Oncology education for family medicine residents: a national needs assessment survey.

BACKGROUND: This study aimed to determine the current state of oncology education in Canadian family medicine postgraduate medical education programs (FM PGME) and examine opinions regarding optimal oncology education in these programs. METHODS: A survey was designed to evaluate ideal and current oncology teaching, educational topics, objectives, and competencies in FM PGMEs. The survey was sent to Canadian family medicine (FM) residents and program directors (PDs). RESULTS: In total, 150 residents and 17 PDs affiliated with 16 of 17 Canadian medical schools completed the survey. The majority indicated their programs do not have a mandatory clinical rotation in oncology (79% residents, 88% PDs). Low rates of residents (7%) and PDs (13%) reported FM residents being adequately prepared for their role in caring for cancer patients (p = 0.03). Residents and PDs believed the most optimal method of teaching oncology is through clinical exposure (65% residents, 80% PDs). Residents and PDs agreed the most important topics to learn (rated ≥4.7 on 5-point Likert scale) were: performing pap smears, cancer screening/prevention, breaking bad news, and approach to patient with increased cancer risk. According to residents, other important topics such as appropriate cancer patient referrals, managing cancer complications and post-treatment surveillance were only taught at frequencies of 52, 40 and 36%, respectively. CONCLUSIONS: Current FM PGME oncology education is suboptimal, although the degree differs in the opinion of residents and PDs. This study identified topics and methods of education which could be focussed upon to improve FM oncology education.

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.

Impact on social inequalities of population strategies of prevention for folate intake in women of childbearing age.

We reviewed the recent assertion that population strategies of prevention may inadvertently widen social inequalities in health. We used folate intake as a case example to examine what is known about the impact on inequalities of 2 population strategies: one agentic (public information campaign) and the other structural (mandatory fortification policy). We found some support for our hypothesis that the mandatory fortification policy was less likely than were the information campaigns to lead to worsening inequalities in health by socioeconomic status or race/ethnicity; however, conclusions were complicated by different outcome variables and different economic and political regimes in which interventions took place.

Population-level interventions in government jurisdictions for dietary sodium reduction: a Cochrane Review.

Background: Worldwide, excessive salt consumption is common and is a leading cause of high blood pressure. Our objectives were to assess the overall and differential impact (by social and economic indicators) of population-level interventions for dietary sodium reduction in government jurisdictions worldwide. Methods: This is a Cochrane systematic review. We searched nine peer-reviewed databases, seven grey literature resources and contacted national programme leaders. We appraised studies using an adapted version of the Cochrane risk of bias tool. To assess impact, we computed the mean change in salt intake (g/day) from before to after intervention. Results: Fifteen initiatives met the inclusion criteria and 10 provided sufficient data for quantitative analysis of impact. Of these, five showed a mean decrease in salt intake from before to after intervention including: China, Finland (Kuopio area), France, Ireland and the UK. When the sample was constrained to the seven initiatives that were multicomponent and incorporated activities of a structural nature (e.g. procurement policy), most (4/7) showed a mean decrease in salt intake. A reduction in salt intake was more apparent among men than women. There was insufficient information to assess differential impact by other social and economic axes. Although many initiatives had methodological strengths, all scored as having a high risk of bias reflecting the observational design. Study heterogeneity was high, reflecting different contexts and initiative characteristics. Conclusions: Population-level dietary sodium reduction initiatives have the potential to reduce dietary salt intake, especially if they are multicomponent and incorporate intervention activities of a structural nature. It is important to consider data infrastructure to permit monitoring of these initiatives.