of a democratic society.toolkit creation process, including the description of the theoretical approaches to work on SEL dimensions and the final structure of the toolkit. On the other hand, we will present results from the analysis of Spanish students’ responses to questionnaires administered before using the toolkit. The purpose of this second part is to evaluate the needs of students in Spain and compare them to skills promoted in the toolkit created under international criteria.The aim of the paper is to present two main products of the development of L2B in Spanish schools. On one hand, we will describe the toolkit is the basis of the experimental intervention in the project. It provides quite simple and “down to earth” educational tools for activating these values in classrooms and school life by (a) assisting in creating a relationship-centered learning environment, (b) promoting instructional methods to support the development of social and emotional skills and (c) developing progress monitoring and assessment practices for different levels at school.The toolkit creation process had the following stages:The (1)Building a workgroup among all project partners.(2)Reporting on the current status of SEL skills assessment and development in schools in different countries.(3)Designing an SEL skills assessment framework defining progression of skill development, indicators of progression and educational objectives for different ages of learners.(4)toolkit structure based on the designed framework.Development of the (5)Generating a draft version, revision, and final version of the toolkit.(6)Translation and production of the toolkit into partner languages.toolkit was based on the experience of 25 professionals  from seven participant countries. Among them were university professors, school-based educators, SEL experts from research institutes, and ministries of education authorities.The creation of the toolkit.Each participant partner carried out current research on SEL skills assessment and development in their country’s schools. Apart from the situation in the participant countries, the search was extended to other countries outside Europe, especially in the United States. After sharing and analyzing all the different models, programs and interventions existing in the different countries as well as the indicators of success of each, CASEL’s effective SEL program was chosen as a starting point from which design and build the toolkit.As described in the introduction section, CASEL identifies interrelated sets of cognitive, affective and behavioral competences that school-based programs should address and that can be clustered into five key domains: self-awareness, self-management, social awareness, relationship skills, and responsible decision-making. Each domain defines a series of competences that were taken as a starting point to define the approach of the According to the CASEL model, as well as to information provided by other programs and experiences, SEL can be promoted at three levels:-Level 1: Relationship-centered learning environments and teaching methods-Level 2: Evidence-based SEL programs-Level 3: Embedding SEL in the core curriculumAfter reviewing the needs of the participant countries, it was decided to focus on Level 1, as it constitutes the basis for creating a safe, caring, well-managed, and relationship-centered environment . MoreoveThree main goals were defined for Level 1:-Goal 1: Self Awareness and Self-Management-Goal 2: Social Awareness and Relationship Skills-Goal 3: Responsible Decision-MakingFor each of the goals, different SEL assessment strategies for teachers were developed, according to the standards shown in the toolkit was defined as a series of chapters/sections, organized as follows:According to previous findings, the decision taken in the exploratory stage and the definition of the framework for SEL assessment, the structure of the (1)toolkit. This section incorporated specific subsections focused on the relationship between SEL skills and academic success as well as between SEL and mental health.What is Social and Emotional Learning: A foundational section to define SEL, explain its benefits, present different evidence-based SEL programs and explain in detail the approach considered in the (2)Building safe and caring educational environments: This section presents SEL development across different levels of the education for children in schools , as well as the educational provisions for SEL in different types of education such as formal, non-formal and informal education.toolkit:(3) Assessment of social and emotional Skills: This chapter reveals the approach adopted to measure social and emotional skills as an ability. From this, it focuses on the practical use of the subsequent parts of the (a)SEL Standards are learning objectives for the development of social and emotional skills for different age groups of students.(b)Formative Assessment Strategies are strategies to build a constant process of assessment and feedback in class that helps teachers and students track their progress and identify areas and needs for improvement.(c)Instructional Tools for the Classroom use are a series of teaching techniques that support SEL in class regardless of subject or the material being learned.(d)Students’ Self-Assessment Tools are instruments monitoring SEL progress at school on different levels including students’ learning, teachers’ practices and the schoolwide characteristics of SEL.(4) SEL in Practice: In this chapter, a whole plan of action is presented to integrate social and emotional education into the life of the entire school as well as of the student:(a)Planning SEL implementation in the school.(b)Creating relationship-centered learning environments in the classroom.(c)Teaching methods to strengthen SEL.(d)Instructional teaching methods organized in a matrix connecting different methods, formative assessment strategies and SEL standards. According to the L2B project design and aims, all of these strategies and methods have been designed and prepared for grades 4 (ages 9 and 10) and 8 (ages 13 and 14).(5) Tools for SEL Assessment at School: Finally, this section provides specific tools to evaluate SEL progress at the previously established levels:(a)Students’ social and emotional skills assessment tools.(b)Classroom assessment tools.(c)Teachers’ self-assessment tools.(d)School-level assessment of SEL.toolkit incorporated several annexes with different samples of the materials proposed to be used including sheets, report forms, checklists, surveys and curriculum models.The toolkit was completed, it was sent for peer review by two external experts: an elementary school class teacher and an expert in SEL, particularly in the CASEL model. The review focused on the entire structure of the toolkit, the comprehensibility of its different sections and chapters, and the practical applicability of the toolkit.Once the final draft version of the toolkit to improve it according the reviewer recommendations and the final English version was finalized.Once both reviews were received, further changes were introduced in the toolkit was translated into seven languages: Finnish, Italian, Latvian, Lithuanian, Portuguese, Slovenian, and Spanish. After translation and final editing, a proof-reading process was conducted to check both the intelligibility of the translations as well as the coherence between the different translated versions of the toolkit.The final approved version of the English toolkit, the main tool for the intervention, was ready, teachers and other professionals of the school community were trained in using the materials during daily activities in the classroom. Moreover, this training also focused on highlighting the benefits of the development of emotional and social learning programs in order to motivate the whole school community, since the success of this tool is based on the community involvement. The next step consisted of evaluating social and emotional competences as well as other relevant variables of students before starting the intervention. The main results of the evaluation are presented in the following section.Once the toolkit are applicable to the Spanish context. Specifically, we will check whether social and emotional competences addressed by the toolkit respond to Spanish students’ socioemotional needs. Since the toolkit was intended to be a dynamic resource, the results will be used for adapting activities and materials to the Spanish context in order to improve the toolkit.The aim of the second phase was to evaluate the extent to which European educational guidelines used for creating the M = 11.45; SD = 2.15) from twelve schools is Spain located in the provinces of Andalucía, Madrid, Castilla y León, Galicia and Asturias. School principals in different cities were contacted and asked to participate in the project after being explained the goals and intended activities.The participants were 1494 primary and secondary education students (46.2% girls) aged between 7 and 16 years old  survey  were alsI have not bullied another student(s) at school during the last month/I have not been bullied at school during the last month to More than once a week.First, students were provided with a definition of bullying. Then, they were asked to respond to two questions taken from the revised Olweus Bully/Victim Questionnaire . The queCantril Ladder technique (0 to 10) according to his or her feelings. Response options varied from the best possible life for you (0) to the worst possible life for you (10).This was measured by an item based on the echnique  which asCompletely disagree) to 5 (Completely agree).A three-item scale measures how students feel about their relationship with teachers at school. Responses ranged from 1  to 5 (Very much).Participants were asked if they faced difficulties in doing tasks related to reading and writing . Responses ranged from 1  and students in secondary school (from 12 to 16 years old). As previous literature does not provide conclusive results about the role of age and gender in terms of SEL, these analyses pretend to learn about dimensions which should be further developed in different groups, if differences exist. Means between groups were compared by Student ferences .Next step consisted on calculating correlations between scales and dimensions measures with the aim of knowing the relationships between variables. To identify connections between