Implementing 'Closing the Gap' policy through mainstream service provision: A South Australian case study.

ISSUE ADDRESSED: The Australian government's 'Closing the Gap' (CTG) strategy has been implemented via multiple strategies. We examined CTG policy in early childhood within Southern Adelaide during the first decade of implementation (2008-2018) and critiqued the complexity and challenges of policy that is designed to promote health and well-being of Aboriginal and Torres Strait Islander children but lacked Aboriginal control. METHODS: A qualitative case study was conducted in Southern Adelaide, and we interviewed 16 policy actors from health and early childhood education sectors. Thematic analysis revealed key themes to show how policy had been implemented through mainstream structures. RESULTS: The rapid roll out of the CTG strategy, the limitations of short-term funding, cuts to Aboriginal health services, tokenistic consultation, and the mainstreaming of service provision were key features of policy implementation. The influence of Aboriginal leaders varied across implementation contexts. Participants advocated for services in health and education that are culturally safe to improve health of children, families, and communities. CONCLUSIONS: The implementation of the CTG strategy in Southern Adelaide was rushed, complex, and lacking Aboriginal control. This contributed to the marginalisation of Aboriginal leaders, and disengagement of families and communities. A more collaborative and Aboriginal led process for policy implementation is essential to reform policy implementation and address health inequity. SO WHAT?: Findings from this study suggest that policy has continued to be implemented I ways that reflect colonial power imbalances. Alternative processes that promote the recognition of Indigenous rights must be considered if we are to achieve the targets set within the CTG strategy.

"Listen with your ears and eyes and heart and your minds and your soul": Implications for decolonising consultation and occupational therapy from case studies on "Closing the Gap" policy implementation.

BACKGROUND: Including Aboriginal and Torres Strait Islander people and communities through consultation has been a key feature of policy implementation throughout the Australian Government's "Closing the Gap" (CTG) strategy. However, consultation often reinforces power imbalances between government and local community and can undervalue or marginalise Indigenous knowledge and leadership. Occupational therapy has a short history of examining colonial power structures within the profession, but there has been limited progress to decolonise consultation and practice. METHODS: Drawing on decolonising research methodology and positioned at the interface of knowledge, comparative case studies were used to understand policy implementation in two regions. In Shepparton, Victoria, CTG policy was implemented predominately through an Aboriginal Community Controlled Health Organisation, and in Southern Adelaide, South Australia, CTG policy was implemented through mainstream state government and non-government providers in the absence of a local Aboriginal-controlled organisation. Findings were examined critically to identify implications for occupational therapy. RESULTS: Our case studies showed that policy stakeholders perceived consultation to be tokenistic and partnerships were viewed differently by Aboriginal and non-Indigenous participants. Participants identified the need to move beyond a rhetoric of "working with" Aboriginal and Torres Strait Islander people, to promote Aboriginal leadership and really listen to community so that policy can respond to local need. The findings of this research show that Aboriginal-controlled services are best positioned to conduct and respond to community consultation. CONCLUSION: A decolonising approach to consultation would shift the status quo in policy implementation in ways that realign power away from colonial structures towards collaboration with Indigenous leadership and the promotion of Aboriginal-controlled services. There are lessons for occupational therapy from this research on policy implementation on authentic, decolonised consultation as a key feature of policy implementation. Shifting power imbalances through prioritising Indigenous leadership and honouring what is shared can drive change in CTG policy implementation processes and outcomes.

Assessing the health impacts of transnational corporations: a case study of Carlton and United Breweries in Australia.

