Do expenditures on public health reduce preventable mortality in the long run? Evidence from the Canadian provinces.

BACKGROUND: Investments in public health - prevention of illnesses, and promotion, surveillance, and protection of population health - may improve population health, however, effects may only be observed over a long period of time. OBJECTIVE: To investigate the potential long-run relationship between expenditures on public health and avoidable mortality from preventable causes. METHODS: We focused on the country spending the most on public health in the OECD, Canada. We constructed a longitudinal dataset on mortality, health care expenditures and socio-demographic information covering years 1979-2017 for the ten Canadian provinces. We estimated error correction models for panel data to disentangle short-from long-run relationships between expenditures on public health and avoidable mortality from preventable causes. We further explored some specific causes of mortality to understand potential drivers. For comparison, we also estimated the short-run relationship between curative expenditures and avoidable mortality from treatable causes. RESULTS: We find evidence of a long-run relationship between expenditures on public health and preventable mortality, and no consistent short-run associations between these two variables. Findings suggest that a 1% increase in expenditures on public health could lead to 0.22% decrease in preventable mortality. Reductions in preventable mortality are greater for males (-0.29%) compared to females (-0.09%). These results are robust to different specifications. Reductions in some cancer and cardiovascular deaths are among the probable drivers of this overall decrease. By contrast, we do not find evidence of a consistent short-run relationship between curative expenditures and treatable mortality, except for males. CONCLUSION: This study supports the argument that expenditures on public health reap health benefits primarily in the long run, which, in this case, represents a reduction in avoidable mortality from preventable causes. Reducing public health expenditures on the premise that they have no immediate measurable benefits might thus harm population health outcomes in the long run.

Risk factors associated with newly diagnosed attention-deficit/hyperactivity disorder in adults: a retrospective case-control study.

BACKGROUND: Knowledge of risk factors for attention-deficit/hyperactivity disorder (ADHD) may facilitate early diagnosis; however, studies examining a broad range of potential risk factors for ADHD in adults are limited. This study aimed to identify risk factors associated with newly diagnosed ADHD among adults in the United States (US). METHODS: Eligible adults from the IQVIA PharMetrics® Plus database (10/01/2015-09/30/2021) were classified into the ADHD cohort if they had ≥ 2 ADHD diagnoses (index date: first ADHD diagnosis) and into the non-ADHD cohort if they had no observed ADHD diagnosis (index date: random date) with a 1:3 case-to-control ratio. Risk factors for newly diagnosed ADHD were assessed during the 12-month baseline period; logistic regression with stepwise variable selection was used to assess statistically significant association. The combined impact of selected risk factors was explored using common patient profiles. RESULTS: A total of 337,034 patients were included in the ADHD cohort (mean age 35.2 years; 54.5% female) and 1,011,102 in the non-ADHD cohort (mean age 44.0 years; 52.4% female). During the baseline period, the most frequent mental health comorbidities in the ADHD and non-ADHD cohorts were anxiety disorders (34.4% and 11.1%) and depressive disorders (27.9% and 7.8%). Accordingly, a higher proportion of patients in the ADHD cohort received antianxiety agents (20.6% and 8.3%) and antidepressants (40.9% and 15.8%). Key risk factors associated with a significantly increased probability of ADHD included the number of mental health comorbidities (odds ratio [OR] for 1 comorbidity: 1.41; ≥2 comorbidities: 1.45), along with certain mental health comorbidities (e.g., feeding and eating disorders [OR: 1.88], bipolar disorders [OR: 1.50], depressive disorders [OR: 1.37], trauma- and stressor-related disorders [OR: 1.27], anxiety disorders [OR: 1.24]), use of antidepressants (OR: 1.87) and antianxiety agents (OR: 1.40), and having ≥ 1 psychotherapy visit (OR: 1.70), ≥ 1 specialist visit (OR: 1.30), and ≥ 10 outpatient visits (OR: 1.51) (all p < 0.05). The predicted risk of ADHD for patients with treated anxiety and depressive disorders was 81.9%. CONCLUSIONS: Mental health comorbidities and related treatments are significantly associated with newly diagnosed ADHD in US adults. Screening for patients with risk factors for ADHD may allow early diagnosis and appropriate management.

Beyond the mean: Distributional differences in earnings and mental health in young adulthood by childhood health histories.

