Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews

The Social Determinants of Refugee Mental Health in the Post-Migration Context: A Critical Review

With the global increase in the number of refugees and asylum seekers, mental health professionals have become more aware of the need to understand and respond to the mental health needs of forced migrants. This critical review summarizes the findings of recent systematic reviews and primary research on the impact of post-migration conditions on mental disorders and PTSD among refugees and asylum seekers. Historically, the focus of mental health research and interventions with these populations has been on the impact of pre-migration trauma. Pre-migration trauma does predict mental disorders and PTSD, but the post-migration context can be an equally powerful determinant of mental health. Moreover, post-migration factors may moderate the ability of refugees to recover from pre-migration trauma. The importance of post-migration stressors to refugee mental health suggests the need for therapeutic interventions with psychosocial elements that address the broader conditions of refugee and asylum seekers' lives. However, there are few studies of multimodal interventions with refugees, and even fewer with control conditions that allow for conclusions about their effectiveness. These findings are interpreted using a social determinants of health framework that connects the risk and protective factors in the material and social conditions of refugees' post-migration lives to broader social, economic and political factors.

A better start for health equity? Qualitative content analysis of implementation of extended postnatal home visiting in a disadvantaged area in Sweden

Background

Health inequities among children in Sweden persist despite the country’s well-developed welfare system and near universal access to the national child health care programme. A multisectoral extended home visiting intervention, based on the principles of proportionate universalism, has been carried out in a disadvantaged area since 2013. The present study investigates the content of the meetings between families and professionals during the home visits to gain a deeper understanding of how it relates to a health equity perspective on early childhood development.

Methods

Three child health care nurses documented 501 visits to the families of 98 children between 2013 and 2016. A qualitative data-driven conventional content analysis was performed on all data from the cycle of six visits per child, and a general content model was developed. Additional content analysis was carried out on the data from visits to families who experienced adverse situations or greater needs.

Results

The analysis revealed that the home visits covered three main categories of content related to the health, care and development of the child; the strengthening of roles and relations within the new family unit; and the influence and support located in the broader external context around the family. The model of categories and sub-categories proved stable over all six visits. Families with extra needs received continuous attention to their additional issues during the visits, as well as the standard content described in the content model.

Conclusions

This study on home visiting implementation indicates that the participating families received programme content which covered all the domains of nurturing care as recommended by the WHO Commission on Social Determinants of Health and recent research. The content of the home visits can be understood to create enabling conditions for health equity effects. The intervention can be seen to represent a practical example of proportionate universalism.

Australia's $40 per pack cigarette tax plans: the need to consider equity

In May 2016, the Australian Government announced that it would implement annual increases in tobacco excise of 12.5% up to and including 2020, raising the cost of a pack of cigarettes to $A40. This increase will lead to Australia having one of the highest prices of cigarettes in the world. Increasing the cost of tobacco is considered by public health experts to be one of the most effective strategies to reduce tobacco use, and is generally well supported by the public. However, tobacco tax increases differentially impact various subgroups of the population. Based on a review of existing literature, this paper examines some of the potential (unintended) consequences of the tax to individual and family income; illicit trade; social stigma and opportunities for lobbying by the tobacco industry. In light of these considerations, we offer strategies that might be used by policymakers to mitigate potential harms. While this paper focuses on the impacts primarily on populations in Australia, the consequences and strategies offered may be useful to other countries implementing tobacco excise increases.

Developing a Return to Work Intervention for Breast Cancer Survivors with the Intervention Mapping Protocol: Challenges and Opportunities of the Needs Assessment

Return to work (RTW) is an important step for breast cancer survivors (BCSs). However, they face many barriers that affect particularly women with low socioeconomic status (SES). Health care, workplace, and insurance actors lack knowledge and collaborate poorly. No intervention to date has proven effective to reduce social disparities in employment after breast cancer. The intervention mapping (IM) protocol is being used in France to develop, implement, and evaluate an intervention to facilitate and sustain RTW after breast cancer [FAciliter et Soutenir le retour au TRAvail après un Cancer du Sein (FASTRACS) project]. The research question of this study was to elicit the needs for RTW after breast cancer from various stakeholders' point of view. The aim of this study was to describe the process and the preliminary results of the needs assessment of the FASTRACS project. Different methods were followed to (a) establish and work with a planning group and (b) conduct a needs assessment to create a logic model of the problem. A planning group was organized to gather the stakeholders with the research team. A review of the literature and indicators was conducted to identify the magnitude of the problem and the factors influencing RTW. A qualitative inquiry was conducted with 12 focus groups and 48 individual semi-structured interviews to explore the needs and experience of the stakeholders. The results of these tasks were the proposition of a charter of partnership to structure the participative process, a review of the scientific evidence and indicators, and the description by the stakeholders of their needs and experience. Many stakeholders disagreed with the concept of "early intervention." They advocated for a better support of BCSs during their RTW, emphasized as a process. Anticipation, intersectoral collaboration, and workplace accommodation were mentioned to fit the needs of the BCS and their environment. A logic model of the problem was elaborated from these data. The ability of the model to consider specific characteristics of women with low SES is discussed, with a view to developing the FASTRACS intervention through the next steps of the IM protocol.

Influence of indoor work environments on health, safety, and human rights among migrant sex workers at the Guatemala-Mexico Border: a call for occupational health and safety interventions

BACKGROUND

Migrant women are over-represented in the sex industry, and migrant sex workers experience disproportionate health inequities, including those related to health access, HIV and sexually transmitted infections (STIs), and violence. Despite calls for occupational sex work interventions situated in labour rights frameworks, there remains a paucity of evidence pertaining to migrant sex workers' needs and realities, particularly within Mexico and Central America. This study investigated migrant sex workers' narratives regarding the ways in which structural features of work environments shape vulnerability and agency related to HIV/STI prevention and violence at the Guatemala-Mexico border.

METHODS

Drawing on theoretical perspectives on risk environments and structural determinants of HIV in sex work, we analyzed in-depth interviews, focus groups, and ethnographic fieldwork conducted with 39 migrant sex workers in indoor work environments between 2012 and 2015 in Tecún Umán, Guatemala.

RESULTS

Participant narratives revealed the following intersecting themes to be most closely linked to safety and agency to engage in HIV/STI prevention: physical features of indoor work environments (e.g., physical layout of venue, proximity to peers and third parties); social norms and practices for alcohol use within the workplace; the existence and nature of management practices and policies on health and safety practices; and economic influences relating to control over earnings and clients. Across work environments, health and safety were greatly shaped by human rights concerns stemming from workplace interactions with police, immigration authorities, and health authorities.

