A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research.

INTRODUCTION: The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated. METHOD: A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018. RESULTS: The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes. CONCLUSION: This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry. IMPLICATIONS: This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Indicators to guide health equity work in local public health agencies: a locally driven collaborative project in Ontario. / Indicateurs pour orienter l'action visant l'équité en matière de santé dans les organismes locaux de santé publique : le programme Projets locaux en Ontario.

INTRODUCTION: Funded by a Public Health Ontario 'Locally Driven Collaborative Project' grant, a team led by public health practitioners set out to develop and test a comprehensive set of indicators to guide health equity work in local public health agencies (LPHAs). METHODS: The project began with a scoping review, consultation with content experts, and development of a face-validated set of indicators aligned with the four public health roles to address health inequities (NCCDH, 2014), plus a fifth set of indicators related to an organizational and system development role. We report here on the field testing of the indicators for feasibility, face validity (clarity, relevance), reliability, and comparability in four Ontario LPHAs. Data were collected by two separate individuals or groups at each site, during two consecutive periods. These individuals participated in separate focus groups at the end of each test period, which further examined indicator clarity, data source availability and relevance. A third focus group explored anticipated indicator uses. RESULTS: Field testing showed that indicators addressed important issues in all public health roles. Although the capacity for indicator use varied, all test sites found the indicators useful. Suggestions for improved clarity were used to refine the final set of indicators, and to develop a Health Equity Indicator User Guide with background information and recommended resources. CONCLUSION: The process of evaluating health equity-related activity within LPHAs is still in its early stages. This project provides Ontario LPHAs with a tool to guide health equity work that may be adaptable to other Canadian jurisdictions.

INTRODUCTION: Grâce au programme Projet locaux financé par Santé publique Ontario, une équipe de professionnels de la santé publique a entrepris de concevoir et de tester un ensemble d'indicateurs afin d'orienter l'action visant l'équité en matière de santé au sein des organismes locaux de santé publique (OLSP). MÉTHODOLOGIE: Le projet a démarré avec un examen de la portée de la littérature, la consultation d'experts sur le sujet et l'élaboration d'un ensemble d'indicateurs de validité apparente conforme aux quatre mandats de la santé publique visant à réduire les inégalités en matière de santé (CCNDS, 2014) auxquels on a ajouté un cinquième ensemble d'indicateurs relatifs au mandat de perfectionnement organisationnel et systémique. Nous rendons compte ici des tests de terrain portant sur la faisabilité, sur la validité apparente (clarté et pertinence), sur la fiabilité et sur la comparabilité de ces indicateurs dans quatre OLSP de l'Ontario. Les données ont été recueillies par deux personnes ou groupes différents dans chaque site et en deux périodes. Ces personnes ont participé à des groupes de discussion à la fin de chaque période d'essai, ce qui a permis pour chaque indicateur un examen approfondi de sa clarté, de la disponibilité des sources de données associées et de sa pertinence. Un troisième groupe de discussion a étudié l'utilisation qui pourrait être faite de ces indicateurs. RÉSULTATS: Les essais de terrain ont montré que les indicateurs ont contribué à résoudre des questions importantes en lien avec tous les mandats en santé publique. Bien que les indicateurs ne possèdent pas tous la même utilité, les sites d'essai les ont tous jugés utiles. Diverses recommandations en matière de clarté ont été suivies pour améliorer l'ensemble final d'indicateurs et pour élaborer un guide d'utilisation des indicateurs d'équité en santé offrant des renseignements généraux et des suggestions de ressources. CONCLUSION: Le processus d'évaluation des activités liées à l'équité en matière de santé dans les OLSP n'en est qu'à ses débuts. Ce projet fournit aux OLSP de l'Ontario un outil d'orientation pour leur travail visant l'équité en matière de santé, outil qui pourrait être adapté aux autres provinces et territoires du Canada.

Participatory action as a research method with public health nurses.