variables will help to organize priorities when designing training programs and will provide a picture of potential interactions between dimensions.toolkit for evaluating the overlap between them and potential needs of Spanish students.Finally, the results obtained were compared with competences and skills included in the In terms of reliability, all the scales were working adequately as Cronbach’s Alpha and McDonald’s omega values were higher than 0.7 see .Only in the self-esteem scale values were lower than the established criteria. Looking at correlations between items and total scores (Discrimination index) it was observed that item 4 was working wrongly as it was not capturing the same meaning as the rest of the scale. Looking at the item stem “I wish I could respect myself more” we concluded that the meaning in Spanish could be confusing as “respect myself” in that item could have a negative or a positive meaning and, then, students could be responding by having in mind different meanings.Then, descriptive analyses were conducted in order to learn about the distribution of responses from Spanish students. self-management and social awareness dimensions exhibited the lowest values whereas self-awareness and relationship management reached the highest means. Looking at responses for scales measuring bullying and school difficulties, we observed that the 88.4% and the 41.6% of the students reached total scores equal or lower to 3 points respectively, whereas only 0.9% of the participants scored more than 6 points in the bullying scale and 5.7% scored higher than 12 points for school difficulties. On the other hand, 46.1% of the students scored 27 points or more in self-esteem, 54% scored 12 points or more in teacher support and 58.5% scored 9 points or more in life satisfaction. Skewness and kurtosis values indicate that all the scales reach acceptable ranges for univariate normality although kurtosis values for bullying indicate that the scale has a peaked distribution.As t-test. Significant differences were found for the self-awareness dimension  in the SECQ, self-esteem , bullying , teacher support , and school difficulties . In all the cases, younger students (7–11 years old) got higher values but according to Cohen’s d values, the effect size was large only for differences in the dimension of teacher support.The means between age groups were compared by the Student’s t-test as well. Significant differences were found for bullying , teacher support  and school difficulties . Girls obtained higher mean values in teacher support and lower values in bullying and school difficulties but the size of the difference was small in all the cases.Means were compared between gender groups by the Student’s Correlations between variables were computed to check relationships between variables and dimensions see .life satisfaction or teacher support. Whereas, these dimensions and positive variables were showed negative and significant correlations with variables expressing the absence of SEL as bullying or school difficulties. On the other hand, positive and significant correlations were obtained between these two variables measuring the absence of SEL (bullying and school difficulties).As expected, significant and positive correlations were obtained between scales indicating SEC and between scales indicating the absence of SEC, whereas significant and negative correlations between scales indicate the opposite. Specifically, all the dimensions in SECQ, where positive values expressed higher levels of SEL, got significant and positive values between them and with other positive variables such as teacher support and bullying, and between bullying and the self-management dimension in the SECQ.Non-significant correlations were only obtained in two cases: between self-management and social awareness are the two dimensions of the SECQ scale scoring lower in Spanish students and, therefore, these should be emphasized by teachers when developing activities for students.According to the results shown in The aim of the paper was twofold. On one hand, the goal was to explain the steps for creating a valid tool to be applied in schools in different countries to help develop social and emotional competences. To do that, professionals from different areas were involved in the design task, and experiences were collected in order to standardize the training for teachers and students to improve social and emotional competences. On the other hand, we aimed to illustrate the potential needs of students in Spain in order to learn about those dimensions less developed in Spanish students and to provide a useful tool for professionals in charge of promoting the training or the creation of programs focused on improving SEL in students.toolkit, we emphasized the importance of including professionals with different approaches as they can contribute to create a realistic tool. In other words, researchers sometimes focused on scientific tools while teachers are centered on their personal experiences. Neither in isolation can create the tools able to provide evidence about their utility. Therefore, it is crucial to combine both fields and incorporate both experiences and scientific knowledge for developing standard and useful procedures that can be evaluated by robust assessment tools. However, that task is not as easy as the academic field and the realities in the classrooms can walk in different directions. But, due to the benefits gathered when including different agents working on educational issues we encourage researchers to ask professionals working directly with students when designing training programs. In that way activities and procedures created will focus on main needs at the same time that they respond to teachers worries and fit to the possibilities they have in their daily work.Regarding the process for designing the self-management and social awareness were less developed and then should go first when working or training SEL in students. As scores for self-awareness were high, maybe indicators within that last dimension could be used as a bridge for working the others. That means as students seem to recognize their feelings and moods, the training can start with helping to recognize these feelings and moods in others and then working with managing feeling emerging in the presence of negative situations. Therefore, this information can help strengthen teacher training to focus on those dimensions. Specifically, our results showed a negative relation between social and emotional competences and bullying habits. These findings are consistent with previous studies (see In relation to the results obtained from the responses of Spanish students, we discovered the dimensions that are less developed in Spain. Values found for SEC dimensions indicated that dies see , hence pdies see . Furtherdies see . Regardidies see . Howevertoolkit teacher training, wherein secondary teachers are made aware of this reduction in competences in adolescent students and can focus on how the toolkit can help to increase these competences.Therefore, these findings should be considered in the toolkit based on international parameters.Some limitations of the study should be drawn. On one hand, results from Spanish students cannot be compared yet to responses from students in other countries. Next studies will focus on analyzing needs from students in other countries and on finding common elements from SEL across countries and potential connections with the students’ achievement. Once we collect data from all participating countries, we will be able to perform a cross-country comparison of the dimensions, which will offer definitive evidence of the utility of the toolkit were not collected now and, therefore, arguments about the utility of the toolkit cannot be supported. Nevertheless, in future researches, we will investigate the variables improving and those being maintained or decreasing. That information will provide evidence to support the utility of the toolkit.Moreover, the changes in the variables after using the To summarize, this paper presents a proposal that contributes to reduce the gap between research and educational policies, thus improving the effectiveness of social and emotional school programs. In addition, the results offer evidence that supports innovative educational methods and policy development to promote better recognition and provide tools for improving the assessment of social and emotional competences across countries. Moreover, the study collected support for keep working on improving programs focused on SEL as according to the literature and experts’ experience it has an impact on students’ daily life.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Ethical Board of the University of Helsinki. Ethical Board of the Universidad Loyola Andalucía. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.toolkit and the data collection as described this manuscript.PA prepared the data sets used for data analyses and wrote the second phase of the study. IL-C described the theoretical framework and was in charge of the literature search. FC and IB are principal researchers of the project in the Spanish work package. FC wrote the first phase of the study. IB was in charge of the analysis of the second phase and of connecting sections. All authors participated in the creation of the The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Despite the growing emphasis on collaboration in public health, there remains a dearth of literature providing tools for the evaluation of coalitions and councils. This study employed social network gap analysis as an evaluation tool. Survey data collected from the Southeastern Health Equity Council members were used to assess connections among members as a whole, by committee, by state, and by health specialty area. Analysis of how well Southeastern Health Equity Council met the representation outlined in its strategic plan was also conducted. Recommendations for improving the network and opportunities to effectively recruit and advance the work of Southeastern Health Equity Council are discussed. DESPITE wide-reaching efforts to address health disparities, health outcomes exhibit persistent and widening gaps.3The complexity of these health disparities has resulted in the deeper specialization of individuals and organizations working to address community health, minority health, and health disparities.6(p90)It is widely accepted that partnerships and collaboration among diverse individuals with unique contributions are imperative for achieving public health goals.7Integrated efforts to address public health issues by involving multiple stakeholders are expected to result in better health outcomes than programs not using a network approach. The rationale behind this is that no single organization has full control over all of the determinants of population health.