CONCLUSIONS

Physical isolation, establishment norms promoting alcohol use, restricted economic agency, and human rights violations related to sex work policies and immigration enforcement were found to exacerbate risks. However, some establishment policies and practices promoted 'enabling environments' for health and safety, supporting HIV/STI prevention, economic agency, and protection from violence and exploitation; these practices and policies were especially crucial for recent migrants. Policy reforms and structural workplace interventions tailored to migrant sex workers' needs are recommended to promote improved working conditions and migrant sex workers' health, safety, and human rights.

Prioritising action to accelerate gender equity and health for women and girls: Microdata analysis of 47 countries

The Sustainable Development Goals set ambitious targets for health. Meeting such will require drastic improvements in the social conditions for women and girls. Understanding which social conditions have the greatest impact on health can help prioritise action, yet there is little comparative data. We use microdata from 338,580 women in 47 low- and middle-income countries to estimate the relative contributions of improved social determinants in bringing about maternal and child health gains over the past 20 years. Regression analyses examine determinants related to education, work, health services, family, and violence; the potential health benefit that could be derived from improving conditions is calculated. Secondary education and child marriage emerge as the strongest and most consistent predictors of health. The largest impact is seen on adolescent births: we estimate that achieving universal completion of secondary schooling for young women could lower adolescent births by 18 percentage points; eliminating child marriages could lower adolescent births by 11 points. Intervening in these two areas could also bring about substantial reductions in the unmet need for family planning, past-year intimate partner violence, and child mortality. Thus, we suggest prioritising policies targeting secondary education and child marriage in order to accelerate gender equity and health.

The NIHR public health research programme: intervention approaches to tackle health inequalities

Background

The National Institute for Health Research (NIHR) Public Health Research (PHR) Programme evaluates interventions intended to improve the health of the public and reduce inequalities in health in the UK. The aim of the research was to establish how projects funded by the PHR Programme between 2009 and 2014 addressed health inequalities.

Methods

A health inequalities intervention framework developed by Bambra et al. was used to map PHR funded studies to a typology. The framework is based on interventions that are characterized by their level of action and their approach to tackling inequalities.

Results

A total of 57 primary research projects funded by the PHR Programme were categorized using the framework; 16 PHR research projects were classified as strengthening individuals, 24 strengthening communities, 15 improving living and school/work conditions and 2 promoting healthy macro policies. Eighteen were classified as targeted interventions whereas 39 were universal.

Conclusions

Mapping the interventions being evaluated by the PHR Programme to a typology differentiated health inequality interventions and illustrates how they are expected to have an impact. Emerging findings will contribute to the evidence base for addressing health inequalities to inform research and future commissioning of public health services.

Redressing or entrenching social and health inequities through policy implementation? Examining personalised budgets through the Australian National Disability Insurance Scheme

Background

Increasing attention is being given to political agenda setting for the social determinants of health. While designing policies that can improve the social determinants of health is critical, so too is ensuring these policies are appropriately administered and implemented. Many policies have the potential to entrench or even expand inequities during implementation. At present little attention has been given to this in the social determinants of health literature.

There is an international trend in the personalisation of funding for care services, from the National Health Service in the England to the Brukerstyrt Personlig Assistanse in Norway. Part of this trend is the Australian National Disability Insurance Scheme (NDIS). The NDIS has the potential to secure gains in health for hundreds of thousands of Australians living with a disability. However, policies are only as good as their implementation.

Methods

As part of a longitudinal study on the implementation of the Australian NDIS, we conducted a systematic document search of policy documents pertaining to the Scheme on the websites of government departments with auspice over the design and implementation of the scheme with the aim of examining issues of equity.

Results and discussion

Scheme architects have argued that the NDIS has the potential to replace a piecemeal and fragmented set of state-determined services with an empowering model of user choice and control. However, without careful attention to both existing inequities and, diversity and difference across populations (e.g. different disability types and different localities), market based approaches such as the NDIS have the serious potential to entrench or even widen inequities.

Conclusions

The research concluded that ‘personalisation’ approaches can widen inequities and inequalities unless careful consideration is given at both policy design and implementation stages.

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 .

Social and material aspects of life and their impact on the physical health of people diagnosed with mental illness

BACKGROUND

People diagnosed with mental illness have shorter lives and poorer physical health, compared to the general population. These health inequities are usually viewed at an individual and clinical level, yet there is little research on the views of mental health consumers on clinical factors in broader contexts.

OBJECTIVE

To elicit the views of consumers of mental health services regarding their physical health and experiences of accessing physical health-care services.

DESIGN

Qualitative exploratory design involving focus groups.

SETTING AND PARTICIPANTS

The research was conducted in the Australian Capital Territory. Participants were consumers of mental health services.

MAIN OUTCOME MEASURES

The Commission on Social Determinants of Health Framework was drawn on to lead deductive analysis of focus group interview transcripts.

RESULTS

Issues impacting consumers included poverty, the neglect of public services and being treated as second-class citizens because of diagnosis of mental illness and/or experiencing a psychosocial disability. These factors were connected with significant barriers in accessing physical health care, including the quality and relevance of health provider communication, especially when the broader contexts of mental health consumer's lives are not well understood.

DISCUSSION AND CONCLUSIONS

These findings suggest the Commission on Social Determinants of Health Framework could be utilized in research and policy, and may provide an effective platform for exploring better health communication with mental health consumers regarding this neglected health inequity.

Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors

Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.

How Economic Analysis Can Contribute to Understanding the Links between Housing and Health

An economic analysis of housing's linkages to health can assist policy makers and researchers to make better decisions about which housing interventions and policies are the most cost-beneficial. The challenge is to include cobenefits. The adoption in 2015 of the UN Sustainable Development Goals underscores the importance of understanding how policies interact, and the merit of comprehensively evaluating cobenefits. We explain our approach to the empirical assessment of such cobenefits in the housing and health context, and consider lessons from empirical economic appraisals of the impact of housing on health outcomes. Critical assumptions relating to cobenefits are explicitly examined. A key finding is that when wider policy outcome measures are included, such as mental health impacts and carbon emission reductions, it is important that effects of assumptions on outcomes are considered. Another is that differing values underlie appraisal, for example, the weight given to future generations through the discount rate. Cost-benefit analyses (CBAs) can better facilitate meaningful debate when they are based on explicit assumptions about values. In short, the insights drawn from an economic framework for housing-and-health studies are valuable, but nonetheless contingent. Given that housing interventions typically have both health and other cobenefits, and incorporate social value judgements, it is important to take a broad view but be explicit about how such interventions are assessed.

The effects of community pharmacy public health interventions on population health and health inequalities: a systematic review of reviews protocol

BACKGROUND

Community pharmacies have great potential to deliver services aimed at promoting health and preventing disease, and are embedded within communities. In the light of a rapid increase in community pharmacy-delivered public health services and an accompanying increase in the evidence base, this systematic review of reviews will synthesise systematic reviews of public health community pharmacy interventions and assess their effects on public health and health inequalities.

