Structural interventions in public health

Objective: To review structural interventions in public health, identify distinct approaches to structural interventions, and assess their implications for HIV-prevention interventions. Method: The MEDLINE, HealthStar, Psychlnfo and Sociofile databases were searched on specific health issues, types of public health interventions, and conceptual topics (e.g. empowerment, social structure, and inequality) to compile a list of public health interventions in the United States. We excluded interventions focused on testing and surveillance unless they specifically facilitated prevention, and educational or media campaigns focused on increasing individuals' level of knowledge about a particular health problem. Results: The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes. We identified two dimensions along which structural interventions can vary. They may locate the source of health problems in factors relating to availability, acceptability, or accessibility; and they may be targeted at the individual, organizational, or environmental levels. All together, this framework suggests nine kinds of structural interventions, and it is possible to identify examples of each kind of intervention across a range of public health issues. Conclusions: The relevance of this framework for developing HIV prevention interventions is considered. (C) 2000 Lippincott Williams & Wilkins.