BACKGROUND: The practices of transnational corporations (TNCs) affect population health through unhealthy products, shaping social determinants of health, or influencing the regulatory structures governing their activities. There has been limited research on community exposures to TNC policies and practices. The aim of this paper was to adapt existing Health Impact Assessment methods that were previously used for both a fast food and an extractives industry corporation in order to assess Carlton and United Breweries (CUB) operations within Australia. CUB is an Australian alcohol company owned by a large transnational corporation Asahi Group Holdings. Data identifying potential impacts were sourced through document analysis, including corporate literature; media analysis, and 12 semi-structured interviews. The data were mapped against a corporate health impact assessment framework which included CUB's political and business practices; products and marketing; workforce, social, environmental and economic conditions; and consumers' adverse health impacts. We also conducted an ecological study for estimating alcohol attributable fractions and burdens of death due to congestive heart disease, diabetes mellitus, stroke, breast cancer, bowel cancer and injury in Australia. Beer attributable fractions and deaths and CUB's share were also estimated. RESULTS: We found both positive and adverse findings of the corporation's operations across all domains. CUB engage in a range of business practices which benefit the community, including sustainability goals and corporate philanthropy, but also negative aspects including from taxation arrangements, marketing practices, and political donations and lobbying which are enabled by a neoliberal regulatory environment. We found adverse health impacts including from fetal alcohol spectrum disorder and violence and aggression which disproportionately affect Indigenous and other disadvantaged populations. CONCLUSION: Our research indicates that studying a TNC in a rapidly changing global financialised capitalist economy in a world which is increasingly being managed by TNCs poses methodological and conceptual challenges. It highlights the need and opportunity for future research. The different methods revealed sufficient information to recognise that strong regulatory frameworks are needed to help to avoid or to mediate negative health impacts.

Reviving health promotion in South Australia: The role of ideas, actors and institutional forces.

Globally health promotion has remained marginalized while biomedical health systems have maintained and even increased their dominance. During 2019-2021 we drew on the local and historical knowledge of actors from multiple sectors through semi-structured interviews and focus groups, to assess the implications of the withdrawal of the state from health promotion in a suburban region of South Australia. Institutional theory enabled in-depth analysis of the ideas, actors, and institutional forces at play in the institutional field, and how these elements come together to maintain the dominance of medicine. We found that the ideas, actors and institutional forces supporting health promotion in the study region have weakened and fragmented. This has happened as biomedicine has increased its dominance in the region's health system, mirroring international trends. The results point to a withdrawal of state and federal governments from health promotion, which has led to severe gaps in leadership and governance, and locally, to a decline in capacity and resources. The state health department reallocated resources to focus on individual behavioural change rather than more structural factors affecting health. While some activities aimed at the social determinants of health or community development strategies remained, these had minimal institutional support. The establishment of a state government wellbeing agency in 2020 prompted an exploration to determine whether the agency and the international wellbeing movement presents an opportunity for a revival of more comprehensive health promotion.

Health promotion has a rich history in South Australia. However, since government withdrew funding and institutional support, health promotion has become increasingly fragmented, unco-ordinated and targeted towards individual behaviour change activities. Analysis of the role of ideas, actors, and institutional forces, such as government policies, found that biomedical approaches to health and health care increasingly dominate the health system and health policy environment in the state and Australia wide. The establishment of a state government wellbeing agency in 2020 prompted optimism from participants that the government may once again take a leadership role in reviving health promotion and prevention strategies.

Conducting a rapid health promotion audit in suburban Adelaide, South Australia: Can it contribute to revitalising health promotion?

ISSUES ADDRESSED: How health promotion is implemented varies and it is often not clear what activities are in place in a region. Understanding the extent of health promotion activities helps planning activities. METHODS: This research involved a rapid audit of the types of health promotion activities in a suburban region of South Australia. This analysis was guided by the WHO Ottawa Charter's principles. To better understand population needs and which health promoting activities may help, an epidemiological, demographic and social determinants of health profile of southern Adelaide described disease patterns and health inequities. RESULTS: While there was evidence of a range of health promoting activities, most concerned individual or behavioural services. A key finding was the small number of activities that the state health department and local health system were responsible for. Alongside local government, NGOs provided the bulk of health promotion activities. In addition, there were no overarching health promotion strategies or coordinating bodies to evaluate the activities. The epidemiological, demographic and social determinants of health profile found persistent health and social inequities. CONCLUSION: This rapid audit of health promotion in a region enabled a quick assessment of the current health promotion situation and provided evidence of gaps and areas where policy change should be advocated. SO WHAT?: The key findings distilled from this research were designed to inform policy priorities to shift health promotion in southern Adelaide onto a trajectory consistent with the Ottawa Charter and prevent further focus on individualised behaviour change strategies known as 'lifestyle drift'.