Research on the long-term effects of health in early life has predominantly relied on parametric methods to assess differences between groups of children. However, this approach leaves a wealth of distributional information untapped. The objective of this study was to assess distributional differences in earnings and mental health in young adulthood between individuals who suffered a chronic illness in childhood compared to those who did not using the non-parametric relative distributions framework. Using data from the Panel Study of Income Dynamics, we find that young adults who suffered a chronic illness in childhood fare worse in terms of earnings and mental health scores in adulthood, particularly for individuals reporting a childhood mental health/developmental disorder. Covariate decompositions suggest that chronic conditions in childhood may indirectly affect later outcomes through educational attainment: had the two groups had similar levels of educational attainment, the proportion of individuals with a report of a chronic condition in childhood in the lower decile of the relative earnings distribution would have been reduced by about 20 percentage points. Findings may inform policy aimed at mitigating longer run effects of health conditions in childhood and may generate hypotheses to be explored in parametric analyses.

The "Long-arm" of chronic conditions in childhood: Evidence from Canada using linked survey-administrative data.

The objective of this study was to investigate the relationship between health conditions in childhood (ages 4-11), and health and socioeconomic outcomes in adulthood (ages 21-33). This study takes advantage of a new linkage between the National Longitudinal Survey of Children and Youth (NLSCY) and administrative tax data from the T1 Family File (T1FF) from Statistics Canada. The NLSCY includes rich longitudinal information on child development, while the T1FF includes administrative tax information on each child in adulthood (e.g., income, social assistance). The primary measures of child health relate to the diagnosis of a chronic condition, affecting the child's physical or mental/developmental health. The results suggest that mental/developmental health conditions in childhood more negatively influence adult health and socioeconomic conditions, compared to physical health conditions. Interaction models reveal modest heterogenous effects; for example, there is some evidence of a cushioning effect from higher household income in childhood, as well as an exacerbating negative effect from lower birth weight for mental/developmental health conditions. Using a covariate decomposition approach to explore underlying pathways, the results reveal that associations between health in early life and outcomes in adulthood are partially explained by differences in cognitive skills (i.e., mathematics test scores) in adolescence (ages 16-17). Results may encourage policy investments to mitigate the occurrence of health conditions in childhood and to ensure timely access to educational supports and health services for children with chronic conditions.

The political and fiscal determinants of public health and curative care expenditures: evidence from the Canadian provinces, 1980-2018.

OBJECTIVES: Public health systems have been centre stage during the COVID-19 pandemic, but governments invest relatively little in public health as compared to curative care. Previous research has shown that public health expenditures are under pressure during recessions and could be politically determined, but very few studies analyze quantitatively their determinants. This study investigates the political and fiscal determinants of public health and curative care expenditures. METHODS: After constructing a dataset building on disaggregated health expenditures in the Canadian provinces from 1975 to 2018, we use error correction models to study the short-run and long-run influence of fiscal and political determinants on public health expenditures and on curative expenditures. Fiscal determinants include measures of public debt charges and federal transfers. Political determinants include government partisanship and election cycles. We also explore whether curative expenditures crowd out public health expenditures. RESULTS: We find no difference between left and right governments in curative care expenditures but show that left governments spend more on public health if we control for past spending decisions in favour of curative care. Fiscal austerity reduces both public health and curative expenditures, and provincial governments use additional intergovernmental transfers to increase their curative care budgets. A growth in the proportion of curative care relative to total health budgets is associated with a decline in public health expenditures. CONCLUSION: Even though they have low political salience, public health expenditures remain driven by partisanship and electoral concerns. Despite their widely acknowledged importance, public health programs develop in the shadow of curative care priorities.

RéSUMé: OBJECTIFS: Bien que les systèmes de santé publique aient occupé le devant de la scène pendant la pandémie de COVID-19, les gouvernements investissent relativement peu dans la santé publique par rapport aux soins de santé curatifs. Des recherches antérieures ont montré que les dépenses de santé publique sont vulnérables aux récessions économiques et pourraient être influencées par la politique, mais très peu d'études analysent quantitativement les déterminants des dépenses de santé publique. Cette étude examine les déterminants politiques et fiscaux des dépenses de santé publique et de soins curatifs. MéTHODES: Nous avons assemblé une base de données regroupant les dépenses de santé désagrégées dans les provinces canadiennes de 1975 à 2018. Nous utilisons des modèles de correction d'erreurs pour étudier l'influence à court et long terme des déterminants fiscaux et politiques des dépenses de santé publique et des dépenses de santé curatives. Les déterminants fiscaux comprennent des mesures des intérêts sur la dette publique et des transferts fédéraux. Les déterminants politiques comprennent l'idéologie du gouvernement et les cycles électoraux. Nous examinons également si la croissance des dépenses curatives entraîne un effet d'éviction sur les dépenses de santé publique. RéSULTATS: Nous ne trouvons aucune différence entre les dépenses en soins curatifs effectuées par les gouvernements de gauche et de droite, mais nous montrons que les gouvernements de gauche dépensent plus en santé publique si nous contrôlons pour les décisions passées en faveur des soins curatifs. L'austérité fiscale réduit à la fois les dépenses de santé publique et les dépenses en soins curatifs, et les gouvernements provinciaux utilisent les transferts intergouvernementaux supplémentaires pour augmenter leurs budgets de soins curatifs. Une augmentation de la proportion des budgets de santé alloués aux soins curatifs est associée à une baisse des dépenses de santé publique. CONCLUSION: Même si elles ont une faible saillance politique, les dépenses de santé publique restent guidées par la partisanerie et les préoccupations électorales. Malgré leur importance largement reconnue, les programmes de santé publique se développent à l'ombre de la priorité donnée aux soins curatifs.

Youth clinic model for youth sexual health: Promising solution to ensure access to care.

OBJECTIVE: To understand the services offered at a youth clinic as a site specializing in youth sexual health services, and the implications of this model for young people's well-being. DESIGN: Qualitative research plan that follows the principles of grounded theory. SETTING: A youth clinic located in an urban neighbourhood in Montréal, Que. PARTICIPANTS: The participants in this study were young patients, aged 18 to 23, accessing the clinic and the health care providers supporting them at the clinic. The clinic's interdisciplinary team consisted of family physicians, nurses, a sexologist, a social worker, and a receptionist. All members of the clinic team (n=8) and 8 youth patients were interviewed. METHODS: Semistructured interview methods were used with the youth participants and health care providers. Youth participants were recruited using convenience sampling. MAIN FINDINGS: The primary results are divided into 3 components: the composition of the interdisciplinary team, with particular attention to the co-location of the team members; particular conditions at youth clinics, notably the presence of a receptionist on the team, financial coverage for certain prescriptions, and longer consultation times allowing for an educational component; and young people's positive perceptions of these services. CONCLUSION: Considered together, the characteristics of a youth clinic promote access to youth sexual health services on several levels. The findings encourage general practitioners to collaborate with services connected to family medicine when supporting young people's sexual health.

Le modèle de clinique jeunesse pour la santé sexuelle des jeunes: Solution gagnante pour assurer l'accès aux soins.

OBJECTIF: Comprendre l'offre de services en clinique jeunesse, un lieu de service destiné à la santé sexuelle des jeunes, ainsi que les implications de ce modèle pour le bien-être des jeunes. TYPE D'ÉTUDE: Un plan de recherche de nature qualitative, respectant les attributs de la théorisation ancrée. CONTEXTE: Une clinique jeunesse située dans un quartier urbain de Montréal (Québec). PARTICIPANTS: Les participants de cette étude étaient de jeunes patients de la clinique âgés de 18 à 23 ans, ainsi que les intervenantes de la clinique jeunesse qui y travaillent. L'équipe interdisciplinaire de la clinique était composée de médecins de famille, d'infirmières, d'une sexologue, d'une travailleuse sociale et d'une réceptionniste. J'ai interviewé toutes les intervenantes de l'équipe (n=8) et 8 jeunes patients. MÉTHODES: J'ai employé des méthodes d'entretiens semi-dirigés auprès des jeunes et des intervenantes. J'ai recruté les jeunes en utilisant un échantillonnage de convenance. PRINCIPALES CONSTATATIONS: Les résultats principaux se définissent sur trois axes. Premièrement, la composition de l'équipe interdisciplinaire, avec une attention particulière à la co-localisation des membres de l'équipe; ensuite, les fonctions particulières aux cliniques jeunesse, notamment la présence d'une réceptionniste propre à l'équipe, la couverture financière de certaines prescriptions, et un temps d'intervention plus long, permettant une composante éducative aux interventions. