Going upstream - an umbrella review of the macroeconomic determinants of health and health inequalities.

BACKGROUND: The social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions. METHODS: Nine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented. RESULTS: The review found a large (n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations. CONCLUSIONS: The results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review. TRIAL REGISTRATION: Protocol for umbrella review prospectively registered with PROSPERO CRD42017068357.

Correction to: The macro-economic determinants of health and health inequalities-umbrella review protocol.

Following publication of the original article [1], the authors opted to correct the following reference on page 3.

The macro-economic determinants of health and health inequalities-umbrella review protocol.

BACKGROUND: The economic determinants of health have been widely recognised as crucial factors affecting health; however, to date, no comprehensive review has been undertaken to summarise these factors and the ways in which they can influence health. We conceptualise the economy as a complex system made up of underlying approaches, regulation from institutions, markets, finance, labour, the public-private balance as well as production and distributional effects, which collectively impact on health through the effect of moderators. This protocol details the methods for an umbrella review to explore the macro-economic factors, strategies, policies and interventions that affect health outcomes and health inequalities. METHODS: We will identify relevant systematic reviews using search terms derived from the Journal of Economic Literature classification. Reviews will be included if they meet the Database of Abstracts and Reviews of Effects criteria for systematic reviews. Reviews of studies with and without controls will be included; both association and intervention studies will be included. Primary outcomes will include but are not limited to morbidity, mortality, prevalence and incidence of conditions and life expectancy. Secondary outcomes will include health inequalities by gender, ethnicity or socio-economic status. Six databases will be searched using tailored versions of our piloted search strategy to locate relevant reviews. Data will be extracted using a standardized pro forma, and the findings will be synthesized into a conceptual framework to address our review aim. DISCUSSION: Our umbrella review protocol provides a robust method to systematically appraise the evidence in this field, using new conceptual models derived specifically to address the study question. This will yield important information for policymakers, practitioners and researchers at the local, national and international level. It will also help set the future research agenda in this field and guide the development of interventions. SYSTEMATIC REVIEW REGISTRATION: This umbrella review protocol has been registered with PROSPERO CRD42017068357 .

Tobacco cessation drug therapy among Canada's Aboriginal people.

The smoking rate among Aboriginal people is more than double the rate of the rest of the Canadian population, and smoking is a major source of morbidity and mortality within this population. Tobacco cessation drug therapy use among Aboriginal smokers is very low. We administered a cross-sectional questionnaire to Aboriginal and non-Aboriginal smokers or recent ex-smokers in 12 First Nations communities in two Canadian provinces from September to December 2004. Participants were asked about smoking cessation advice and perceptions of three drug therapy agents. The overall response rate was 82% (407 Aboriginal and 102 non-Aboriginal smokers or ex-smokers). A substantial proportion reported tobacco cessation or reduction in the previous year (Aboriginal 46% vs. non-Aboriginal 32%). Aboriginal participants were less likely to seek physician services (prevalence OR [pOR] = 0.45, 95% CI = 0.27-0.74, p = .001) and less willing to use nicotine patch (pOR = 0.6, 95% CI = 0.38-0.96, p = .03) or bupropion (pOR = 0.50, 95% CI = 0.29-0.84, p = .008). Among First Nations participants, who receive a drug therapy subsidy, lack of awareness of the subsidy were associated with less willingness to use drug therapy; further, the requirement for a physician prescription was perceived as a barrier. Among all participants, utilization of physician services (pOR = 2.2, 95% CI = 1.50-3.20, p<.001) and receiving drug therapy advice from a physician (pOR = 7.7, 95% CI = 4.17-14.3, p<.001) was associated with willingness to use drug therapy. In conclusion, many Aboriginal smokers are interested in and attempt cessation, but underutilization of physician services and low willingness to use drug therapy may explain their lower use of drug therapy. Physicians need to provide advice on drug therapy, and policy makers should eliminate the need for a physician prescription. Future studies can explore cultural attitudes toward cessation drug therapy and physician services.

Addressing the non-medical determinants of health: a survey of Canada's health regions.