Exploring access to, use of and benefits from population-oriented digital health services in Australia.

The provision of population-oriented, on-demand digital health services in many countries exemplifies the perceived utility of digital health services in supporting population health. Yet, limited knowledge exists regarding the equity of these services. Using mixed-method research, we recruited users of a health website and general practice patients to surveys (n = 441) and telephone interviews (n = 40). We contribute specific evidence investigating barriers to access, use and benefit from digital health services within an equity framework that incorporates social determinant factors, eHealth Literacy and trust. Our research highlights the foundational role of trust in predicting use, showcases which groups are unlikely to benefit from population-oriented digital health services, and proposes strategies to enhance the equity of these services. The theoretical framework we developed serves as a roadmap for future health promotion research and action by outlining the complex and interrelated pathways that can promote and threaten digital health equity.

Australian policies on water management and climate change: are they supporting the sustainable development goals and improved health and well-being?

BACKGROUND: Sustainable management of the natural environment is essential. Continued environmental degradation will lead to worsened health outcomes in countries and across generations. The Sustainable Development Goals (SDGs) provide a framework for viewing the preservation of natural environments and the promotion of health, well-being and health equity as interconnected pursuits. Within the SDG framework the goals of promoting environmental sustainability and human health are unified through attention to the social determinants of health and health equity (SDH/HE). This paper presents findings from a document analysis of all Australian environment sector policies and selected legislation to examine whether and how current approaches support progress toward achieving SDG goals on water, climate change, and marine ecosystems (Goals 6, 13 and 14), and to consider implications for health and health equity. RESULTS: Consideration of a broad range of SDH/HE was evident in the analysed documents. Related collaborations between environment and health sectors were identified, but the bulk of proposed actions on SDH/HE were initiated by the environment sector as part of its core business. Strengths of Australian policy in regard to SDGs 6, 13 and 14 are reflected in recognition of the effects of climate change, a strong cohesive approach to marine park protection, and recognition of the need to protect existing water and sanitation systems from future threats. However, climate change strategies focus predominately on resilience, adaptation and heat related health effects, rather than on more comprehensive mitigation policies. The findings emphasise the importance of strengthened cross-sectoral action to address both the drivers and effects of environmental degradation. A lack of policy coherence between jurisdictions was also evident in several areas, compounded by inadequate national guidance, where vague strategies and non-specific devolution of responsibilities are likely to compromise coordination and accountability. CONCLUSIONS: Evidence on planetary health recognises the interconnectedness of environmental and human health and, as such, suggests that ineffective management of climate change and water pose serious risks to both the natural environment and human well-being. To address these risks more effectively, and to achieve the SDGs, our findings indicate that cross-jurisdiction policy coherence and national coordination must be improved. In addition, more action to address global inequities is required, along with more comprehensive approaches to climate change mitigation.

The health impacts of extractive industry transnational corporations: a study of Rio Tinto in Australia and Southern Africa.