METHODS/DESIGN

Systematic review methodology will be used to identify all systematic reviews that describe the health and health equity effects of community pharmacy public health interventions. Twenty databases will be searched using a pre-determined search strategy to evaluate community pharmacy-delivered public health interventions. Findings from the included reviews will be pooled, and a narrative synthesis executed to identify overarching patterns and results.

DISCUSSION

Findings will support future decision-making around how community pharmacy public health services can be used alongside other strategies to promote health, prevent disease and reduce health inequalities.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42017056264 .

Unemployment and HIV mortality in the countries of the Organisation for Economic Co-operation and Development: 1981-2009

OBJECTIVES

To determine an association between unemployment rates and human immunodeficiency virus (HIV) mortality in the Organisation for Economic Co-operation and Development (OECD).

DESIGN

Multivariate regression analysis.

PARTICIPANTS

OECD member states.

SETTING

OECD.

MAIN OUTCOME MEASURES

World Health Organization HIV mortality.

RESULTS

Between 1981 and 2009, a 1% increase in unemployment was associated with an increase in HIV mortality in the OECD (coefficient for men 0.711, 0.334-1.089, p = 0.0003; coefficient for women 0.166, 0.071-0.260, p = 0.0007). Time lag analysis showed a significant increase in HIV mortality for up to two years after rises in unemployment: p = 0.0008 for men and p = 0.0030 for women in year 1, p = 0.0067 for men and p = 0.0403 for women in year 2.

CONCLUSIONS

Rises in unemployment are associated with increased HIV mortality. Economic fiscal policy may impact upon population health. Policy discussions should take into consideration potential health outcomes.

Taking stock of the social determinants of health: A scoping review

BACKGROUND

In recent decades, the social determinants of health (SDOH) has gained increasing prominence as a foundational concept for population and public health in academic literature and policy documents, internationally. However, alongside its widespread dissemination, and in light of multiple conceptual models, lists, and frameworks, some dilution and confusion is apparent. This scoping review represents an attempt to take stock of SDOH literature in the context of contemporary population and public health.

METHODS

We conducted a scoping review to synthesize and map SDOH literature, informed by the methods of Arksey and O'Malley (2005). We searched 5 academic and 3 grey literature databases for "social determinants of health" and "population health" or "public health" or "health promotion," published 2004-2014. We also conducted a search on "inequity" or "inequality" or "disparity" or "social gradient" and "Canad*" to ensure that we captured articles where this language was used to discuss the SDOH. We included articles that discussed SDOH in depth, either explicitly or in implicit but nuanced ways. We hand-searched reference lists to further identify relevant articles.

FINDINGS

Our synthesis of 108 articles showed wide variation by study setting, target audience, and geographic scope, with most articles published in an academic setting, by Canadian authors, for policy-maker audiences. SDOH were communicated by authors as a list, model, or story; each with strengths and weaknesses. Thematic analysis identified one theme: health equity as an overarching and binding concept to the SDOH. Health equity was understood in different ways with implications for action on the SDOH.

CONCLUSIONS

Among the vast SDOH literature, there is a need to identify and clearly articulate the essence and implications of the SDOH concept. We recommend that authors be intentional in their efforts to present and discuss SDOH to ensure that they speak to its foundational concept of health equity.

Can inequality be tamed through boundary work? A qualitative study of health promotion aimed at reducing health inequalities

This paper examines the organisational dynamics that arise in health promotion aimed at reducing health inequalities. The paper draws on ethnographic fieldwork among public health officers in Danish municipalities and qualitative interviews from an evaluation of health promotion programmes targeting homeless and other marginalised citizens. Analytically, we focus on 'boundary work', i.e. the ways in which social and symbolic boundaries are established, maintained, transgressed and negotiated, both at the administrative level and among frontline professionals. The paper discusses three types of boundary work: (i) demarcating professional domains; (ii) setting the boundaries of the task itself; and (iii) managing administrative boundaries. The main argument is that the production, maintenance and transgression of these three types of boundaries constitute central and time-consuming aspects of the practices of public health professionals, and that boundary work constitutes an important element in professional practices seeking to 'tame a wicked problem', such as social inequalities in health. A cross-cutting feature of the three types of boundary work is the management of the divide between health and social issues, which the professionals seemingly seek to uphold and transgress at the same time. The paper thus contributes to ongoing discussions of intersectoral action to address health inequalities. Furthermore, it extends the scope and application of the concept of boundary work in the sociology of public health by suggesting that the focus in previous research on professional demarcation be broadened in order to capture other types of boundaries that shape, and are shaped by, professional practices.

Conceptual Models of Social Determinants of Health: A Narrative Review

BACKGROUND

There are several conflicting conceptual models to explain social determinants of health (SDH) as responsible for most health inequalities. This study aimed to present these models in historical perspective and provide main component of SDH models as an SES indicators.

METHODS

This was a narrative study using international databases to retrieve literature dealing with conceptual models of SDH. All publication in English language until Mar 2015 was included. The CASP and PRISMA were used to summarize the literature.

RESULTS

Overall, 248 publications were retrieved and screened. After exclusion of irrelevant and duplicates, 94 citations were found to be relevant and 21 publications included in this review. In general, 21 models of SDH were found: some models presented before year 1995(n=4), some models presented between 1995 and 2005 (n=13) and some models presented after 2005 (n=4). However, we found three categories of indicators that contribute to SDH models and that were classic factors, fixed and demographic factors and proxy factors.

CONCLUSION

Reduction of socioeconomic inequalities in health requires understanding of mechanisms and causal pathways; therefore, every country needs to design the specific model. As the available models are for developed countries, lack of a specific model for developing ones is tangible. As there is no gold standard related to SES indicators, therefore, it is proposed to use the various indicators based on life course approach, which leads to understanding and adopting effective policy interventions.

Linking families with pre-school children from healthcare services to community resources: a systematic review protocol

BACKGROUND

Poor health and health inequalities persist despite increasing investment in health improvement programmes across high-income countries. Evidence suggests that to reduce health inequalities, a range of activities targeted at different levels within society and throughout the life course should be employed. There is a particular focus on addressing inequalities in early years as this may influence the experience of health in adulthood. To address the wider determinants of health at a community level, a key intervention which can be considered is supporting patients to access wider community resources. This can include processes such as signposting, referral and facilitation. There is a lack of evidence synthesis in relation to the most effective methods for linking individuals from health services to other services within communities, especially when considering interventions aimed at families with young children.