(par 5)Based on this approach, public health councils and coalitions (herein councils) are formed as an integrated approach that pools knowledge and resources for the purpose of impacting the health of a targeted population.12Social networks comprise relationships between individuals or organizations. To capture these relationships, social network analysis—herein defined as the systematic analysis of relationships among a bounded group of individuals20The use of social network theory—the theory that social network structures influence social dynamics and interactions16One approach to social network evaluation of councils is to use network metrics to assess potential “gaps,” herein defined as aspects of network structure that might limit the effectiveness of the council. Gap analysis was first introduced in business process and service quality improvement research by Parasuraman et alTraditional and current measures of coalition effectiveness lack the ability to assess the structure of the network. Council effectiveness is often measured by member satisfaction, commitment to the coalition, and the quality of planning efforts.Formed in 2011, SHEC is one of 10 regional health equity councils under the National Partnership for Action to End Health Disparities (NPA). Spearheaded by the US Department of Health & Human Services Office of Minority Health, NPA is the first national multisector community- and partnership-driven effort on behalf of health equity. The SHEC corresponds to US Department of Health & Human Services Region IV (RHECIV), which comprises 8 states in the American Southeast: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee. This voluntary association of 40 voting members (5 per state) is designed to bring together leaders from diverse backgrounds in minority health and health disparity elimination, including health care providers, health care–focused organizations, academia, public health agencies, economic development, faith-based organizations, grassroots organizations, and other nonprofit organizations and businesses. The diversity of SHEC ensures adequate input from diverse sectors on the council's efforts to understand and address health disparities in the region. According to the SHEC strategic plan, the stated purpose of SHEC is “to build collaboration and partnerships to achieve health equity in the Southeast region of the US” with the mission “to inform policy, change systems, and increase awareness for health equity ... in the target areas of health care access, healthy food access, cultural competence, and health disparities knowledge and awareness.” Also stated in the strategic plan, SHEC, like many health councils, is designed to bring together members from broad areas  to form partnerships deemed necessary to address health disparities.One area in which collaboration can be enhanced is through the systematic study of the relationships present and the opportunity for growth and change within council networks. Using SHEC as a case study, this research introduces SNGA methods for public health collaboration and partnerships. The SNGA is herein defined as an assessment of a network for the purpose of identifying the difference between the actual and potential performance of said network. More specifically, we present SNGA as a method for evaluating networks, such as councils, to assess the existence of relationships for the purpose of making recommendations for improvement to those relationships and the network more broadly.The purpose of this article is to use SHEC as a case study to highlight the utility of SNGA for improving council effectiveness. In doing so, we (1) contribute to SHEC's strategy to address health disparities in the region through the gap analysis of partnerships, (2) develop a database of SHEC partnerships, and (3) make recommendations to SHEC on how to improve and utilize existing partnerships. In examining the existing collaborative relationships among members of SHEC, we make recommendations for improving the ability of the Council's effectiveness in meeting its stated goals. Moreover, through documenting the processes used in this case study, we contribute to the literature on collaboration evaluation through the introduction of SNGA.To collect the data needed to assess partnerships among the members of SHEC, we conducted an online survey to solicit information on the relationships and affiliations for each member. The purpose of the survey was to develop social networking models in an effort to better understand partnerships, reach the desired goal of analyzing partnerships among SHEC, and develop a better understanding of the broad-based constituency served by the Council for the purposes of improving collaborative partnerships and ultimately advancing regional efforts around health disparities.A survey instrument was adapted from the one used for the evaluation of the Gulf States Health Policy Center coalitionThe survey was distributed by e-mail and administered through Survey Monkey to all active SHEC members as of May 2017. The survey was open for 4 weeks. In partnership with a Health Equity Internship Program, funded by the Centers for Disease Control and Prevention (cooperative agreement no. 6U38OT0001370302), a master's-level student served as a 12-week intern and sent reminder e-mails to all members who had not taken the survey after week 1, as well as reminder phone calls as needed after weeks 2 and 3.The data were analyzed by first looking at descriptive statistics of the nonsocial network questions. We calculated frequencies of responses by the sector of the respondent's primary position  and by the committee on which they served . To evaluate the perception of Council's effectiveness, we calculated frequencies for responses regarding the effectiveness of the Council in meeting its stated objectives in the past year and in the upcoming year.Next, the SNGA was conducted to examine the relationships among SHEC members and the opportunities for partnership development. All social network analyses were conducted using the UCInet software . The SHEC members rated their relationship with all other members on a scale from 1 to 5 in which 1 = do not know; 2 = know only by name but would not know face; 3 = casually know as a member of SHEC; 4 = have worked together as part of a group; and 5 = have worked together personally. Network connections for nonresponding SHEC members were imputed on the basis of the responses of their fellow SHEC members. Thus, for a relationship in which only 1 person  responded, we used his or her response to determine the relationship of the member who did not respond. Analyses were conducted at SHEC whole network level, at the committee level, and at the state level. Results are presented through social network maps in which a square represents a SHEC member and each line between squares represents the existence of a relationship. The size of the square represents the member's power in the SHEC network, in which actors with a larger power are presented by a larger square. Power was calculated as a weighted measure of a member's number of connections, as well as the 1 to 5 relationship rating level of those connections.Respondents were asked to indicate what populations they worked with in regard to health. The responses were coded according to population characteristics, including race, age, income, and gender to form categories of health areas. The connections between members within these health areas were quantified by total number of connections, total number of reported 5's , and the lowest number of connections by a single member within each health area. If 20 people provide relationship data points for 19 others (the whole group minus themselves), there are 380 possible relationship data points (20 × 19) if we do not assume reciprocity, or 190 possible relationships if we do assume reciprocity.To examine what organizations and affiliations are represented by SHEC members, respondents were asked to list all other affiliations they have related to the work of SHEC. We assessed SHEC partnerships by member affiliations, as well as the health disparity focus of their primary organization. We first looked at the frequencies of members presenting 4 primary health areas—race, age, income, and gender—and the existing versus potential relationships among members working in similar health areas. Next, primary organizations, as well as all affiliations, were coded to align with the sectors listed in SHEC Strategic Plan: education and research; health and human services; government; health care professionals; populations and communities; and private, civic (nonprofit and community-based), or media/communications.Out of 40 council members, 32 council members responded to the member survey. The SHEC comprises representatives from many different areas, with 31% of responding members classifying their position as working for a nonprofit organization that is primarily focused in public health, 28% of responding members classifying their position as academic working in public health, 9% of responding members as state employed working in public health, 6% as academic not working in public health, 3% as nonprofit not primarily focused on public health, and 22% in other areas, including corporate workplaces and medical services  for a total of 199 organizations represented among SHEC members. A full list of these affiliations was compiled to develop a partnership directory that can be utilized by SHEC for both information dissemination and building strategic partnerships as opportunities arise.Twenty Council members (50%) had affiliations in health areas involving race, which means that 380 connections could exist between members with this focus (20 respondents multiplied by the 19 members other than themselves without consideration of reciprocity). Of these, 319 (83.8%) responses indicated an existing relationship , or media/communications. This information could then be used to recruit new members in these areas as vacancies