BACKGROUND: Operations of transnational corporations (TNCs) affect population health through production methods, shaping social determinants of health, or by influencing regulation of their activities. Research on community exposures to TNC practices and policies has been limited. Our research on extractive industries examined Rio Tinto in Australia and Southern Africa to test methods for assessing the health impacts of corporates in high and middle income jurisdictions with different regulatory frameworks. METHODS: We adapted existing Health Impact Assessment methods. Data identifying potential impacts were sourced through media analysis, document analysis, company literature and semi-structured interviews. The data were mapped against a corporate health impact assessment framework (CHIA) which included Rio Tinto's political and business practices; productions; and workforce, social, environmental and economic conditions. RESULTS: Both positive and detrimental aspects of Rio Tinto's operations were identified. Requirements imposed by Rio Tinto on its global supply chain are likely to have positive health impacts for workers. However, political lobbying and membership of representative organisations can influence government policy in ways that are unfavourable to health and equity. Positive impacts include provision of direct employment under decent working conditions, but countered by an increase in precariousness of employment. Commitments to upholding sustainable development principles are undermined by limited site remediation and other environmental impacts. Positive contributions are made to national and local economies but then undermined by business strategies that include tax minimisation. CONCLUSION: Our study confirmed that it is possible to undertake a CHIA on an extractive industry TNC. The different methods provided sufficient information to understand the need to strengthen regulations that are conducive to health; the opportunity for Rio Tinto to extend corporate responsibility initiatives and support their social licence to operate; and for civil society actors to inform their advocacy towards improving health and equity outcomes from TNC operations.

Assessing the health impact of transnational corporations: a case study on McDonald's Australia.

BACKGROUND: The practices of transnational corporations affect population health through production methods, shaping social determinants of health, or influencing the regulatory structures governing their activities. There has been limited research on community exposures to TNC policies and practices. Our pilot research used McDonald's Australia to test methods for assessing the health impacts of one TNC within Australia. METHODS: We adapted existing Health Impact Assessment methods to assess McDonald's activities. Data identifying potential impacts were sourced through document analysis, including McDonald's corporate literature; media analysis and semi-structured interviews. We commissioned a spatial and socioeconomic analysis of McDonald's restaurants in Australia through Geographic Information System technology. The data was mapped against a corporate health impact assessment framework which included McDonald's Australia's political and business practices; products and marketing; workforce, social, environmental and economic conditions; and consumers' health related behaviours. RESULTS: We identified both positive and detrimental aspects of McDonald's Australian operations across the scope of the CHIA framework. We found that McDonald's outlets were slightly more likely to be located in areas of lower socioeconomic status. McDonald's workplace conditions were found to be more favourable than those in many other countries which reflects compliance with Australian employment regulations. The breadth of findings revealed the need for governments to strengthen regulatory mechanisms that are conducive to health; the opportunity for McDonald's to augment their corporate social responsibility initiatives and bolster reputational endorsement; and civil society actors to inform their advocacy towards health and equity outcomes from TNC operations. CONCLUSION: Our study indicates that undertaking a corporate health impact assessment is possible, with the different methods revealing sufficient information to realise that strong regulatory frameworks are need to help to avoid or to mediate negative health impacts.

Assessing the health impact of transnational corporations: its importance and a framework.

BACKGROUND: The adverse health and equity impacts of transnational corporations' (TNCs) practices have become central public health concerns as TNCs increasingly dominate global trade and investment and shape national economies. Despite this, methodologies have been lacking with which to study the health equity impacts of individual corporations and thus to inform actions to mitigate or reverse negative and increase positive impacts. METHODS: This paper reports on a framework designed to conduct corporate health impact assessment (CHIA), developed at a meeting held at the Rockefeller Foundation Bellagio Center in May 2015. RESULTS: On the basis of the deliberations at the meeting it was recommended that the CHIA should be based on ex post assessment and follow the standard HIA steps of screening, scoping, identification, assessment, decision-making and recommendations. A framework to conduct the CHIA was developed and designed to be applied to a TNC's practices internationally, and within countries to enable comparison of practices and health impacts in different settings. The meeting participants proposed that impacts should be assessed according to the TNC's global and national operating context; its organisational structure, political and business practices (including the type, distribution and marketing of its products); and workforce and working conditions, social factors, the environment, consumption patterns, and economic conditions within countries. CONCLUSION: We anticipate that the results of the CHIA will be used by civil society for capacity building and advocacy purposes, by governments to inform regulatory decision-making, and by TNCs to lessen their negative health impacts on health and fulfil commitments made to corporate social responsibility.