BACKGROUND: The Canadian health system is undergoing reform. Over the past decade a prominent trend has been creation of health regions. This structural shift is concurrent with a greater emphasis on population health and the broad determinants of health. In parallel, there is a movement toward more intersectoral collaboration (i.e., collaboration between diverse segments of the health system, and between the health system and other sectors of society). The purpose of this exploratory study is to determine the self-reported level of internal action (within regional health authorities) and intersectoral collaboration around 10 determinants of health by regional health authorities across Canada. METHODS: From September 2003 to February 2004, we undertook a survey of regional health authorities in Canadian provinces (N = 69). Using SPSS 12.0, we generated frequencies for the self-reported level of internal and intersectoral action for each determinant. Other analyses were done to compare rural/suburban and urban regions, and to compare Western, Central and Eastern Canada. RESULTS: Of the 10 determinants of health surveyed, child development and personal health practices were self-reported by the majority of health regions to receive greatest attention, both internally and through intersectoral activities. Culture, gender and employment/working conditions received least attention in most regions. CONCLUSION: The exploratory survey results give us the first Canadian snapshot of health regions' activities in relation to the broad range of non-medical determinants of health. They provide a starting data set for baselining future progress, and for beginning deeper analyses of specific areas of action and intersectoral collaboration.

HIV/AIDS: testing and risk behaviors among British Columbia's rural Aboriginal population.

OBJECTIVES: Over the last decade, there has been growing concern in the public health sector over the spread of Human Immunodeficiency Virus (HIV) in Canada's Aboriginal population. However, there continues to be a general lack of HIV awareness and its risk factors in Aboriginal communities. STUDY DESIGN AND METHODS: This study investigated HIV testing patterns, perceptions and risk factors within 7 community organizations through the use of face-to-face interviews. The objectives of this research project were to 1) describe the prevalence of HIV testing; 2) describe issues concerning confidentiality related to the HIV testing; 3) identify the prevalence of risk factors for HIV transmission; and, 4) build research capacity in the Aboriginal community. RESULTS: Two hundred and nineteen Aboriginal persons participated in interviews. Off-reserve residents (pOR: 0.48, 95% CI: 0.29 - 0.80) were significantly more likely to use illicit drugs than reserve residents. Sixty percent of participants had reported undergoing HIV testing at some point. Two-spirited participants (pOR: 16.1, 95% CI: 2.13-121.06), those who previously tested for a Sexually Transmitted Disease (pOR: 2.94, 95% CI: 1.73-4.98), those currently using cocaine (pOR: 3.88, 95% CI: 1.25 - 12.0), and those who reported to "never", or "some of the time" use clean needles (pOR: 11.0, 95% CI: 1.36- 88.66) were significantly more likely to undergoing HIV testing. On-reserve residents (pOR: 0.55, 95% CI: 0.35-0.87) and respondents older than 40 years of age (pOR: 0.40, 95% CI: 0.19 - 0.86) were less likely to undergo HIV testing. CONCLUSIONS: Participants with HIV risk factors are more likely to be tested for HIV in rural areas and confidentiality issues were not a barrier to testing for most participants. Off-reserve residents were more likely to undergo HIV testing, the reasons for which require additional research. Finally, public health units are often under-utilized as locations to seek testing.

Harm reduction services for British Columbia's First Nation population: a qualitative inquiry into opportunities and barriers for injection drug users.

BACKGROUND: Aboriginal injection drug users are the fastest growing group of new Human Immunodeficiency Virus cases in Canada. However, there remains a lack of comprehensive harm reduction services available to First Nation persons, particularly for First Nation people dwelling in rural and reserve communities. This paper reports findings from an exploratory study of current harm reduction practices in First Nation communities. The purpose of this study was to provide an overview of the availability and content of current harm reduction practices, as well as to identify barriers and opportunities for implementing these services in First Nation communities. METHODS: Key informant interviews were conducted with 13 addictions service providers from the province of British Columbia, Canada. RESULTS: Participants identified barriers to these services such as community size and limited service infrastructure, lack of financial resources, attitudes towards harm reduction services and cultural differences. CONCLUSION: It was recommended that community education efforts be directed broadly within the community before establishing harm reduction services and that the readiness of communities be assessed.

Women's health resources: facilitating a community of care for midlife women.

Since 1981 research has explored the role of women's health centres in providing health information and education to women in a non-traditional setting. These settings have been designed to provide more appropriate, and often more comprehensive, care by responding to the specific health issues and needs of women across the age continuum. The type of care and resources provided by these centres make a significant contribution to women's capacity for participation in decisions and action around their own, health. This article examines the service delivery and perceived roles of one such centre, the Women's Health Resources (WHR) centre in Calgary, Canada. Data for this paper were extracted from WHR evaluation forms for 199 midlife women seeking individual consultation, as well as personal interviews that were conducted with four female staff members. Clients of the WHR cited numerous reasons for seeking service at the centre, the most common being for emotional health care, nutritional consultation or more comprehensive information on a specific illness. Three major components of service provision at the centre were identified: information, psychological care and complementarity of services. Women used the information they gained from WHR services to aid in health decision-making and as a resource for empowerment in being partners in their own health. Clients noted that the WHR was a valuable source of additional information beyond what their own family physician and/or specialist were able to provide. The feminist and woman-centred care at WHR, in conjunction with the emphasis on education, offers an invaluable source of information and services for women. Through the shared experiences of both the clients and staff of this centre, this article provides an outline of how such services are perceived and utilized.

Representation strategies in public participation in health policy: the Aboriginal Community Health Council.

Within Canada's Aboriginal population, an ongoing health promotion strategy has been the facilitation of community participation in the development and application of health policy. The Calgary Health Region's Aboriginal Community Health Council has provided a setting for involving the local Aboriginal population in health policy and program development for over a decade. This paper represents the results of a case study to identify the Council's strategies for this work. Data sources included documents, such as meeting minutes and other reports; key informant interviews with past and present Council members and health region representatives; and participant observation of Council functions. Although direct membership in the Council provided a core approach for representing the community, other strategies were actively utilized to involve the public. These included building links and partnerships with community organizations, networking, consultation activities and the identification of special needs groups.

Homelessness and health in Canada: research lessons and priorities.

This article was for prepared for an international think-tank on reducing health disparities and promoting equity for vulnerable populations. Its purposes are to provide an overview of homelessness research and to stimulate discussion on strategic directions for research. We identified studies on homelessness, with an emphasis on Canadian research. Studies were grouped by focus and design under the following topics: the scope of homelessness, the health status of homeless persons, interventions to reduce homelessness and improve health, and strategic directions for future research. Key issues include the definition of homelessness, the scope of homelessness, its heterogeneity, and competing explanations of homelessness. Homeless people suffer from higher levels of disease and the causal pathways linking homelessness and poor health are complex. Efforts to reduce homelessness and improve health have included biomedical, educational, environmental, and policy strategies. Significant research gaps and opportunities exist in these areas. Strategic research will require stakeholder and community engagement, and more rigorous methods. Priorities include achievement of consensus on measuring homelessness, health status of the homeless, development of research infrastructure, and ensuring that future initiatives can be evaluated for effectiveness.

Access and utilization of health services by British Columbia's rural Aboriginal population.

PURPOSE: To provide a picture of the access and use of health services by Aboriginal British Columbians living in both reserve and off-reserve communities. DESIGN/METHODOLOGY/APPROACH: This project represents a collaborative effort between the University of British Columbia and multiple Aboriginal community partners. Between June and November 2003, 267 face-to-face interviews were conducted with Aboriginal persons in seven rural community organizations across the province. FINDINGS: This paper reports on the results of a survey of 267 Aboriginal clients. It was found that a substantial number of survey respondents accessed health services provided by an Aboriginal person. Although most respondents felt that services were available, they also identified a number of concerns. These revolved around the need to travel for services, as well as a lack of access to more specialized services. A number of self-reported barriers to service were also identified. These findings have several policy implications and will be useful to service planners. RESEARCH LIMITATIONS/IMPLICATIONS: Several questions for additional research were identified including the need to establish an inventory of service problem areas and investigating service and benefit policy and community awareness issues. ORIGINALITY/VALUE: This paper provides policy makers with knowledge on the rural Aboriginal population, a population that has faced long standing problems in accessing appropriate health services.

An exploratory study of binge drinking in the Aboriginal population.

There is little research available on binge drinking among the Aboriginal population. Between March and June 2004, 15 Aboriginal persons participated in a semi-structured interview related to their binge drinking behaviors. The majority of participants were women and described a family history of alcoholism and childhood abuse. Factors that contributed to a reduction in binge drinking were often related to an acute event combined with gradual life changes. Supporting influences to remain sober included positive social support networks, role models, personal development, and cultural/spiritual practices.