arise. The results indicate that the areas of health care and media/communications are underrepresented  and 2 of the Tennessee members, where the network was the strongest, had the longest tenure on the Council. We also noted the absence of many relationships within committees. Based on the results of the SNGA, recommendations were made to SHEC in 2 areas: (1) collaboration and partnerships and (2) filling strategic gaps within the Council. Within these areas, this study yields 8 specific recommendations, which are marked within parentheses throughout this section.onboarding mentorship program in which returning members are paired with new members to provide guidance in efforts related to the mission of SHEC. Mentors can be identified on the basis of common state association, common health area, or common committee within SHEC, all of which can be identified through the tool introduced in this study.First, in regard to collaboration and partnerships, there is a significant gap in the number of, and strength of, relationships between incoming and returning members (those with 2 or more years on the Council) of SHEC. For instance, much of the gap between the Florida and Tennessee network structures can be attributed to the tenure of the members from those states, with the former comprising new members and the latter comprising returning members. Based on this observation, we recommend an (1) each committee work to include all members of their committee in current projects and programs and (3) the success of the committees with higher degrees of collaboration be documented and replicated in the committees with lower levels of collaboration. Here, we also note that the Violence as a Public Health Issue committee was formed just 4 months prior to the survey, which may partially explain the differences for this committee.The SNGA of the SHEC committees revealed that not all members of each committee are working as part of that committee and that there are distinct differences in the level of collaboration when comparing committees. Based on the observation of differences across committees, we recommended that (2) leadership positions within SHEC should be sensitive to states represented to ensure that actor power is distributed among the states, (5) states should coordinate efforts to communicate around health issues, events, and programs relevant to their individual states, and (6) a state leadership designation should be made for an individual within each state responsible for coordinating that state's Council members.We find that state collaboration is much more limited than committee collaboration. With the exception of Tennessee, Council members do not know all other members in their state. Based on this observation, we have 3 recommendations: (4) a Partnership Directory, which for SHEC was developed using the survey and SNGA presented within this article, be utilized to identify the affiliations of SHEC members and to utilize these partnerships strategically for both input  and output (dissemination/communication of efforts of SHEC).Second, the SHEC SNGA provides information useful for strategically filling gaps within the SHEC as membership openings become available. No Council members represent faith-based organizations or local government, and there is limited representation from media/communication. Given the role that these stakeholders play in health in the Southeast, we recommend representation from these communities on SHEC or as advisors to SHEC. We find that there are 200 organizations represented on the Council (inclusive of SHEC), which presents a strength of the Council in terms of constituency and dissemination. However, this strength is not fully achieved when Council members are not active within SHEC. Based on this observation, we recommend that (6) an intervention that targets deficiencies in collaboration among members working on similar issues in public health. The SNGA can be further utilized to identify a member from each group with a high number of connections—a high network power. He or she would be responsible for identifying areas of collaboration between specific members. This would increase the amount of relationships in the network that could report working personally with each other. Similarly, within the organizations and affiliations data, the lack of media/communications respondents shows a need for expertise in this area. We recommend (8) a search be conducted to identify personnel in this sector who could fill this gap and contribute to SHEC.According to the data, the connection among SHEC members within each of the health area demographic groups  was relatively strong. However, the number of members who had reported working personally with these group-based potential connections was low. Therefore, we recommend (7) As a final recommendation to SHEC, this study should be reproduced annually following the implementation of the aforementioned recommendations to assess progress in SHEC social networks. The data provided herein can serve as a baseline evaluation for charting growth in the areas of collaborations and partnerships and in strategic gaps in partnerships. We also recommend that this study be replicated in other Regional Health Equity Council regions to allow for each of the regions to identify their own strengths and weaknesses in collaborations, partnerships, and representation. This will also allow the Office of Minority Health and the NPA to identify regions, committees, and states that exhibit exemplary collaboration and for these to be studied and replicated. Finally, these data can be used to assess the relationship between strong collaboration and effectiveness in work toward eliminating health disparities in the United States.In this article, we have used SNGA methods to measure partnerships with the SHEC as a whole, within committees, state networks, and among members working on similar public health issues. In this case study, partners within SHEC vary in their network connectivity. Variability results from differences in resources, availability, priorities, and level of integration into the network.Although many health organizations have begun to pursue collaborative approaches for addressing community-level health issues, there remain limited tools for evaluating these approaches.Just as SNGA draws from social network analysis and theories, as well as gap analysis, it contributes to evaluation studies and methods in these areas. It also contributes to the literature on public health evaluation. While 8 specific recommendations were developed for SHEC using these analysis methods, the recommendations would vary on the basis of the case examined. However, the tools can be applied and adapted across cases on public health collaboration. Given the common need to measure the formation, structure, and progression of relationships to improve council structure,20Several factors limited this study. Although the member survey had a good response rate,The complexity of health disparities has resulted in specialization among individuals working in public health. In response, public health efforts often focus on coalition building to bring together collaboration across multiple partners in a culturally sensitive and contextual way. Although public health partnerships and collaboration bring together diverse individuals with unique contributions to help meet the challenges of health disparities, there remains dearth of literature providing tools for council evaluation. Through a presentation of the SHEC case study, we have presented the methods by which SNGA can be conducted to evaluate public health networks for the purpose of improving their effectiveness. Applying SNGA to evaluate the SHEC produced 8 recommendations for improving the council network. Future research is recommended to assess the effectiveness of these recommendations if enacted by the SHEC and apply the SNGA across more and diverse public health councils.


Alcohol consumption has been linked to an increased risk for various types of cancer. A combined analysis of more than 200 studies assessing the link between alcohol and various types of cancer  sought to investigate this association in more detail. This meta-analysis found that alcohol most strongly increased the risks for cancers of the oral cavity, pharynx, esophagus, and larynx. Statistically significant increases in risk also existed for cancers of the stomach, colon, rectum, liver, female breast, and ovaries. Several mechanisms have been postulated through which alcohol may contribute to an increased risk of cancer. Concurrent tobacco use, which is common among drinkers, enhances alcohol’s effects on the risk for cancers of the upper digestive and respiratory tract. The analysis did not identify a threshold level of alcohol consumption below which no increased risk for cancer was evident. Regular alcohol consumption can have numerous consequences, beneficial or detrimental, on the health of the drinker. For example, light-to-moderate alcohol consumptionAlcohol consumption also has been linked to cancers of the large bowel  in both men and women and to breast cancer in women, although these associations have not yet been proven unequivocally. Nevertheless, because these are the two most common types of cancer in developed countries after lung cancer, even a moderate increase in risk may result in a relatively large number of additional cases and therefore have important public health implications. The association between alcohol consumption and other types of cancer  is still controversial .The increased risk of cancer among heavy drinkers is primarily attributed to the alcohol  in alcoholic beverages. Thus, the risk tends to increase with the overall amount of ethanol consumed. It is still unclear, however, whether any defined consumption threshold exists below which no increased risk for cancer is evident .To evaluate the overall effects of alcohol on the cancer risk of a population, one must accurately quantify its effects on various types of tumors. To this end, researchers have performed comprehensive meta-analyses of published studies investigating the relationship between alcohol intake and the risk for numerous types of cancer. Meta-analyses are studies that pool data from several studies, thereby substantially enhancing the overall number of cases evaluated. This approach allows researchers to detect relationships that may have been overlooked in the