METHOD/DESIGN

The aim of this study is to understand the way health services can best help parents, carers and families with pre-school children to engage with local services, groups and agencies to address their wider health and social needs. The review may inform future guidance to support families to address wider determinants of health. The study is a systematic review, and papers will be identified from the following electronic databases: Web of Science, Embase, MEDLINE and CINAHL. A grey literature search will be conducted using an internet search engine and specific grey literature databases (TRiP, EThOS and Open Grey). Reference lists/bibliographies of selected papers will be searched. Quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the CASP tool for qualitative studies. Data will be synthesised in a narrative form and weighted by study quality.

DISCUSSION

It is important to understand how health services can facilitate access to wider services for their patients to address the wider determinants of health. This may impact on the experience of health inequalities. This review focuses on how this can be achieved for families with pre-school children, and the evidence obtained will be useful for informing future guidance on this topic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034066.

Building social capital to promote adolescent wellbeing: a qualitative study with teens in a Latino agricultural community

Background

Latino youth, particularly in rural settings, experience significant disparities in rates of teen pregnancy and violence. Few data are available regarding social and structural influences on Latino youth’s developmental trajectories, specifically on factors that promote wellbeing and protect them from engagement in high-risk sexual and violence-related behaviors.

Methods

Forty-two youth aged 13 to 19 years old were recruited from middle schools and youth leadership programs to participate in one of eight community-based focus groups in Salinas, a predominantly Latino, urban center in California’s rural central coast. Focus groups covered youths’ experiences with the risk and protective factors associated with exposure to violence and romantic relationships. Four researchers completed coding with a Grounded Theory approach, informed by the theoretical frameworks of the social ecological model and social capital. The study’s design and participant recruitment were informed by a community advisory board of local youth-serving organizations and health care providers.

Results

Participants described family lives rich in bonding social capital, with strong ties to parents and near-peer family members. They reported that while parents had a strong desire to promote healthful behaviors and social mobility, they often lacked the bridging or linking social capital required to help youth navigate structural systems, such as college applications and access to confidential health care. Youth also reported that some families link their children to negative social capital, such as exposure to gang affiliation.

Conclusion

Adolescents in this agricultural community identified robust sources of bonding social capital within their families. However, they identified limitations in their families’ capacities to link them to structural resources in education, employment, and health care that could support healthful behaviors and upward social mobility.

The impact of redistributing power to disadvantaged families in Hungary

Summary

The Commission on Social Determinants of Health (CSDH) formulated recommendations along which health inequalities can be successfully tackled anywhere in the world. The situation of the Roma minority in Europe provides countless opportunities for the translation of these guidelines into action that should be guided by coherent and evidence-based strategies integrating lessons learned in smaller-scale field projects. Our paper describes the long-term evaluation of a locally initiated housing project in Hungary carried out more than a decade after implementation, which highlights the salience of the CSDH's recommendations and critical factors for success and sustainability. The project provides evidence for the long-term positive impact on education of the social housing project implemented by an empowered community through delegating decision making to a board of representatives of the beneficiaries in all decisions, including financial ones. Educational level greatly improved, and all houses–inhabited by 17 out of 20 families who initially entered the project—remained in good condition, properly equipped and decorated after 13 years of implementation, in spite of an increase of unemployment during the same period which led to reduced income and deterioration of the families' economic situation. Better housing conditions for vulnerable people can be sustained and result in increased educational level if incremental improvement is aimed for and coupled with the redistribution of power at the local level.

Addressing health inequalities by using Structural Funds. A question of opportunities

Making up a third of the EU budget, Structural and Investment Funds can provide important opportunities for investing in policies that tackle inequalities in health. This article looks back and forward at the 2007-2013 and 2014-2020 financial periods in an attempt to inform the development of health equity as a strand of policy intervention under regional development. It combines evidence from health projects funded through Structural Funds and a document analyses that locates interventions for health equity under the new regulations. The map of opportunities has changed considerably since the last programming period, creating more visibility for vulnerable groups, social determinants of health and health systems sustainability. As the current programming period is progressing, this paper contributes to maximizing this potential but also identifying challenges and implementation gaps for prospective health system engagement in pursuing health equity as part of Structural Funds projects. The austerity measures and their impact on public spending, building political support for investments as well as the difficulties around pursuing health gains as an objective of other policy areas are some of the challenges to overcome. European Structural and Investment Funds could be a window of opportunity that triggers engagement for health equity if sectors adopt a transformative approach and overcome barriers, cooperate for common goals and make better use of the availability of these resources.

Rethinking the relationship between socio-economic status and health: Making the case for sociological theory in health inequality research

AIM

The aim of this study is to analyse previous explanations of social inequality in health and argue for a closer integration of sociological theory into future empirical research.

METHODS

We examine cultural-behavioural, materialist, psychosocial and life-course approaches, in addition to fundamental cause theory. Giddens' structuration theory and a neo-materialist approach, inspired by Bruno Latour, Gilles Deleuze and Felix Guattari, are proposed as ways of rethinking the causal relationship between socio-economic status and health.

CONCLUSIONS

Much of the empirical research on health inequalities has tended to rely on explanations with a static and unidirectional view of the association between socio-economic status and health, assuming a unidirectional causal relationship between largely static categories. We argue for the use of sociological theory to develop more dynamic models that enhance the understanding of the complex pathways and mechanisms linking social structures to health.

Sustainable Development Goals: an opportunity for health in Africa?

The purpose of this article is to examine to what extent the Sustainable Development Goals (SDGs) hold out new promises for health in Africa. Two significant shortcomings will have to be overcome. Application of a 'social determinants of health' approach is still woefully difficult in Africa due to the stronghold that international actors maintain over local governments. The persistence of a 'turnkey' concept of health policies is reflected in the coexistence of a disparate range of programmes and measures, often driven by the development partners. Thus the low level of institutional complementarities is a crucial issue in the effective implementation of the SDGs.

Ethnic Minorities with Diabetes Differ in Depressive and Anxiety Symptoms and Diabetes-Distress

Objective. To determine the association between ethnicity, diabetes-distress, and depressive and anxiety symptoms in adult outpatients with diabetes. Research Design and Methods. Diabetes-distress (Problem Areas in Diabetes Scale, PAID5), depressive and anxiety symptoms (Extended Kessler-10, EK10), and quality of life (Short-Form 12, SF12) were assessed in an ethnic diverse diabetes outpatient population of a teaching hospital in Amsterdam. Descent of one's parents and self-classified ethnicity were obtained to define ethnicity. HbA1c, clinical data, and socioeconomic status were derived from the medical charts. Based on established cut-offs for PAID5- and EK10-scores, emotional distress was dichotomized for the purpose of logistic regression analyses. Results. Of 1007 consecutive patients approached, 575 participated. Forty-nine percent were of non-Dutch ethnicity and 24.7% had type 1 diabetes. Diabetes-distress was reported by 12.5% of the native Dutch patients and by 22.0%, 34.5%, and 42.6% of the Surinamese, Turkish, and Moroccan patients, respectively. Prevalence of depressive symptoms was 9.4% in native Dutch patients and 20.4%, 34.5%, and 27.3% in the other groups mentioned. Diabetes-distress and Moroccan origin were significantly associated (OR = 3.60, p < .01) as well as depressive symptoms and Turkish origin (OR = 4.23, p = .04). Conclusions. Different ethnic minorities with diabetes vary in their vulnerability for emotional distress, warranting clinical attention. Future research should elucidate explanatory factors and opportunities for tailored interventions.