AIM: This article explores and describes participatory action research (PAR) as a preferred method in addressing nursing practice issues. This is the first study that used PAR with public health nurses (PHNs) in Canada to develop a professional practice model. BACKGROUND: Participatory action research is a sub-category of action research that incorporates feminist and critical theory with foundations in the field of social psychology. For nurses, critical analysis of long-established beliefs and practices through PAR contributes to emancipatory knowledge regarding the impact of traditional hierarchies on their practice. DESIGN: This study used participatory action, a non-traditional but systematic research method, which assisted participants to develop a solution to a long-standing organizational issue. METHOD: The stages of generating concerns, participatory action, acting on concerns, reflection and evaluation were implemented from 2012 - 2013 in an urban Canadian city, to develop a professional practice model for PHNs. FINDINGS: Four sub-themes specific to PAR are discussed. These are "participatory action research engaged PHNs in development of a professional practice model;" "the participatory action research cycles of "Look, Think, Act" expanded participants' views;" "participatory action research increased awareness of organizational barriers;" and "participatory action research promoted individual empowerment and system transformation." CONCLUSIONS: This study resulted in individual and system change that may not have been possible without the use of PAR. The focus was engagement of participants and recognition of their lived experience, which facilitated PHNs' empowerment, leadership and consciousness-raising.

Organizational level indicators to address health equity work in local public health agencies: A scoping review.

OBJECTIVE: To determine what organizational level indicators exist that could be used by local Ontario public health agencies to monitor and guide their progress in addressing health equity. METHOD: This scoping review employed Arksey and O'Malley's (2005) six-stage framework. Multiple online databases and grey literature sources were searched using a comprehensive strategy. Studies were included if they described or used indicators to assess an organization's health equity activity. Abstracted indicator descriptions were classified using the roles for public health action identified by the Canadian National Collaborating Centre for Determinants of Health (NCCDH). Health equity experts participated in a consultation phase to examine items extracted from the literature. SYNTHESIS: Eighteen peer-reviewed studies and 30 grey literature reports were included. Abstracted indicators were considered for 1) relevance for organizational assessment, 2) ability to highlight equity-seeking populations, and 3) potential feasibility for application. Twenty-eight items formed the basis for consultation with 13 selected health equity experts. Items considered for retention were all noted to require significant clarification, definition and development. Those eliminated were often redundant or not an organizational level indicator. CONCLUSION: Few evidence-based, validated indicators to monitor and guide progress to address health inequities at the level of the local public health organization were identified. There is a need for continued development of identified indicator items, including careful operationalization of concepts and establishing clear definitions for key terms.

Reorienting Public Health Nurses' Practice With a Professional Practice Model.

Purpose Documents articulating public health nurses' (PHNs') roles, including Canadian standards and competencies, depict a broad focus working at multiple levels to improve population outcomes through the promotion of health equity. Conversely, Canadian experts depict a looming crisis, based on the rising disconnect between daily activities and ideal practice. While perfectly positioned, PHNs' skills and abilities are under-utilized and largely invisible. The intention of this study was to develop a model to support the full scope of equity-focused PHN practice. Method A participatory action research approach was used. Qualitative data were gathered using semistructured interview guides during audio-recorded meetings. The data were coded into central themes using content analysis and constant comparison. A researcher reflexive journal and field notes were kept. A significant feature was full participant involvement. Results The outcome was a professional practice model to reframe the PHN role to focus on population health and equity. The model was imperative in promoting full scope of practice, dealing with workload pressures, and describing PHNs' value within the organization and broader health system. Conclusion Professional practice models hold promise as frameworks to depict autonomous practice activities, situated within organizations and healthcare systems, and underpinned by nursing knowledge.

Does public health advocacy seek to redress health inequities? A scoping review.