To what extent do Australian child and youth health policies address the social determinants of health and health equity?: a document analysis study.

BACKGROUND: There is a significant body of evidence that highlights the importance of addressing the social determinants of child and youth health. In order to tackle health inequities Australian governments are being called upon to take action in this area at a policy level. Recent research suggests that the health and well-being of children and youth in Australia is 'middle of the road' when compared to other OECD countries. To date, there have been no systematic analyses of Australian child/youth health policies with a social determinants and health equity focus and this study aimed to contribute to addressing this gap. METHODS: Document analysis of seventeen strategic level child/youth health policies across Australia used an a priori coding framework specifically developed to assess the extent to which health departments address the social determinants of child/youth health and health equity. Policies were selected from a review of all federal and state/territory strategic health department policies dated between 2008 and 2013. They were included if the title of the policy addressed children, youth, paediatric health or families directly. We also included whole of government policies that addressed child/youth health issues and linked to the health department, and health promotion policies with a chapter or extensive section dedicated to children. RESULTS: Australian child/youth health policies address health inequities to some extent, with the best examples in Aboriginal or child protection policies, and whole of government policies. However, action on the social determinants of child/youth health was limited. Whilst all policies acknowledge the SDH, strategies were predominantly about improving health services delivery or access to health services. With some exceptions, the policies that appeared to address important SDH, such as early childhood development and healthy settings, often took a narrow view of the evidence and drifted back to focus on the individual. CONCLUSIONS: This research highlights that policy action on the social determinants of child/youth health in Australia is limited and that a more balanced approach to reducing health inequities is needed, moving away from a dominant medical or behavioural approach, to address the structural determinants of child/youth health.

A Detailed Analysis of the Past 20 Years of US FDA-Approved Prescription to Over-the-Counter Switches.

OBJECTIVES: This evaluation assesses the quantity, uniqueness, and innovative nature of the past 20 years of Rx-to-OTC (RTO) switches, where a current prescription (Rx) product is reclassified for over-the-counter (OTC) status. Broadening access to more OTC drugs with well-established safety and efficacy could help to reduce healthcare expenditure and address public health challenges. METHODS: The FDA-maintained RTO switch list website was accessed to generate the primary dataset. Each product listed was assessed for the current OTC availability in the United States of its active ingredient, pharmacological class, and indication to determine its innovative quality. Descriptive statistics were employed in this study. RESULTS: From January 2002 through August 2022 there were 45 RTO switches. Among these, 51.1% involved a new to OTC active ingredient, 22.2% involved a new pharmacological class, 6.6% involved a new indication, and 82.2% were considered follow-on products that introduced a new to OTC active ingredient or new dosage form of an already marketed active ingredient to treat an existing OTC indication. A small minority (6.6%) were considered an exceptional innovation that would offer US consumers a genuinely novel OTC product, providing a new to OTC active pharmaceutical ingredient, pharmacological class, and indication. Overall, there was 1 exceptional innovation every 6.7 years. CONCLUSIONS: Over 40 RTO switches have come to the OTC market in the past 20 years; however, exceptional innovations that expand access to new to OTC active ingredients for new indications are rare. Policies and strategies that result in more innovative switches that can benefit consumers and public health should be evaluated.

Patient Factors in the Dose Selection of Oral Sumatriptan for Acute Migraine: A Post Hoc Analysis of Two Randomized Controlled Studies.