Community matrons as problem-solvers for people living with multi-co-morbid disease

Working with patients in their own homes gives community matrons an advantage of seeing patients in the context of their everyday lives. This allows comprehensive assessment of need with an aim of promoting health or promoting stability for people living with chronic disease. Complex issues are resolved through problem-solving and this can result in patients being maintained in their own homes and thus in reduced unplanned hospitalisation. Data were collected from participants using semi-structured interviews and audio diaries. The sample comprised professionals: CMs (n=21), managers (n=4), former commissioners (n=2) and GPs (n=3); and patients (n=10) and their family carers (n=5). In this article, data from community matrons is discussed. Community matrons often drew on the social determinants model of health to problem solve and to create meaningful strategies that work for patients in their care. Raising awareness of the high-level skills of community matrons and promoting appreciation of the importance of a social determinants model of health is important in explaining why nurses are such a crucial element of the primary health care workforce.

Consideration of health inequalities in systematic reviews: a mapping review of guidance

BACKGROUND

Given that we know that interventions shown to be effective in improving the health of a population may actually widen the health inequalities gap while others reduce it, it is imperative that all systematic reviewers consider how the findings of their reviews may impact (reduce or increase) on the health inequality gap. This study reviewed existing guidance on incorporating considerations of health inequalities in systematic reviews in order to examine the extent to which they can help reviewers to incorporate such issues.

METHODS

A mapping review was undertaken to identify guidance documents that purported to inform reviewers on whether and how to incorporate considerations of health inequalities. Searches were undertaken in Medline, CINAHL and The Cochrane Library Methodology Register. Review guidance manuals prepared by international organisations engaged in undertaking systematic reviews, and their associated websites were scanned. Studies were included if they provided an overview or discussed the development and testing of guidance for dealing with the incorporation of considerations of health inequalities in evidence synthesis. Results are summarised in narrative and tabular forms.

RESULTS

Twenty guidance documents published between 2009 and 2016 were included. Guidance has been produced to inform considerations of health inequalities at different stages of the systematic review process. The Campbell and Cochrane Equity Group have been instrumental in developing and promoting such guidance. Definitions of health inequalities and guidance differed across the included studies. All but one guidance document were transparent in their method of production. Formal methods of evaluation were reported for six guidance documents. Most of the guidance was operationalised in the form of examples taken from published systematic reviews. The number of guidance items to operationalise ranges from 3 up to 26 with a considerable overlap noted.

CONCLUSIONS

Adhering to the guidance will require more work for the reviewers. It requires a deeper understanding of how reviewers can operationalise the guidance taking into consideration the barriers and facilitators involved. This has implications not only for understanding the usefulness and burden of the guidance but also for the uptake of guidance and its ultimate goal of improving health inequalities considerations in systematic reviews.

What is policy and where do we look for it when we want to research it?

Public health researchers are increasingly concerned with achieving 'upstream' change to achieve reductions in the global burden of disease and health inequalities. Consequently, understanding policy and how to change it has become a central goal of public health. Yet conceptualisation of what constitutes policy and where it can be found is very limited within this field. Our glossary demonstrates that policy is many headed. It is located in a vast array of documents, discussions dialogues and actions which can be captured variously by formal and informal forms of documentation and observation. Effectively understanding policy and its relevance for public health requires an awareness of the full range of places and contexts in which policy work happens and policy documents are produced.

Gender differences in the impact of population-level alcohol policy interventions: evidence synthesis of systematic reviews

BACKGROUND AND AIMS

Consistent review-level evidence supports the effectiveness of population-level alcohol policies in reducing alcohol-related harms. Such policies interact with well-established social, cultural and biological differences in how men and women perceive, relate to and use alcohol, and with wider inequalities, in ways which may give rise to gender differences in policy effectiveness. This paper aimed to examine the extent to which gender-specific data and analyses were considered in, and are available from, systematic reviews of population-level alcohol policy interventions, and where possible, to conduct a narrative synthesis of relevant data.

METHODS

A prior systematic 'review of reviews' of population level alcohol interventions 2002-2012 was updated to May 2014, all gender-relevant data extracted, and the level and quality of gender reporting assessed. A narrative synthesis of extracted findings was conducted.

RESULTS

Sixty-three systematic reviews, covering ten policy areas, were included. Five reviews (8%) consistently provided information on baseline participation by gender for each individual study in the review and twenty-nine (46%) reported some gender-specific information on the impact of the policies under consideration. Specific findings include evidence of possible gender differences in the impact of and exposure to alcohol marketing, and a failure to consider potential unintended consequences and harm to others in most reviews.

CONCLUSIONS

Gender is poorly reported in systematic reviews of population-level interventions to reduce alcohol-related harm, hindering assessment of the intended and unintended effects of such policies on women and men.

Population-level interventions in government jurisdictions for dietary sodium reduction

BACKGROUND

Excess dietary sodium consumption is a risk factor for high blood pressure, stroke and cardiovascular disease. Currently, dietary sodium consumption in almost every country is too high. Excess sodium intake is associated with high blood pressure, which is common and costly and accounts for significant burden of disease. A large number of jurisdictions worldwide have implemented population-level dietary sodium reduction initiatives. No systematic review has examined the impact of these initiatives.

OBJECTIVES

• To assess the impact of population-level interventions for dietary sodium reduction in government jurisdictions worldwide.• To assess the differential impact of those initiatives by social and economic indicators.

SEARCH METHODS

We searched the following electronic databases from their start date to 5 January 2015: the Cochrane Central Register of Controlled Trials (CENTRAL); Cochrane Public Health Group Specialised Register; MEDLINE; MEDLINE In Process & Other Non-Indexed Citations; EMBASE; Effective Public Health Practice Project Database; Web of Science; Trials Register of Promoting Health Interventions (TRoPHI) databases; and Latin American Caribbean Health Sciences Literature (LILACS). We also searched grey literature, other national sources and references of included studies.This review was conducted in parallel with a comprehensive review of national sodium reduction efforts under way worldwide (Trieu 2015), through which we gained additional information directly from country contacts.We imposed no restrictions on language or publication status.