individual studies because of the relatively small sample size and insufficient statistical power of those individual studies. This article summarizes the major findings of one such meta-analysis , 2000.MEDLINE, Current Contents, EMBASE, CAB Abstracts, and Core Biomedical Collection) for studies published between 1966 and 2000. Second, the investigators reviewed all references in the resulting articles to identify any studies that had not been found in the database search. And third, to ensure that the list of studies included was as complete as possible, the investigators conducted a manual search of the most relevant journals of epidemiology and medicine and compared their search results with those of other general reviews and meta-analyses published on this topic.To identify scientific articles to include in the meta-analysis, the researchers followed three steps: First, they conducted a search of several bibliographic databases —the cases—with a similar group of people without the disease— the controls. Investigators then collect information  for both groups to determine whether differences exist between the groups. For example, significant differences between the groups with respect to alcohol intake suggest that alcohol was a causative factor in the disease. Cohort studies follow a group of initially healthy people over a prolonged period of time. At the outset, the investigators determine the participants’ drinking patterns so that they can relate drinking patterns and disease development during the followup period.The findings of the study were expressed as relative risk (RR) or odds ratio (OR) and considered at least three levels of alcohol consumption. The RR determines the strength of the relationship between a variable  and the development of a disease. The RR for a disease among people without the variable  is defined as 1.0. A RR among people with the variable  of greater than 1.0 indicates that the variable increases the risk of the disease. Conversely, an RR of less than 1.0 indicates that the variable has a protective effect. (The OR is used to estimate the RR under certain conditions.)The article reported the number of cases and non-cases  and estimates of the RR or OR for each exposure level.Two readers, who received no information on the names and affiliations of the authors of each study or the alcohol-related results, independently determined the eligibility of each article for inclusion in the meta-analysis. When the results of a study were published in more than one article, only the most recent and complete article was included in the analysis.To estimate the effect of alcohol consumption on the risk for each type of cancer studied, based on the pooled data from all studies included in the meta-analysis, the investigators used meta-regression models—statistical models developed specifically for such analyses , 2000. FTo determine the effects of alcohol on the risk for various types of cancer, the researchers used three statistical methods. They first pooled the original published data for each type of cancer. Subsequently, they determined the relationship between alcohol consumption and the risk for a given type of cancer by fitting to the pooled data several statistical models called fractional models . Such moIn all, 229 studies (183 case-control studies and 46 cohort studies) met the eligibility criteria and were included in the meta-analysis. These studies, which reported a total of 115,199 cases, investigated alcohol’s effects on the risk for developing cancer at a total of 19 sites in the body or at all sites combined (see the table and figure for a summary of the studies and their findings for each of those sites). For five of the cancer sites , alcohol’s effects were analyzed in only one or two studies; in these cases, the researchers could not calculate the pooled RR or 95-percent confidence interval (95% CI).For most of the tumor types included in the studies, the analysis found a dose-dependent increase in risk from alcohol consumption—that is, greater alcohol consumption was associated with a greater increase in risk. Alcohol most strongly increased the risks for cancers of the oral cavity and pharynx , esophagus RR=4.2) and larynx (RR=3.2). Appreciably smaller, although still statistically significant at the 5-percent level,.2 and laThe researchers also investigated whether gender modified the effect of alcohol intake on the risk for each type of cancer. Statistically significant gender differences existed only for esophageal and liver cancer—where the alcohol-related risk was higher in women than in men—but not for other types of cancer.The results of eight appropriate studies were pooled to determine the relationship between alcohol consumption and the risk of cancer at all sites combined. This analysis found that alcohol consumption of at least 50 grams  per day significantly increased the risk of developing any type of cancer.As with other meta-analyses of published studies, the analysis presented here has various limitations and strengths. One limitation is that for most types of cancer included, the estimates of alcohol’s effects tended to vary widely among the individual studies, making interpretation of the pooled data more difficult. Part of this variability may result from differences in the characteristics of the subjects included in the studies. For example, the gender of the study participants may play a role because potential differences in alcohol breakdown  exist between men and women and may systematically influence the overall pooled estimates , 2000.To control for this possibility, the investigators included separate analyses for men and women in their statistical models, where feasible. However, gender explained a significant portion of the observed variability in study results only for esophageal and liver cancer, but not for other types of cancers. Another limitation of this and other meta-analyses is that alcohol consumption levels may have been systematically underreported in several studies, leading to biased RR estimates.The statistical power of this meta-analysis also is somewhat limited because, although it included more than 115,000 cases, the numbers of cases for certain types of cancers  were relatively small. Similarly, for certain cancers, there were only a few cases with certain levels of alcohol consumption . Furthermore, biases resulting from confounding factors may have affected the pooled estimates. A confounding factor is a variable that is related to both the exposure variable  and the risk of disease . For example, alcohol intake may appear to be positively associated with lung cancer but the actual association may be confounded by cigarette smoking, which is related with both alcohol intake  and the risk of lung cancer.One of the strengths of this meta-analysis is that the investigators performed a separate analysis of studies that also reported estimates adjusted for tobacco use, which contributes to various forms of cancer, prominently lung cancer. Such analyses were conducted for most cancers of the upper airways and digestive tract, as well as for lung and bladder cancer. These analyses found that tobacco use had a substantial modifying effect not only on the alcohol-related risks for lung and bladder cancer but also on the risk for laryngeal cancer. For example, when the investigators considered only studies reporting RRs not adjusted for tobacco use, the pooled RR for lung cancer at the highest level of alcohol consumption was 6.30. When they excluded such studies from the analysis and considered only studies reporting estimates adjusted for tobacco use, however, the pooled RR declined to 1.07. This finding indicates that alcohol itself only weakly increases the risk for lung cancer and that lung cancer risk primarily results from tobacco use, which is common in heavy drinkers. For laryngeal cancer, tobacco use also substantially influences the risk, though a strong association with alcohol consumption, indicated by a RR of 3.24, remained even when considering only studies presenting adjusted estimates.The association between various levels of alcohol consumption and an increased risk of liver cancer remains difficult to interpret even with the pooled data used in this meta-analysis. This difficulty results from the fact that, as discussed earlier, the association between alcohol consumption and liver cancer is only indirect. Furthermore, patients with liver cancer resulting from cirrhosis typically have reduced their alcohol consumption by the time they develop liver cancer . This chResearchers have known about the relationship between heavy alcohol consumption and the risk for esophageal and other upper digestive and respiratory tract cancers since the beginning of the last century. Furthermore, substantial epidemiological evidence (as reviewed in this article) accrued over the past 50 years has shown that alcohol contributes to the development of these cancers. Nevertheless, the mechanisms underlying alcohol-related cancer development remain largely unclear.To date, no experimental evidence indicates that alcohol by itself can cause cancer—that is, that alcohol can act as a complete carcinogen. Over the past few decades, however, several animal studies have indicated that alcohol can have a cocarcinogenic, or cancer-promoting, effect. This means that when alcohol is administered together with other known cancer-inducing agents , it promotes or accelerates cancer development. This effect was noted for several digestive tract cancers, specifically cancers of the esophagus and the nonglandular forestomachFor other cancers of the digestive tract , however, the results are less clear and generally are variable across studies, possibly because of differences in study design. Researchers also have no clear understanding of the potential mechanisms through which alcohol might act as a cocarcinogen at these sites . MoreoveFor female breast cancer, the meta-analysis described here confirms the existence of a strong dose-risk relationship between alcohol consumption level and breast cancer risk. The exact role of alcohol in the development of breast cancer remains unclear. It is possible, however, that for breast cancer and other types of cancer related to disturbances in female hormone levels, alcohol may act by altering the metabolism and blood levels of female hormones, such as estrogen . MoreoveAlcohol and tobacco enhance each other’s effects  on the risk for cancers of the upper digestive and respiratory tract.The synergism between alcohol and tobacco also implies that cancers of the upper digestive and respiratory tract in Europe and North America are extremely rare among people who have never smoked, and only limited data are available on the effects of alcohol in those “never-smokers.” Those limited data indicate that for oral and pharyngeal cancers  as well Researchers have made several attempts to determine whether different types of alcoholic beverages have different effects on cancer risk. Some studies found no apparent differences in the cancer risks associated with various beverages, whereas others have reported greater risks with spirits than with wine or beer . ResearcTaken together, these findings appear to indicate that the most frequently consumed beverage in each region or country tends to be the beverage associated with the highest estimated RR. However, this topic requires further study. Some researchers have suggested that drinks containing higher alcohol concentrations are more deleterious per gram of alcohol than drinks with lower alcohol concentrations. The evidence for this hypothesis, however, is weak and inconclusive .This meta-analysis includes most published information on alcohol and cancer and, the limitations discussed above notwithstanding, consequently provides the most accurate estimates of the RRs for common cancers considered to be alcohol-related. Some of the findings are novel and of specific relevance. For example, the analysis was unable to identify a threshold level of alcohol consumption below which no increased risk for cancer is evident. Furthermore, this meta-analysis found that the association of alcohol with the risk for oral and pharyngeal cancer appears to be stronger than the association with esophageal or laryngeal cancer across increasing levels of alcohol intake.In terms of risk assessment, this meta-analysis confirms that high levels of alcohol consumption  result in a substantial risk of cancer development at several sites. Lower levels of consumption result in a moderately increased risk for various cancers. At the same time, other studies have shown that moderate alcohol consumption can have protective effects against certain types of heart disease. Accordingly, one must determine whether moderate alcohol consumption results in an overall favorable or unfavorable risk-benefit balance for the individual drinker or an entire population. This balance depends on the age, gender, and baseline disease rates among the members of a given population. In addition, genetic factors also may influence a person’s risk-benefit balance as suggested by the previously mentioned findings that the association between alcohol consumption and female breast cancer may be limited to women with a family history of breast cancer  . Consequ


In the European Union, the Environmental Impact Assessment (EIA) Directive (2014/52/EU) and Strategic Environmental Assessment (SEA) Directive (2011/92/EU) emphasise the assessment of population and human health. The directives require health to be considered within Environmental Impact Assessment (EIA) and Strategic Environmental Assessment (SEA). To date, health is mainly considered in connection with negative environmental factors and in terms of risk assessments. The integration of health in EIA as well as SEA has not been investigated in a Danish context, and this study aims to address the missing knowledge. There is a need for a more comprehensive health assessment within EIA and SEA to comply with the EIA and SEA directives. An integration of health into EIA and SEA will ensure a sound examination of health determinants which can improve decision making and thus comprehensively promote and protect health. To establish the status of the inclusion of the assessment of impacts on health into EIA and SEA, a literature review was performed. In addition, a survey addressed to researchers and practitioners was conducted and analysed through a comparative analysis. The survey examined the needs of practitioners and researchers, focusing on the Danish context, regarding the inclusion of health into EIA and SEA. Enhanced intersectoral cooperation of the health and environmental sectors, more specific guidance documents, and underlying this, stronger political support, were identified among needs for more comprehensive health assessments. Environmental degradation, the loss of biodiversity and various consequences of climate change are threatening the planet and consequently also human health . At the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”  population and human health” [Another contributing factor to the opposition towards HIA as a stand-alone document could be the current nine to twelve months approval process for EIAs in Denmark . The dev health” ,12.There are two common ways to integrate a comprehensive health assessment into EIA/SEA. One is to assess health impacts more comprehensively within the usual assessment of impacts. The other is to integrate a stand-alone HIA into EIA/SEAs. A third approach which could be further reviewed was brought forward by a practitioner. It was suggested to conduct a screening on health impacts with a subsequent decision on whether to conduct a full HIA.soil, air, water, chemicals, noise, safety etc.”, as expressed by a practitioner in the survey. Further, one third of all practitioners had never integrated health into EIA/SEA. This might have contributed to the lack of progress regarding practitioners’ experiences and competencies to include health into environmental assessments. The examination of the literature review pertaining to most EIA/SEAs also showed that impacts assessed were mainly related to environmental factors. This is in line with the WHO’s conception that health assessments within EIA/SEA are often constrained to environmental or biophysical factors [Determinants of Health Model and assessing the scope in the light of the model could facilitate a more comprehensive health assessment. It could aid practitioners to detect interrelations between determinants and could thus enhance examining all important factors.Practitioners generally supported the integration of a more comprehensive health assessment but were simultaneously restrained. The lack of health-related training and the lack of guidelines for health in EIA/SEA posed barriers to include a comprehensive health assessment into EIA/SEA. This showed the practitioner’s understanding of environmental influences on health. Although some practitioners might acknowledge the interrelation of health and environment, most practitioners emphasised that the health assessment should pertain to environmental impacts such as “ factors . This prWithin the survey, respondents emphasised that collaboration between the different sectors could facilitate the inclusion of health into EIA/SEA, whereas institutional barriers impede the inclusion of health into environmental assessments. However, practitioners raised concerns that a health assessment within EIA/SEAs could lead to a reduced environmental assessment. Accordingly, it was mentioned that health assessments should be conducted within other types of impact assessments, which focus more on social factors. Thus, it must be ensured that the environmental assessment itself will not be neglected through the integration of health. However, this issue can be circumvented by enhanced cross-sectional cooperation while conducting the assessment. Cooperation can facilitate communication between the sectors, which can lay the ground for a comprehensive assessment of both, the environment and health. Collaborating with health professionals could lead to training programs for practitioners to enhance health-related competencies within environmental assessments.Respondents agreed that the lack of professionals, experienced or educated in health-related fields was a crucial barrier to include health into EIA/SEA. At the same time, practitioners and especially Danish practitioners, had little consultation with health professionals in the process of conducting EIA/SEAs, which might be a result of institutional barriers between the health and environment sectors. This also became apparent when investigating the SEAs of the Tivat airport extension in Montenegro, the waste management plan in Serbia and the high-speed railway in Lithuania ,17,18. TThe SEA in Montenegro focussed on negative impacts through the environmental factor noise, but vulnerable facilities such as health and educational facilities were mentioned. The engagement of stakeholders facilitated the consideration of some health determinants other than environmental factors . PresumaThe SEA conducted on the waste management plan in Serbia encompassed environmental factors, built environment and housing as well as employment and livelihood. For human health, objectives addressed risk minimisation through emissions, health promotion through minimising “environmental problems” and the creation of jobs . A more In the case of Lithuania, the Ministry of Health was engaged within the SEA ,24. The In Denmark, the survey indicated that cooperation between the health and the environmental sector while conducting EIAs was also limited. The VVM law in Denmark has only been in operation since 2017. Since then, population and human health must also be considered within Danish EIAs. As the results of the survey showed, the collaboration between researchers and practitioners was limited.Additionally, both Danish EIAs did not indicate a collaboration with health professionals. This is represented within the EIAs by the coverage of mainly environmental factors. The EIA by DSB on the maintenance workshop only mentioned health impacts in correlation with harmful waste. The EIA of the biogas plant in the municipality of Svendborg concentrated on safety issues but also on potential positive health impacts due to a decrease in bacteria.Within the EIA/SEAs, limited collaboration among environmental and health professionals led to fewer considerations of health impacts. Possible reasons for the constrained cooperation could be the lack of information regarding contacts to health professionals. Most practitioners of the survey worked in environmental-related sectors, which could also explain the lack of experience with health and health-related competencies within EIA/SEAs. Further, researchers or health consultants might not be aware of specific EIA/SEA procedures and methods, which could inhibit collaborations and prevent the assessment of relevant factors. This issue could be countered by educating health professionals regarding the procedures and methods of EIA/SEA. Collaboration between the health and environmental sectors could minimise the potential lack of experiences, which were emphasised as a main barrier for the inclusion of health into EIA/SEA by the respondents of the survey.By reaching out directly to researchers within the field of public health, the aim was to assess their experiences regarding consultation on health issues within EIA/SEAs. Most of the ten researchers considered themselves HIA researchers. However, many researchers who conducted the survey had never been consulted in the process of conducting EIA/SEA. Their area of expertise, although in the area of health, might be too theoretical to transfer to the practical nature of EIA/SEAs. Hence, the researchers who completed the survey might not be equipped to consult within EIA/SEA. To achieve a realistic view on the topic of whether health professionals consult within EIA/SEAs, the question should be directed to health professionals with more practical work experience.However, the lack of cooperation could also indicate an employment gap, which could be used as an opportunity by public health professionals to engage and impart health-related knowledge. This would be in line with many respondents’ emphasising that a public health background should be required to assess health within EIA/SEA. As the WHO suggested already in 2014, the cooperation of health and environmental sectors should be established as early as possible in the process of conducting an impact assessment . The estGuidelines are a basic tool used that can be used to implement environmental assessments and thereby facilitate comprehensive outcomes. Within the survey, respondents were asked in various ways on their current use and need of further guidance documents.The respondents clearly emphasised the need for more guidance documents, and the lack of guidance as a barrier to include health into environmental assessments. This pertained to the need for more guidance regarding the inclusion of health, specific to the four types of assessment  and specific to the areas. More guidance documents specific to the types could clarify the starting point of the assessments, explain the meaning and implications for each type and elaborate whether there are issues to be addressed, activities to be implemented or work to be done in a specific timeframe. Further, the responsibility for preparing the report should be clarified. An example is Denmark, where EIAs on projects are the responsibility of the project proponent, often conducted by a consultant company, and EIAs of plans and programmes are conducted by an authority such as a municipality or ministry .Not only did the respondents express the need for guidance documents generally and specific to the type, but also specific to the area, regarding the inclusion of health into EIA/SEA. In the survey, ten areas were listed as retrieved from Annex I and II of the 2011 EIA Directive and paragraph 10 and 11 of the SEA Directive ,12. In cThe question is, however, who can develop these guidance documents? They should be developed by a reliable entity, and a further asset would be to have mutually agreed guidance documents within the EU. A reliable entity could be the WHO, or another established internationally operating organisation. This could ensure that the development of the documents would be both comprehensive and evidence based. While developing the documents, parties from all areas such as environment, health, economy and policy should be considered to establish a document that is tailored to the needs of all stakeholders involved and that is in line with the EC directives. To have mutually agreed guidance documents on EU level could result in a standardisation and simplification of conducting EIA/SEAs. The adaption to the national context is crucial to ensure the guidance document is readily applicable.In the survey, almost all participants stated the use of guidance documents as a source when conducting EIA/SEA. Guidance documents could aid in suggesting suitable sources for the different stages of the assessment. It could specify on sources that could be used for assessing, examining and analysing quantitative as well as qualitative data. More specifically this could mean guidance for accessing scientific databases and literature. By that, procedures could be fostered, and the operation of the assessment could be enhanced.human health, the document only provides a footnote stating that human health is a broad term and should be assessed on a context-specific basis [The EC has produced guidance documents to assist practitioners in conducting EIAs while complying with the directives. However, an examination of the documents proved that many topics were only covered superficially. Especially the terms population and human health received little attention. Regarding the term ic basis .All in all, guidance documents are crucial for the implementation of any impact assessments. Guidance documents should define terms and provide options for methods and analytical approaches to aid the assessment. National as well as international political support can initiate the process of developing guidance documents, it can foster cooperation between sectors and can result in accessible and transparent outputs.There are political incentives that can facilitate the use of HIAs or health assessments. Montenegro and Serbia are in the process of accession to the EU. Serbia officially applied for an EU membership in 2009 and Montenegro in 2008 . The SEAIn the context of including population and human health into EIAs, Denmark showed limited political support. The VVM law does not elaborate on the inclusion of population and human health into EIA, and neither are the terms defined. This indicates a lack of political support on the assessment of health, which could in turn explain the low requirements for health within EIAs.Some Danish practitioners who conducted the survey expressed the need for relevant laws pertaining to health within EIA. As the VVM law covers this area, the need could be translated to develop additions to the law, such as definitions of the terms related to health or enhanced examples regarding what health factors to consider. Definitions and examples could also be a part of guidance documents, which is currently not the case.EIA and SEA are established and comprehensive tools to assess the significant effects of plans, programmes and projects on the environment. Since the amendment of the EIA Directive, effects on population and human health must be assessed to ensure the prevention of any adverse effects on health. The HIA is a comprehensive and established tool to assess health. Its approaches and methods to assess and analyse health impacts can aid EIA/SEAs. Due to the HIAs aim to assess all potential health impacts, the tool provides a natural basis for assessing direct and indirect as well as positive and negative health impacts.The reviewed environmental assessments revealed that health determinants assessed within EIA/SEAs mostly pertained to environmental factors. Hence, there is a need for health assessments that go beyond environmental factors and include other relevant health determinants, such as the ones listed in The health assessment could be fostered by intersectoral cooperation between the environmental and health sectors within EIA/SEAs. As the WHO suggested already in 2014, the cooperation of health and environmental sectors should be established as early as possible in the process of conducting an impact assessment. Encouraging more health-related training and establishing potential entry points for health professionals into the process of conducting EIA/SEA could facilitate cooperation. Here, political support could promote practices to include health into EIA/SEA.The comparison of researchers’ and practitioners’ views on the inclusion of health into environmental assessments aided in revealing their opinions. Due to the rather small sample size, their perceptions cannot represent the view of all researchers and practitioners working in the field. Establishing a survey based on a larger population could reveal crucial and representative opinions on the topic of health within EIA/SEAs. Nevertheless, the perceptions of researchers and practitioners regarding health inclusion into EIA/SEA showed that there is a need for more guidance documents. These guidance documents should elaborate on essential terms such as population and human health. Their meaning is crucial to develop comprehensive health assessments. The guidance documents can be established by international organisations such as the WHO as they represent reliable institutions. However, there must be an effort on national level as well, to translate those documents into the national language and contexts. This can ensure comprehensibility for those practically applying the guidance documents on environmental assessments.Additional or enhanced guidance documents,Engagement of health professionals in the environmental sector,Health-related training, andPolitical support.To summarise this study, a list of recommendations is provided, resulting from the reviewed literature and the compared perceptions of practitioners and researchers to include health into EIA/SEA. The recommendations aim to inform decision making and official guidelines to ensure the consideration of the broader health determinants within environmental assessments. The list encompasses the most important and strongly emphasised points backed by the literature review and survey results presented throughout this study:To generalise results on a European level, more research must be conducted. This could include a more comprehensive analysis of EIA/SEA reports within different countries. Moreover, a survey conducted in EU member states could generate information about health in environmental assessments as perceived by practitioners and researchers. However, the results of this article can be used to understand the complexity of integrating health into environmental assessments. Further, there might be similar aspects for integrating health into environmental assessments in other countries, which could be used to support decision making.