INTRODUCTION: Patients are seeking greater involvement in their healthcare. It therefore may be beneficial to provide guidance on initial oral sumatriptan dose selection for the treatment of acute migraine in nontraditional settings, such as telehealth and other remote forms of medical care. We sought to determine whether clinical or demographic factors are predictive of oral sumatriptan dose preference. METHODS: This was a post hoc analysis of two clinical studies designed to determine preference for 25, 50, or 100 mg oral sumatriptan. Patients were aged 18-65 years with at least a 1 year history of migraine and experienced, on average, between one and six severe or moderately severe migraine attacks per month, with or without aura. Predictive factors were demographic measures, medical history, and migraine characteristics. Possibly predictive factors were identified using three analyses: classification and regression tree analysis, marginal significance (P < 0.1) within a full-model logistic regression, and/or selection within a forward-selection procedure in a logistic regression. A reduced model containing the variables identified in the preliminary analyses was developed. Due to differences in study design, data were not combined. RESULTS: A dose preference was expressed by 167 patients in Study 1 and 222 patients in Study 2. Gender and medical history of urologic and/or psychological conditions in Study 1 and duration of migraine history, height, and medical history of endocrine or neurologic disease and headache severity in Study 2 were identified as possibly predictive. The predictive model showed low positive predictive value (PPV; 23.8%) and low sensitivity (21.7%) for Study 1. For Study 2, the model showed moderate PPV (60.0%) but low sensitivity (10.9%). CONCLUSIONS: No clinical or demographic characteristics alone or in combination were consistently or strongly associated with preference for oral sumatriptan dose level. TRIAL REGISTRATION: The studies on which this paper is based were conducted before trial registration indexes were introduced.

Gastrointestinal effects of the addition of ascorbic acid to aspirin.

Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, have been associated with the damage to the gastrointestinal tract. One proposed mechanism of injury to the gastrointestinal mucosa by NSAIDs is oxygen radical-dependent microvascular injury. There is reasonable evidence to support the benefit of the addition of ascorbic acid, an ingredient with antioxidant properties, to moderate the adverse gastrointestinal (GI) effects of aspirin. Pharmacokinetic data have demonstrated that aspirin and ascorbic acid combination therapy can assist in mitigating the decrease in levels of ascorbic acid secondary to aspirin monotherapy. Endoscopic evaluation has demonstrated that the addition of ascorbic acid to aspirin significantly improves Lanza scores and rates of blood loss when compared to aspirin administration alone. When taken with ascorbic acid, the patient-reported tolerability of aspirin has been shown to be comparable to paracetamol and placebo. The existing body of evidence is relevant to short-term therapy with analgesic aspirin doses, and extrapolation to long-term therapy with low-dose aspirin is not appropriate. The purported benefit of an aspirin and ascorbic acid combination is a local observance and is not suspected to influence the adverse GI effects experienced as a result of systemic prostaglandin inhibition. Nevertheless, ascorbic acid may be a viable addition to the strategies employed to improve the gastrointestinal tolerability of aspirin.

City deals and health equity in Sydney, Australia.

'City Deals' are new governance instruments for urban development. Vast evidence exists on the relationship between urban factors and health equity, but little research applies a health equity lens to urban policy-making. This paper does precisely that for the Western Sydney City Deal (WSCD) in Australia. We conducted a critical discourse analysis of publicly available documents and interviews with the WSCD's main architects, applying insights from relevant theories. We find 'pro-growth' discourse to encourage economic investment dominates any references to disadvantage. Interviewees maintained the WSCDs fundamental purpose is to rebalance urban investment toward the historically disadvantaged West. However, the WSCD makes limited reference to health and none to equity. Institutionalised governance practices that favour private investments in infrastructure remain the dominant force behind the WSCD. We document how a shift to 'place-based' infrastructure has promise for equity but struggles to overcome institutionalised approaches to urban investments.

Creating Political Will for Action on Health Equity: Practical Lessons for Public Health Policy Actors.

BACKGROUND: Despite growing evidence on the social determinants of health and health equity, political action has not been commensurate. Little is known about how political will operates to enact pro-equity policies or not. This paper examines how political will for pro-health equity policies is created through analysis of public policy in multiple sectors. METHODS: Eight case studies were undertaken of Australian policies where action was either taken or proposed on health equity or where the policy seemed contrary to such action. Telephone or face-to-face interviews were conducted with 192 state and non-state participants. Analysis of the cases was done through thematic analysis and triangulated with document analysis. RESULTS: Our case studies covered: trade agreements, primary healthcare (PHC), work conditions, digital access, urban planning, social welfare and Indigenous health. The extent of political will for pro-equity policies depended on the strength of path dependency, electoral concerns, political philosophy, the strength of economic and biomedical framings, whether elite interests were threatened and the success or otherwise of civil society lobbying. CONCLUSION: Public health policy actors may create political will through: determining how path dependency that exacerbates health inequities can be broken, working with sympathetic political forces committed to fairness; framing policy options in a way that makes them more likely to be adopted, outlining factors to consider in challenging the interests of elites, and considering the extent to which civil society will work in favour of equitable policies. A shift in norms is required to stress equity and the right to health.

Frequently Reported Adverse Events With Smoking Cessation Medications: Post Hoc Analysis of a Randomized Trial.

OBJECTIVE: To compare the incidence, severity, and clinical course of frequently reported adverse events (AEs) after treatment with smoking cessation pharmacotherapies. METHODS: This was a multinational, multicenter, post hoc analysis of frequently reported treatment-emergent AEs from a large, phase 4, double-blind, randomized, triple-dummy, placebo-controlled trial (EAGLES), conducted between November 30, 2011, and January 13, 2015, that included smokers with and without psychiatric disorders (N=8144). Treatments were varenicline 1 mg twice daily, bupropion sustained-release 150 mg twice daily, and nicotine patch 21 mg once daily with tapering (12-week treatment, 12-week nontreatment follow-up), with incidence, time to onset, and duration of frequently reported AEs (≥5% of participants in any treatment group) measured. Risk differences for AEs for varenicline and bupropion vs nicotine patch were compared. RESULTS: Across frequently reported AEs, nausea, insomnia, abnormal dreams, anxiety, irritability, dry mouth, fatigue, and application site pruritus differed significantly in active treatment vs placebo groups. Risk differences were as follows: for nausea with varenicline vs nicotine patch, 15.50% (95% CI, 13.20% to 17.80%); for insomnia with bupropion vs nicotine patch, 2.58% (CI, 0.65% to 4.51%); and for abnormal dreams with varenicline and bupropion vs nicotine patch, -2.49% (CI, -4.35% to -0.64%) and -5.60% (CI, -7.27% to -3.93%), respectively. Frequently reported AEs of severe intensity and treatment discontinuation were experienced by less than 1.5% and less than 3% of participants across all groups, respectively. CONCLUSION: Active treatments were well tolerated with comparable AE profiles. Most AEs are not clinically important, and prescribers can reassure patients that those experienced will be manageable. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01456936.

Can health and health equity be advanced by urban planning strategies designed to advance global competitiveness? Lessons from two Australian case studies.

BACKGROUND: The purpose of this article is to investigate whether the neo-liberal goal of global economic competitiveness when included alongside image-inspired social goals such as liveability and environmental goals such as sustainability can lead to policies that impact positively on health and health equity. The paper presents an analysis of the content and intent of strategic planning and transport plans from two Australian state governments. METHODS: The analysis was undertaken using a thematic document analysis of each plan and interviews with agents (n = 21) directly involved in the preparation of each document. FINDINGS: Key strategic documents formulated under a neo-liberal hegemony simultaneously provided and reduced opportunities to promote and advance health. The policies viewed goals like liveability and sustainability as means of enhancing their cities' image in global competition for exogenous capital flows. Although liveability has many definitions, one definition was able to be used in one jurisdiction as an avenue to include a broad array of social determinants of health into urban planning policy. However, a productivity or a narrowly focussed image narrative can undermine the social determinants of health credentials of liveability. Overemphasising immediate city problems like road congestion as mechanisms to enhance global competitiveness can undermine necessary long-term strategies for city planning that are known to improve liveability and human health. Even where liveability is at the fore, there is a high risk of exacerbating spatial inequities through liveability investments for competitive advantage because they tend to flow to parts of cities with the greatest connections to the global economy, not those with the greatest social need. CONCLUSIONS: A neo-liberal-inspired competitive city paradigm provides opportunities for the advancement of health in urban development. However, when driven by the goals of productivity and/or liveability as image enhancement it can potentially exacerbate health inequities.