SELECTION CRITERIA

We included population-level initiatives (i.e. interventions that target whole populations, in this case, government jurisdictions, worldwide) for dietary sodium reduction, with at least one pre-intervention data point and at least one post-intervention data point of comparable jurisdiction. We included populations of all ages and the following types of study designs: cluster-randomised, controlled pre-post, interrupted time series and uncontrolled pre-post. We contacted study authors at different points in the review to ask for missing information.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data, and two review authors assessed risk of bias for each included initiative.We analysed the impact of initiatives by using estimates of sodium consumption from dietary surveys or urine samples. All estimates were converted to a common metric: salt intake in grams per day. We analysed impact by computing the mean change in salt intake (grams per day) from pre-intervention to post-intervention.

MAIN RESULTS

We reviewed a total of 881 full-text documents. From these, we identified 15 national initiatives, including more than 260,000 people, that met the inclusion criteria. None of the initiatives were provided in lower-middle-income or low-income countries. All initiatives except one used an uncontrolled pre-post study design.Because of high levels of study heterogeneity (I² > 90%), we focused on individual initiatives rather than on pooled results.Ten initiatives provided sufficient data for quantitative analysis of impact (64,798 participants). As required by the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) method, we graded the evidence as very low due to the risk of bias of the included studies, as well as variation in the direction and size of effect across the studies. Five of these showed mean decreases in average daily salt intake per person from pre-intervention to post-intervention, ranging from 1.15 grams/day less (Finland) to 0.35 grams/day less (Ireland). Two initiatives showed mean increase in salt intake from pre-intervention to post-intervention: Canada (1.66) and Switzerland (0.80 grams/day more per person. The remaining initiatives did not show a statistically significant mean change.Seven of the 10 initiatives were multi-component and incorporated intervention activities of a structural nature (e.g. food product reformulation, food procurement policy in specific settings). Of those seven initiatives, four showed a statistically significant mean decrease in salt intake from pre-intervention to post-intervention, ranging from Finland to Ireland (see above), and one showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention (Switzerland; see above).Nine initiatives permitted quantitative analysis of differential impact by sex (men and women separately). For women, three initiatives (China, Finland, France) showed a statistically significant mean decrease, four (Austria, Netherlands, Switzerland, United Kingdom) showed no significant change and two (Canada, United States) showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention. For men, five initiatives (Austria, China, Finland, France, United Kingdom) showed a statistically significant mean decrease, three (Netherlands, Switzerland, United States) showed no significant change and one (Canada) showed a statistically significant mean increase in salt intake from pre-intervention to post-intervention.Information was insufficient to indicate whether a differential change in mean salt intake occurred from pre-intervention to post-intervention by other axes of equity included in the PROGRESS framework (e.g. education, place of residence).We identified no adverse effects of these initiatives.The number of initiatives was insufficient to permit other subgroup analyses, including stratification by intervention type, economic status of country and duration (or start year) of the initiative.Many studies had methodological strengths, including large, nationally representative samples of the population and rigorous measurement of dietary sodium intake. However, all studies were scored as having high risk of bias, reflecting the observational nature of the research and the use of an uncontrolled study design. The quality of evidence for the main outcome was low. We could perform a sensitivity analysis only for impact.

AUTHORS' CONCLUSIONS

Population-level interventions in government jurisdictions for dietary sodium reduction have the potential to result in population-wide reductions in salt intake from pre-intervention to post-intervention, particularly if they are multi-component (more than one intervention activity) and incorporate intervention activities of a structural nature (e.g. food product reformulation), and particularly amongst men. Heterogeneity across studies was significant, reflecting different contexts (population and setting) and initiative characteristics. Implementation of future initiatives should embed more effective means of evaluation to help us better understand the variation in the effects.

Mapping public health research across the National Institute for Health Research 2006-2013

Background

Public health research is an important component of United Kingdom (UK) health research and strategic analysis of its breadth and balance is key to ensure value. The National Institute for Health Research (NIHR) is one of the main funders of health research in the UK and includes many research programmes and schools. This study reports on public health research funded by the NIHR between April 2006 and March 2013.

Methods

The NIHR research programmes and schools were asked for information about all research funded during the study period. Firstly, projects were classified as a public health research project according to inclusion and exclusion criteria. The public health research projects were further categorised according to the Public Health Outcomes Framework and the National Institute for Health and Care Excellence taxonomy.

Results

Approximately 3000 research projects were funded by the NIHR, of which about 900 were relevant to public health. This represents approximately one-third of the research portfolio. All NIHR research funding programmes and schools funded research related to public health. The most prevalent domain of the Public Health Outcomes Framework was ‘healthcare public health and preventing premature mortality’ and there were a large number of health planning and self-management projects. One-quarter of projects were concerned with mental health and behavioural conditions.

Conclusions

The NIHR is a significant funder of research relevant to public health. This analysis offers a snapshot of the breadth and balance of NIHR research, which forms a basis for discussion. This is important for the NIHR and other research funders as it shows areas that are better represented and opportunities to fill important gaps. Appropriate research priority setting is an integral part of a needs-led research agenda and adds value to research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3521-z) contains supplementary material, which is available to authorized users.

Mapping Environmental Inequalities Relevant for Health for Informing Urban Planning Interventions-A Case Study in the City of Dortmund, Germany

Spatial differences in urban environmental conditions contribute to health inequalities within cities. The purpose of the paper is to map environmental inequalities relevant for health in the City of Dortmund, Germany, in order to identify needs for planning interventions. We develop suitable indicators for mapping socioeconomically-driven environmental inequalities at the neighborhood level based on published scientific evidence and inputs from local stakeholders. Relationships between socioeconomic and environmental indicators at the level of 170 neighborhoods were analyzed continuously with Spearman rank correlation coefficients and categorically applying chi-squared tests. Reclassified socioeconomic and environmental indicators were then mapped at the neighborhood level in order to determine multiple environmental burdens and hotspots of environmental inequalities related to health. Results show that the majority of environmental indicators correlate significantly, leading to multiple environmental burdens in specific neighborhoods. Some of these neighborhoods also have significantly larger proportions of inhabitants of a lower socioeconomic position indicating hotspots of environmental inequalities. Suitable planning interventions mainly comprise transport planning and green space management. In the conclusions, we discuss how the analysis can be used to improve state of the art planning instruments, such as clean air action planning or noise reduction planning towards the consideration of the vulnerability of the population.

Implications for public health research of models and theories of disability: a scoping study and evidence synthesis

Background

Public health interventions that are effective in the general population are often assumed to apply to people with impairments. However, the evidence to support this is limited and hence there is a need for public health research to take a more explicit account of disability and the perspectives of people with impairments.

Objectives

(1) To examine the literature on theories and models of disability; (2) to assess whether or not, and how, intervention studies of effectiveness could incorporate more inclusive approaches that are consistent with these theories and models; and (3) to use the findings to draw out implications for improving evaluative study designs and evidence-based practice.