The public health (PH) sector is ideally situated to take a lead advocacy role in catalysing and guiding multi-sectoral action to address social determinants of health inequities, but evidence suggests that PH's advocacy role has not been fully realised. The purpose of this review was to determine the extent to which the PH advocacy literature addresses the goal of reducing health and social inequities, and to increase understanding of contextual factors shaping the discourse and practice of PH advocacy. We employed scoping review methods to systematically examine and chart peer-reviewed and grey literature on PH advocacy published from January 1, 2000 to June 30, 2015. Databases and search engines used included: PubMed, CINAHL, PsycINFO, Social Sciences Citation Index, Google Scholar, Google, Google Books, ProQuest Dissertations and Theses, Grey Literature Report. A total of 183 documents were charted, and included in the final analysis. Thematic analysis was both inductive and deductive according to the objectives. Although PH advocacy to address root causes of health inequities is supported theoretically and through professional practice standards, the empirical literature does not reflect that this is occurring widely in PH practice. Tensions within the discourse were noted and multiple barriers to engaging in PH advocacy for health equity were identified, including a preoccupation with individual responsibilities for healthy lifestyles and behaviours, consistent with the emergence of neoliberal governance. If the PH sector is to fulfil its advocacy role in catalysing action to reduce health inequities, it will be necessary to address advocacy barriers at multiple levels, promote multi-sectoral efforts that implicate the state and corporations in the production of health inequities, and rally state involvement to redress these injustices.

Report of an equity-focused health impact assessment of a proposed universal parenting program in Manitoba.

OBJECTIVES: To assess potential inequitable impacts of a proposed Teen Triple P Positive Parenting Program (Teen PPP) in Manitoba to achieve equity of access and outcomes for families of diverse backgrounds; recommend (if required) alternative actions to promote greater equity of access and outcomes for families participating in Teen PPP; and evaluate the influence of recommendations on implementation of the proposed program. INTERVENTION: An equity-focused health impact assessment (EfHIA) of the proposed Teen PPP was conducted, using a standard EfHIA framework. Methods used to assess potential Teen PPP impacts included: a literature review, key informant interviews and 14 community consultations. Evidence was analyzed, summarized and presented to the project Steering Committee (SC), along with draft recommendations for ensuring that equity is considered in Teen PPP planning and rollout. OUTCOMES: The SC prioritized 12 possible inequitable impacts of Teen PPP with potential to prevent certain parents/caregivers either from accessing the proposed program or benefitting adequately from the program, causing them to drop out prematurely. Recommendations for avoiding these impacts were finalized by the SC and presented to provincial government officials responsible for the proposed program. Follow-up interviews with these individuals indicated that the recommendations were well received and raised equity-related issues that will be considered in future program planning decisions. CONCLUSION: EfHIA is a proven planning tool for ensuring that health equity is considered in all policies, which is one of the necessary conditions for reducing inequities and closing the health equity gap throughout Canada within a generation.

A multiple case study of intersectoral public health networks: experiences and benefits of using research.

BACKGROUND: Network partnerships between public health and third sector organisations are being used to address the complexities of population level social determinants of health and health equity. An understanding of how these networks use research and knowledge is crucial to effective network design and outcome evaluation. There is, however, a gap in the literature regarding how public health networks use research and knowledge. The purpose of this paper is to report on the qualitative findings from a larger study that explored (1) the experiences of public health networks with using research and knowledge, and (2) the perceived benefits of using research and knowledge. METHODS: A multiple case study approach framed this study. Focus group data were collected from participants through a purposive sample of four public health networks. Data were analyzed using Framework Analysis and Nvivo software supported data management. Each network had the opportunity to participate in data interpretation. RESULTS: All networks used published research studies and other types of knowledge to accomplish their work, although in each network research and knowledge played different but complementary roles. Neither research nor other types of knowledge were privileged, and an approach that blended varied knowledge types was typically used. Network experiences with research and knowledge produced individual and collective benefits. A novel finding was that research and knowledge were both important in shaping network function. CONCLUSIONS: This study shifts the focus in the current literature from public health departments to the community setting where public health collaborates with a broader spectrum of actors to ameliorate health inequities. Both formal research and informal knowledge were found to be important for collaborative public health networks. Examining the benefits of research and knowledge use within public health networks may help us to better understand the relationships among process (the collaborative use of research and knowledge), structure (networks) and outcomes (benefits).

A Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA).

The Canadian public health sector's foundational values of social justice and equity, and its mandate to promote population health, make it ideally situated to take a strong lead in addressing persistent and unacceptable inequities in health between socially disadvantaged, marginalized or excluded groups and the general population. There is currently much attention paid to improving understanding of pathways to health equity and development of effective population health interventions to reduce health inequities. Strengthening the capacity of the public health sector to develop, implement and sustain equity-focused population health initiatives - including readiness to engage in a social justice-based equity framework for public health - is an equally essential area that has received less attention. Unfortunately, there is evidence that current capacity of the Canadian public health sector to address inequities is highly variable. The first step in developing a sustained approach to improving capacity for health equity action is the identification of what this type of capacity entails. This paper outlines a Conceptual Framework of Organizational Capacity for Public Health Equity Action (OC-PHEA), grounded in the experience of Canadian public health equity champions, that can guide research, dialogue, reflection and action on public health capacity development to achieve health equity goals.

Developing guidelines for quality community health nursing clinical placements for baccalaureate nursing students.

Rapidly increasing enrollment in Canadian schools of nursing has triggered the development of innovative clinical placement sites. There are both opportunities and challenges inherent in the delivery of clinical nursing education in diverse community settings. As part of the Canadian Association of Schools of Nursing's (CASN) ongoing work to assist its members and ensure baccalaureate graduates are prepared to meet the Canadian Community Health Nursing Standards of Practice at an entry-to-practice level, the CASN Sub-Committee on Public Health (funded by the Public Health Agency of Canada) conducted extensive national consultations with representatives from both academic and practice settings, as well as key national organizations. The resultant Guidelines for Quality Community Health Nursing Clinical Placements, released by CASN in 2010, aim to provide direction to Canadian schools of nursing and practice settings in addressing the challenges and opportunities arising from the changing context of community health nursing student clinical placements.

The role of public health agencies in addressing child and family poverty: public health nurses' perspectives.

Poverty rates among child-bearing families in industrialised countries remain unacceptably high and have significant implications for population health. Both today and in the past, public health nurses have observed the impact of poverty on family health and well-being every day in their practice; yet, their perspectives on their role in addressing child and family poverty are currently absent from the literature. This paper presents findings of a qualitative descriptive study that explored perspectives of public health nurses in an urban Canadian setting about the impact of poverty on the well-being of children and families, and the potential roles of health organisations and public health nurses in addressing this issue. A key finding is the large gap between the role that nurses believe they can potentially play, and their current role. Barriers that public health nurses encounter when attempting to address poverty are identified, and implications of the findings for public health policy, practice, and research are discussed.

Community health clinical education in Canada: part 1--"state of the art".

This paper presents the findings of a survey of community health clinical education in twenty-four Canadian pre-licensure baccalaureate nursing programs. A qualitative research design was used, involving a content analysis of Canadian course syllabi and supporting documents for community health courses. This study afforded a cross-sectional understanding of the "state of the art" of community health clinical education in Canadian schools of nursing. Clinical course conceptual approaches, course objectives, types of clinical sites, format and number of clinical hours, and methods of student evaluation are identified. The findings suggest the need for a national dialogue or consensus building exercise regarding curriculum content for community health nursing. Informing this dialogue are several strengths including the current focus on community health (as opposed to community-based) nursing education, and a solid socio-environmental perspective informing clinical learning and practice. The national data set generated by this study may have relevance to nursing programs globally.

Community health clinical education in Canada: part 2--developing competencies to address social justice, equity, and the social determinants of health.

Recently, several Canadian professional nursing associations have highlighted the expectations that community health nurses (CHNs) should address the social determinants of health and promote social justice and equity. These developments have important implications for (pre-licensure) CHN clinical education. This article reports the findings of a qualitative descriptive study that explored how baccalaureate nursing programs in Canada address the development of competencies related to social justice, equity, and the social determinants of health in their community health clinical courses. Focus group interviews were held with community health clinical course leaders in selected Canadian baccalaureate nursing programs. The findings foster understanding of key enablers and challenges when providing students with clinical opportunities to develop the CHN role related to social injustice, inequity, and the social determinants of health. The findings may also have implications for nursing programs internationally that are addressing these concepts in their community health clinical courses.

Preparing the community health nursing workforce: internal and external enablers and challenges influencing undergraduate nursing programs in Canada.

The Canadian Schools of Nursing (CASN) task force on public health was mandated to facilitate Schools of Nursing to provide students with the foundation required to meet the Canadian Community Health Nursing Standards of Practice. This paper reports on an environmental scan that explored barriers and enablers influencing the integration of community health nursing content in baccalaureate education in Canada. Data was collected over three phases including: 1) a pan-Canadian survey of nursing schools, 2) completion of open-ended workbook questions by educators, policy makers, administrators, and community health nursing managers attending a pan-Canadian symposium on community health nursing, and 3) recorded notes from the symposium. The response rate for the survey was 72.5% (n = 61 schools) and approximately 125 stakeholders participated in symposium activities. Internal and external enablers and challenges as well as recommendations for practice and education are presented.

Development of the role of public health nurses in addressing child and family poverty: a framework for action.

AIM: The purpose of this paper is to invite dialogue about how public health nurses could best address child and family poverty. Their current role is reviewed and a framework for expanding this role is presented. BACKGROUND: The negative health consequences of poverty for children are well-documented worldwide. The high levels of children living in poverty in wealthy industrialized countries such as Canada should be of concern to the health sector. What role(s) can public health nurses play in addressing child and family poverty? METHOD: A review of scholarly literature from Canada, the United States of America and the United Kingdom was conducted to ascertain support for public health nurses' roles in reducing poverty and its effects. We then reviewed professional standards and competencies for nursing practice in Canada. The data were collected between 2005 and 2006. FINDINGS: Numerous nursing scholars have called for public health nurses to address the causes and consequences of poverty through policy advocacy. However, this role was less likely to be identified in professional standards and competencies, and we found little empirical evidence documenting Canadian public health nurses' efforts to engage in this role. Public health nurses' roles in relation to poverty focus primarily on assisting families living in poverty to access appropriate services rather than directing efforts at the policy level. Factors associated with this limited involvement are identified. We suggest that the conceptual framework developed by Blackburn in the United Kingdom offers direction for a more fully developed public health nursing role. Prerequisites to engaging in the strategies articulated in the framework are discussed. CONCLUSION: Given more organizational support and enhanced knowledge and skills, public health nurses could be playing a greater role in working with others to make child and family poverty history.

Barriers to population-focused health promotion: the experience of public health nurses in the province of Manitoba.

There is growing evidence that population health is influenced by broad socio-environmental factors that require population-focused health promotion strategies. The author reports on a study of the perspectives of public health nurses (PHNs) on the nature of their health promotion practice in the Canadian province of Manitoba, highlighting their perceptions about barriers to population-focused health promotion. A descriptive, exploratory research design was used to conduct standardized open-ended interviews with 24 PHNs in 3 geographically and demographically diverse health authorities. There were remarkable similarities in PHNs' perceptions about their practice. Three categories of barrier to population-focused health promotion were identified: barriers at the level of individual PHNs; organizational barriers (culture, policies, processes); and extra-organizational barriers at the level of the community or province. The results point to a gap between the theory that population-focused health promotion is at the heart of PHN practice and the experience of PHNs at the 3 sites. A concerted effort to address the barriers is needed so that PHNs in Manitoba can play a leadership role in creating a health-care system that truly invests in population health.

Population health as a framework for public health practice: a Canadian perspective.

I explored the discourse on population health within 3 diverse regional health authorities in Manitoba, Winnipeg, with a focus on the public health sector. At all study sites, population health was viewed primarily as an epidemiological tool for population health assessment and surveillance rather than as an approach to taking action on the broad determinants of health. My findings suggest that concerns about the limitations of population health as a framework for public health efforts to reduce inequities in health are warranted.