An assessment of the joint associations of aspirin and statin use with C-reactive protein concentration.

BACKGROUND: The use of aspirin alone and statins alone has been shown to reduce markers of inflammation, including C-reactive protein (CRP); however, their combination has been poorly studied. METHODS: In a cross-sectional analysis of black and white adults > or =45 years old from the REGARDS cohort, the associations of aspirin and statin use with CRP were examined. Individuals requiring nonsteroidal anti-inflammatory drug therapy or those taking aspirin for reasons other than cardioprotection were excluded from analysis. Participants were classified into 1 of 4 groups: aspirin only (n = 3,673), statin only (n = 1,898), both agents (n = 3,008), or neither agent (n = 7,718). RESULTS: Estimated mean CRP was 2.78 mg/L for subjects taking neither drug, 2.73 mg/L with aspirin only, 2.29 mg/L with statins only, and 2.03 mg/L for subjects taking both agents. The combined use of both agents was associated with an apparent synergistically lower CRP; the mean CRP level among these combined users was 0.21 mg/L lower than that anticipated from additive association related to aspirin and statins alone (P for interaction = .01). Associations were larger among participants reporting a history of cardiovascular disease. In addition, among statin users, the use of aspirin for >5 years compared with < or =5 years was associated with apparent significantly lower CRP concentrations (P = .01). CONCLUSIONS: The combined use of aspirin and statins was associated with a synergistically lower CRP concentration, especially among participants taking aspirin for >5 years. Given the limitations of this study and the modest associations, randomized controlled trial evidence is needed to confirm the findings.

Addressing Health Equity Through Action on the Social Determinants of Health: A Global Review of Policy Outcome Evaluation Methods.

BACKGROUND: Epidemiological evidence on the social determinants of health inequity is well-advanced, but considerably less attention has been given to evaluating the impact of public policies addressing those social determinants. Methodological challenges to produce evidence on policy outcomes present a significant barrier to mobilising policy actions for health equities. This review aims to examine methodological approaches to policy evaluation of health equity outcomes and identify promising approaches for future research. METHODS: We conducted a systematic narrative review of literature critically evaluating policy impact on health equity, synthesizing information on the methodological approaches used. We searched and screened records from five electronic databases, using pre-defined protocols resulting in a total of 50 studies included for review. We coded the studies according to (1) type of policy analysed; (2) research design; (3) analytical techniques; (4) health outcomes; and (5) equity dimensions evaluated. RESULTS: We found a growing number of a wide range of policies being evaluated for health equity outcomes using a variety of research designs. The majority of studies employed an observational research design, most of which were cross-sectional, however, other approaches included experimental designs, simulation modelling, and meta-analysis. Regression techniques dominated the analytical approaches, although a number of novel techniques were used which may offer advantages over traditional regression analysis for the study of distributional impacts of policy. Few studies made intra-national or cross-national comparisons or collected primary data. Despite longstanding challenges of attribution in policy outcome evaluation, the majority of the studies attributed change in physical or mental health outcomes to the policy being evaluated. CONCLUSION: Our review provides an overview of methodological approaches to health equity policy outcome evaluation, demonstrating what is most commonplace and opportunities from novel approaches. We found the number of studies evaluating the impacts of public policies on health equity are on the rise, but this area of policy evaluation still requires more attention given growing inequities.