Review methods

The project is a scoping review of the literature. The first stage examines theories and models of disability and reflects on possible connections between theories of disability and public health paradigms. This discussion is used to develop an ethical–empirical decision aid/checklist, informed by a human rights approach to disability and ecological approaches to public health. We apply this decision aid in the second stage of the review to evaluate the extent to which the 30 generic public health reviews of interventions and the 30 disability-specific public health interventions include the diverse experiences of disability. Five deliberation panels were also organised to further refine the decision aid: one with health-care professionals and four with politically and socially active disabled people.

Results

The evidence from the review indicated that there has been limited public health engagement with theories and models of disability. Outcome measures were often insensitive to the experiences of disability. Even when disabled people were included, studies rarely engaged with their experiences in any meaningful way. More inclusive research should reflect how people live and ‘flourish’ with disability.

Limitations

The scoping review provides a broad appraisal of a particular field. It generates ideas for future practice rather than a definite framework for action.

Conclusions

Our ethical–empirical decision aid offers a critical framework with which to evaluate current research practice. It also offers a resource for promoting more ethical and evidence-based public health research that is methodologically robust while being sensitive to the experiences of disability.

Future work

Developing more inclusive research and interventions that avoid conceptualising disability as either a ‘burden’ or ‘problem’ is an important starting point. This includes exploring ways of refining and validating current common outcome measures to ensure that they capture a diverse range of disabling experiences, as well as generating evidence on meaningful ways of engaging a broad range of disabled children and adults in the research process.

Funding

The National Institute for Health Research Public Health Research programme.

Addressing social determinants of health inequities through settings: a rapid review

Changing settings to be more supportive of health and healthy choices is an optimum way to improve population health and health equity. This article uses the World Health Organisation's (1998) (WHO Health Promotion Glossary. WHO Collaborating Centre for Health Promotion, Department of Public Health and Community Medicine, University of Sydney, NSW) definition of settings approaches to health promotion as those focused on modifying settings' structure and nature. A rapid literature review was undertaken in the period June-August 2014, combining a systematically conducted search of two major databases with targeted searches. The review focused on identifying what works in settings approaches to address the social determinants of health inequities, using Fair Foundations: the VicHealth framework for health equity. This depicts the social determinants of health inequities as three layers of influence, and entry points for action to promote health equity. The evidence review identified work in 12 settings (cities; communities and neighbourhoods; educational; healthcare; online; faith-based; sports; workplaces; prisons; and nightlife, green and temporary settings), and work at the socioeconomic, political and cultural context layer of the Fair Foundations framework (governance, legislation, regulation and policy). It located a relatively small amount of evidence that settings themselves are being changed in ways which address the social determinants of health inequities. Rather, many initiatives focus on individual behaviour change within settings. There is considerable potential for health promotion professionals to focus settings work more upstream and so replace or integrate individual approaches with those addressing daily living conditions and higher level structures, and a significant need for programmes to be evaluated for differential equity impacts and published to provide a more solid evidence base.

Complex health care interventions: Characteristics relevant for ethical analysis in health technology assessment

Complexity entails methodological challenges in assessing health care interventions. In order to address these challenges, a series of characteristics of complexity have been identified in the Health Technology Assessment (HTA) literature. These characteristics are primarily identified and developed to facilitate effectiveness, safety, and cost-effectiveness analysis. However, ethics is also a constitutive part of HTA, and it is not given that the conceptions of complexity that appears relevant for effectiveness, safety, and cost-effectiveness analysis are also relevant and directly applicable for ethical analysis in HTA. The objective of this article is therefore to identify and elaborate a set of key characteristics of complex health care interventions relevant for addressing ethical aspects in HTA. We start by investigating the relevance of the characteristics of complex interventions, as defined in the HTA literature. Most aspects of complexity found to be important when assessing effectiveness, safety, and efficiency turn out also to be relevant when assessing ethical issues of a given health technology. However, the importance and relevance of the complexity characteristics may differ when addressing ethical issues rather than effectiveness. Moreover, the moral challenges of a health care intervention may themselves contribute to the complexity. After identifying and analysing existing conceptions of complexity, we synthesise a set of five key characteristics of complexity for addressing ethical aspects in HTA: 1) multiple and changing perspectives, 2) indeterminate phenomena, 3) uncertain causality, 4) unpredictable outcome, and 5) ethical complexity. This may serve as an analytic tool in addressing ethical issues in HTA of complex interventions.

Housing Satisfaction in Finland with Regard to Area, Dwelling Type and Tenure Status

AIM

This study presents a comprehensive examination of housing satisfaction in Finland and how it associates with different types of residential area, dwelling and tenure status taking into account socio-demographic and socioeconomic variables.

METHODS

Associations between housing satisfaction and types of residential area, dwelling and tenure status were analysed by multivariate logistic regression using questionnaire data from a random sample of Finnish households (response rate 44%, N=1,308).

RESULTS

Respondents from rural areas and those living in houses were statistically significantly (p<0.05) more satisfied with indoor thermal conditions in summer than respondents living in city centres (OR 2.01) and apartments (OR 1.75), respectively. Homeowners were more satisfied with the dwelling (OR 3.19), indoor air quality (OR 1.73) and thermal conditions in winter (OR 2.63), and reported moisture or mould damage (OR 0.37) and neighbour noise disturbance (OR 0.60) less frequently than tenants.

CONCLUSION

Based on this study, the most important factors determining differences in housing satisfaction were tenure status and type of the dwelling. In the context of housing policy development, these results warrant a special consideration of housing quality in rental apartments. The results can also be used for making comparative assessments (e.g. detecting areas of relative strengths or needing improvement) of multifamily buildings and residential areas.

The effects of public health policies on population health and health inequalities in European welfare states: protocol for an umbrella review

BACKGROUND

The welfare state is potentially an important macro-level determinant of health that also moderates the extent, and impact, of socio-economic inequalities in exposure to the social determinants of health. The welfare state has three main policy domains: health care, social policy (e.g. social transfers and education) and public health policy. This is the protocol for an umbrella review to examine the latter; its aim is to assess how European welfare states influence the social determinants of health inequalities institutionally through public health policies.

METHODS/DESIGN

A systematic review methodology will be used to identify systematic reviews from high-income countries (including additional EU-28 members) that describe the health and health equity effects of upstream public health interventions. Interventions will focus on primary and secondary prevention policies including fiscal measures, regulation, education, preventative treatment and screening across ten public health domains (tobacco; alcohol; food and nutrition; reproductive health services; the control of infectious diseases; screening; mental health; road traffic injuries; air, land and water pollution; and workplace regulations). Twenty databases will be searched using a pre-determined search strategy to evaluate population-level public health interventions.