Purpose: The Limited English Proficient (LEP) population experiences well-documented suboptimal health outcomes and substandard provider experiences. The lack of national estimates on the size of the LEP population relative to the healthcare setting makes examining health outcomes for this population very difficult. This analysis addresses this limitation by publishing population estimates for LEP persons enrolled in Medicare, Medicaid, and Duals (enrolled in Medicare and Medicaid). Focusing on the Medicare and Medicaid programs provides an important foundation as these programs are not only the largest insurers in the United States but are also governed by legislation that requires LEP persons to receive equitable access to care.Methods: Data from the 2014 American Community Survey Public Use Microdata Sample (ACS PUMS) were used to produce national estimates and measures of statistical accuracy for the LEP population enrolled in Medicare and/or Medicaid (LEPMM).Results: In 2014, there were approximately 8.7 million LEP persons enrolled in Medicare, Medicaid, or both programs . The LEPMM was concentrated along the western and eastern coastlines and the southwestern region, with California and New York each containing more than 1 million LEPMMs. The LEPMM was also highly diverse with varying disability status, and most were racial or ethnic minorities and elderly.Conclusion: These findings provide a foundation for measuring an understudied and at-risk population that will enable population health professionals to develop effective culturally and linguistically, and appropriate services and policies that address health disparities in the LEPMM. Beginning with Title VI of the Civil Rights Act of 1964, federal law prohibits discrimination based on national origin, including language preference, with specific regulations banning discrimination in the provision of Medicare and Medicaid.18 Recent policies have further entrenched language access with a focus on the rights of LEP persons. The National CLAS Standards (2013) was developed with the goal of guaranteeing access to culturally and linguistically appropriate services for LEP beneficiaries19 and the Medicare Improvements for Patients and Providers Act of 2008 demonstrates a continued legal commitment to guaranteeing language access and evaluating provider compliance. Overall, these policies demonstrate that LEP beneficiaries are an important subpopulation for CMS and the agency is legally required to protect their rights in the healthcare setting.In 2013, Medicare and Medicaid programs constituted the largest insurers in the United States, covering over 109 million combined beneficiaries.Despite the increasing growth of the LEP population, CMS has limited information on the language preferences and needs of its beneficiary population. This analysis addresses this gap in the literature by using the American Community Survey (ACS) Public Use Microdata Sample (PUMS) to provide the first estimates of the size of the LEP population enrolled in Medicare and/or Medicaid population, with the goal of enhancing LEP-focused health policy and research.21To enumerate and describe the LEPMM, this analysis uses the PUMS files from the U.S. Census Bureau, 2014 ACS 1-year files. The ACS is an ongoing survey of the U.S. population that collects data on topics such as language preference and health insurance status, and is the primary source for limited English proficiency estimates used by the U.S. Department of Health and Human Services.For this analysis, ACS PUMS data were used to identify persons who reported speaking a language other than English at home, spoke English less than very well, and reported enrollment in Medicare, Medicaid, or both . Hispanic ethnicity included persons of any racial group who reported Hispanic ethnicity. This analysis includes non-Hispanic members of the following racial groups: White, Black, Asian, American Indian or Alaska Native (AIAN), Other, and Multiracial. The ACS collects information on six types of difficulty related to disability: hearing, visual, cognitive, ambulatory, self-care, and independent living. Respondents reporting any one of these disability types were classified as having a disability. This analysis excludes unknown, illegible, N/A, or blank responses, which impact the estimates, as data on the LEP population contain a high degree of missingness.Due to missing information on LEP status in the 2014 ACS PUMS, estimates regarding LEP status are missing for nearly 9 million members of the Medicare, Medicaid, and/or Duals population. Therefore, it is possible that this analysis significantly underestimates the size of the LEP population. This may impact the Medicaid program most substantially, as 98.6% of all persons' missing information regarding their LEP status reported enrollment in Medicaid. Medicare (0.7%) and Duals (0.6%) had substantially lower rates of missingness. Consequently, readers should interpret these estimates as conservative estimates that represent a lower bound of the LEPMM, particularly regarding the Medicaid program.22 are also reported with the population estimates. These statistics allow for the measurement of statistical reliability and provide valuable information regarding the usability of the estimates for the LEPMM. The sampling error is directly related to sample size and is expected to increase as the sample size decreases and vice versa; thus the sample size accompanies all estimates in this analysis.Because the ACS is a sample of the U.S. population, the estimates produced using the PUMS data also contain sampling error. To ensure that appropriate conclusions are drawn about the quality of the data, the standard error (SE), the margin of error (MOE), and the coefficient of variation (CV)22 and demonstrates the extent to which the population estimate deviates from the true population value.23 The MOE is used to calculate the confidence intervals (CIs), which represent the range that is expected to contain the average value of the estimate, given the level of confidence. For interpretation purposes, the 90% confidence level indicates that we should expect the true population size to fall between the upper and lower CIs in 9 of 10 samples. The lower CI is calculated by subtracting the MOE from the estimate, while the upper CI is calculated by adding the MOE to the estimate. Finally, the CV measures the relative amount of sampling error that accompanies an estimate and reflects the ratio of the SE to the estimate itself.24 Because it is expressed as a percent, it is useful in understanding the overall validity of an estimate compared to other estimates. As the CV approaches 0, the reliability of the estimate increases and provides evidence that the estimate is accurate; as the CV approaches 100, the reliability of the estimate decreases and indicates that the estimate may not be accurate or interpretable.In the context of the ACS PUMS data, the SE measures the variability of the estimate due to samplingAs shown in The ACS determines a respondent's preferred language by asking if they speak a language other than English at home and, if so, having them write-in their preferred language. Based on the 2014 ACS, there were over 100 language groups. Knowing the size, geographic location, and language group characteristics of the federally insured population is important for complying with federal policy and evaluating federal programs. However, due to limitations in data collection, CMS currently lacks accurate population estimates that reflect the size and diversity of its beneficiary population. This analysis addresses this gap by using ACS PUMS data to estimate the size of the LEPMM and describe its demographic and health characteristics.25 LEPMMs comprised a meaningful portion of the overall Medicare, Medicaid, and dually enrolled population. In addition to the myriad laws, regulations, and policies demonstrating the importance of the LEPMM, the sheer size  indicates that providers are increasingly likely to encounter LEPMM persons. This research revealed that LEPMM persons tend to reside along the western and eastern coastlines, southwestern region, and in midwestern states of Illinois, Michigan, and Minnesota. Examining the demographic and health features of the LEPMM showed that a majority of LEPMMs were racial or ethnic minorities, aged 65 and older, and had lower levels of educational attainment with Dual LEPs reporting the highest prevalence of disability. Among federally insured LEP persons, our study showed that 50,000 or more spoke 19 different languages.In 2014, with a population totaling almost 8.7 million,26 Evidence has shown a reduction in readmission rates and expenditures when hospitals provide convenient access to interpreters.27 In addition, dosing errors among Hispanic parents, who may be LEP or have limited health literacy, have been shown to be problematic; however, the ability to better characterize the LEP population may assist in reducing these errors.28 Also, providing language-concordant care  may be a feasible solution to thwart health disparities experienced by LEP patients.29To ensure equity in healthcare, it will be necessary for providers and healthcare systems to provide culturally and linguistically appropriate services for their LEP patients. A recent study by Lee et al. (2017) showed that among Chinese- and Spanish-speaking patients, a bedside interpreter phone system intervention was associated with greater informed consent; however, a disparity was still observed regarding the care of LEP patients.Overall, results from this study will enable providers to better serve their LEP patients. Providers located along the East Coast, West Coast, and Southwest should expect to have the majority of LEP patient encounters, given that over 80% of the entire LEPMM resides in these regions. In addition, providers should be aware that nearly 60% of all LEPMMs speak Spanish as their primary language; therefore, it might be beneficial to focus on Spanish language translation services in the geographic regions densely occupied by LEPMMs.Using ACS PUMS data was a major strength of the study. These data allowed for the generation of reliable and national estimates of the LEPMM. To our knowledge, this is the first time that national estimates, along with measures of statistical accuracy, have been produced on the U.S. LEPMM. This foundation will help support the provision of culturally and linguistically appropriate services for the LEPMM. However, the ACS PUMS data do not capture information on respondents preferred language to obtain health information. Therefore, we were unable to gauge the health literacy level of the study population and this should be examined in future research. As the U.S. population continues to become more diverse, it is critical to have national data sources that provide this information. Even with these limitations, the estimates described herein will inform policy decisions regarding the health needs of one of the most at-risk and growing federally-insured populations., Medicaid, and dually enrolled populations. In the CMS Strategic Language Access Plan,21 the goal is to ensure that 90% of beneficiaries requesting LEP-related materials and/or assistance receive it during the first attempt and they are satisfied with the customer service provided at least 80% of the time. However, without knowing which languages are most likely to be encountered, it is very difficult for providers to accurately prepare for language requests. Therefore, accurate population estimates of language group by program are essential to the implementation of federal laws and policies aimed at enumerating and servicing the LEPMM. These study findings move federal planning and provider efficiency toward the ultimate goal of providing equitable access to healthcare across multiple language groups. With demographic data describing where LEPMM persons live and which languages they speak, both the government and healthcare providers can operate more effectively by strategically targeting those areas with the greatest degree of language need.LEP persons represent a sizable and meaningful portion of the overall Medicare