Bridging the gap between knowledge and action on the societal determinants of cardiovascular disease: how one Canadian community effort hit – and hurdled – the lifestyle wall

Community coalition-driven interventions to reduce health disparities among racial and ethnic minority populations

BACKGROUND

Racial and ethnic disparities in health status are pervasive at all stages of the life cycle. One approach to reducing health disparities involves mobilizing community coalitions that include representatives of target populations to plan and implement interventions for community level change. A systematic examination of coalition-led interventions is needed to inform decision making about the use of community coalition models.

OBJECTIVES

To assess effects of community coalition-driven interventions in improving health status or reducing health disparities among racial and ethnic minority populations.

SEARCH METHODS

We searched MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index, Dissertation Abstracts, System for Information on Grey Literature in Europe (SIGLE) (from January 1990 through September 30, 2013), and Global Health Library (from January 1990 through March 31, 2014).

SELECTION CRITERIA

Cluster-randomized controlled trials, randomized controlled trials, quasi-experimental designs, controlled before-after studies, interrupted time series studies, and prospective controlled cohort studies. Only studies of community coalitions with at least one racial or ethnic minority group representing the target population and at least two community public or private organizations are included. Major outcomes of interest are direct measures of health status, as well as lifestyle factors when evidence indicates that these have an effect on the direct measures performed.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each study.

MAIN RESULTS

Fifty-eight community coalition-driven intervention studies were included. No study was considered to be at low risk of bias. Behavioral change outcomes and health status change outcomes were analyzed separately. Outcomes are grouped by intervention type. Pooled effects across intervention types are not presented because the diverse community coalition-led intervention studies did not examine the same constructs or relationships, and they used dissimilar methodological designs. Broad-scale community system level change strategies led to little or no difference in measures of health behavior or health status (very low-certainty evidence). Broad health and social care system level strategies leds to small beneficial changes in measures of health behavior or health status in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions led to beneficial changes in health behavior measures of moderate magnitude in large samples of community residents (very low-certainty evidence). Lay community health outreach worker interventions may lead to beneficial changes in health status measures in large samples of community residents; however, results were not consistent across studies (low-certainty evidence). Group-based health education led by professional staff resulted in moderate improvement in measures of health behavior (very low-certainty evidence) or health status (low-certainty evidence). Adverse outcomes of community coalition-led interventions were not reported.

AUTHORS' CONCLUSIONS

Coalition-led interventions are characterized by connection of multi-sectoral networks of health and human service providers with ethnic and racial minority communities. These interventions benefit a diverse range of individual health outcomes and behaviors, as well as health and social care delivery systems. Evidence in this review shows that interventions led by community coalitions may connect health and human service providers with ethnic and racial minority communities in ways that benefit individual health outcomes and behaviors, as well as care delivery systems. However, because information on characteristics of the coalitions themselves is insufficient, evidence does not provide an explanation for the underlying mechanisms of beneficial effects. Thus, a definitive answer as to whether a coalition-led intervention adds extra value to the types of community engagement intervention strategies described in this review remains unattainable.

Wellness 101: health education for the university student

Purpose

This paper aims to describe two phases of a mixed‐method study: in phase I, the wellness practices of students at a Canadian university are reported. These data informed the re‐development of a first‐year health education course. Subsequent to its revision, phase II of the study assessed the impact of the course on students' wellness practices and learnings.

Design/methodology/approach

In phase I, 855 students completed a survey rating ten wellness practices relating to themselves. Survey results were explored further in focus groups with 60 students. In phase II, a pre‐ and post‐design assessed the impact of the health education curriculum. Wellness practices were surveyed, at the beginning and end of term, and content analysis was conducted on students' assignments.

Findings

In phase I, the mean overall wellness score was 779.7 out of 1,000 or “good”. Students scored highest in sexuality and safety, and lowest in physical activity and nutrition. Qualitative analyses revealed four primary themes important to students' wellness: being or holistic health; belonging or feeling connected to others and the campus; becoming or studying to achieve a professional or scholarly degree; and balance – or the search for stability. In phase II, significant changes were found for seven wellness scores when comparing the beginning and end of semester. Analysis of course assignments found that students left the course with enhanced affect and knowledge levels.

Originality/value

The results support the argument that a health education curriculum, responsive to students' identified needs, and in conjunction with a healthy campus environment, promises to enhance student wellness.

Unmet healthcare need, gender, and health inequalities in Canada

Unmet healthcare need should be rare in nations with a universally accessible publicly funded healthcare system such as Canada. This however is not the case. This study examines the extent to which predictors of such need are consistent with various paradigmatic approaches (e.g., structural-critical, social capital, social support, and lifestyle) that consider such issues. Analyses of data from a probability sample of 2536 urban residents in British Columbia specified the relationship of unmet need with socioeconomic issues such as income, gender, and housing tenure, community issues such as social networks and social support, and traditional lifestyle or behavioural risk factors. The structural-critical model concerned with socio-demographics provided the most parsimonious explanation for having an unmet healthcare need. Consistent with a structural-critical approach, gender was found to be a reliable predictor of having an unmet health need in each of the models tested. Increasing federal transfers to healthcare and providing childcare and other community supports that are of special value for women may help to reduce unmet healthcare need.

The health buck stops where? Thematic framing of health discourse to understand the context for CVD prevention

Using a constructed week methodology, we analyzed media summaries for the type of health discourse (health care delivery, disease-specific prevention, lifestyle risk factors, public/environmental health disease, social determinants of health) portrayed over a 5-year period as a means of describing the context within which health staff worked to prevent heart disease in one Canadian province. The results reveal that heart disease received very little media coverage, despite provincial health data revealing it to be the leading cause of mortality, morbidity, and health care costs. Coverage of the health care system dominated the media landscape over the 5-year period. The study findings also suggest that the health discourses in the media summaries were represented as primarily thematic, rather than as episodic narratives, relieving any one level of government as entirely responsible for the health of its constituents. Media advocacy strategies may be a means to redress the imbalance of health discourses presented by the media.

Angina and socio-economic status in Ontario: how do characteristics of the county you live in influence your chance of developing heart disease?

OBJECTIVE

To assist in the development of community heart health programming and policy development, the Central West Health Planning Information Network (CWHPIN) was asked by its partners to collaborate in obtaining information that might clarify the relationships between socio-economic status (SES) and heart disease among residents of Ontario, Canada. The purpose of this component of the project was to explore, at the county level, how much of the variation in angina pectoris (angina) could be explained by SES variables.

STUDY DESIGN

Linear regression modeling was used to identify key predictors of angina hospitalization rates in counties Ontario-wide.

RESULTS

Results of the linear regression modeling showed that SES variables (most notably education and occupation) were key predictors of angina, even when traditional risk factors (i.e., smoking, etc.) were included in the analysis.

CONCLUSION

This study demonstrates that, at the county level, socio-economic variables such as education and occupation have a significant relationship with rates of heart disease at the population level, even when including the traditional risk factors in the analysis.