DISCUSSION

Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects of welfare states on population health and health inequalities. The review will document contextual information on how population-level public health interventions are organised, implemented and delivered. This information can be used to identify effective interventions that could be implemented to reduce health inequalities between and within European countries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016025283.

[Same words, different meanings: How epidemiological terminology struggles with population health intervention research]

Public health research differs from clinical epidemiological research in that its focus is primarily on the population level social and structural determinants of individual health and the interventions that might ameliorate them, rather than having a primary focus on individual-level risks. It is typically concerned with the proximal and distal causes of health problems, and their location within complex systems, more than with single exposures. Thus, epidemiological terms and concepts may have very different implications when used in the context of population health. This paper considers some key differences in relation to terms like 'population', 'baseline', 'control group' 'outcome' and 'adverse effects'. Even the concept of an 'intervention' often needs careful handling. The paper concludes that there is a need for an expanded, and more realistic use of these terms in the population health intervention research context.

Desperately seeking reductions in health inequalities: perspectives of UK researchers on past, present and future directions in health inequalities research

Following government commitments to reducing health inequalities from 1997 onwards, the UK has been recognised as a global leader in health inequalities research and policy. Yet health inequalities have continued to widen by most measures, prompting calls for new research agendas and advocacy to facilitate greater public support for the upstream policies that evidence suggests are required. However, there is currently no agreement as to what new research might involve or precisely what public health egalitarians ought to be advocating. This article presents an analysis of discussions among 52 researchers to consider the feasibility that research-informed advocacy around particular solutions to health inequalities may emerge in the UK. The data indicate there is a consensus that more should be been done to learn from post-1997 efforts to reduce health inequalities, and an obvious desire to provide clearer policy guidance in future.However, discussions as to where researchers should now focus their efforts and with whom researchers ought to be engaging reveal three distinct ways of approaching health inequalities, each of which has its own epistemological foundations. Such differences imply that a consensus on reducing health inequalities is unlikely to materialise. Instead, progress seems most likely if all three approaches are simultaneously enabled.

Low level of attention to health inequalities in prevention planning activities of the Italian Regions

Background

Health promotion and prevention activities should tackle health inequalities to reduce disparities in health among disadvantaged populations. This study aimed to assess the extent to which the Italian Regions considered health inequalities during the planning of prevention activities, to detect geographical differences and to identify the possible determinants of differences in attention to health inequalities.

Methods

The 19 Regional Prevention Plans (RPPs) developed by Italian Regions within the National Prevention Plan (NPP) 2010–2013 were assessed using a specific tool to address the level of attention to health inequalities. Univariate and multivariate analyses were performed to identify regional characteristics associated with a higher level of attention to health inequalities.

Results

Of the 702 projects included in the 19 RPPs, only 56 (8.0 %) specifically addressed issues related to health inequalities. The results of the multivariate analysis showed that a higher level of attention was associated with the macroarea of intervention ‘prevention in high-risk groups’, with the higher quality of the Strategic Plan Section of the RPP and with the higher percentage of migrants in the Region in 2010. Moreover, projects that addressed the topic of health inequalities were more likely to be developed in the Northern Regions, in Regions with a lower level of ‘linking social capital’ and with a Higher Regional Health Care Expenditure (RHCE) as a percentage of Regional Gross Domestic Product (RGDP) in 2010.

Conclusions

The level of attention to health inequalities in the regional planning process of prevention activities 2010–2013 in Italy is low. The results of this study supported the new round of prevention planning in Italy, and highlight the urgent need to increase the number of policies and interventions able to reduce health inequalities.

Mental health outcomes in times of economic recession: a systematic literature review

Background

Countries in recession experience high unemployment rates and a decline in living conditions, which, it has been suggested, negatively influences their populations’ health. The present review examines the recent evidence of the possible association between economic recessions and mental health outcomes.

Methods

Literature review of records identified through Medline, PsycINFO, SciELO, and EBSCO Host. Only original research papers, published between 2004 and 2014, peer-reviewed, non-qualitative research, and reporting on associations between economic factors and proxies of mental health were considered.

Results

One-hundred-one papers met the inclusion criteria. The evidence was consistent that economic recessions and mediators such as unemployment, income decline, and unmanageable debts are significantly associated with poor mental wellbeing, increased rates of common mental disorders, substance-related disorders, and suicidal behaviours.

Conclusion

On the basis of a thorough analysis of the selected investigations, we conclude that periods of economic recession are possibly associated with a higher prevalence of mental health problems, including common mental disorders, substance disorders, and ultimately suicidal behaviour. Most of the research is based on cross-sectional studies, which seriously limits causality inferences. Conclusions are summarised, taking into account international policy recommendations concerning the cost-effective measures that can possibly reduce the occurrence of negative mental health outcomes in populations during periods of economic recession.

Proportionate universalism in practice? A quasi-experimental study (GoWell) of a UK neighbourhood renewal programme's impact on health inequalities

Recommendations to reduce health inequalities frequently emphasise improvements to socio-environmental determinants of health. Proponents of 'proportionate universalism' argue that such improvements should be allocated proportionally to population need. We tested whether city-wide investment in urban renewal in Glasgow (UK) was allocated to 'need' and whether this reduced health inequalities. We identified a longitudinal cohort (n = 1006) through data linkage across surveys conducted in 2006 and 2011 in 14 differentially disadvantaged neighbourhoods. Each neighbourhood received renewal investment during that time, allocated on the basis of housing need. We grouped neighbourhoods into those receiving 'higher', 'medium' or 'lower' levels of investment. We compared residents' self-reported physical and mental health between these three groups over time using the SF-12 version 2 instrument. Multiple linear regression adjusted for baseline gender, age, education, household structure, housing tenure, building type, country of birth and clustering. Areas receiving higher investment tended to be most disadvantaged in terms of baseline health, income deprivation and markers of social disadvantage. After five years, mean mental health scores improved in 'higher investment' areas relative to 'lower investment' areas (b = 4.26; 95% CI = 0.29, 8.22; P = 0.036). Similarly, mean physical health scores declined less in high investment compared to low investment areas (b = 3.86; 95% CI = 1.96, 5.76; P < 0.001). Relative improvements for medium investment (compared to lower investment) areas were not statistically significant. Findings suggest that investment in housing-led renewal was allocated according to population need and this led to modest reductions in area-based inequalities in health after five years. Study limitations include a risk of selection bias. This study demonstrates how non-health interventions can, and we believe should, be evaluated to better understand if and how health inequalities can be reduced through strategies of allocating investment in social determinants of health according to need.

Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews

OBJECTIVE

To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care.

DESIGN

Systematic review of reviews.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion.

DATA SYNTHESIS

Extracted data were synthesised using a narrative approach.

RESULTS

91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality.

CONCLUSIONS

There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies.

PROSPERO REGISTRATION NUMBER

CRD42014009410.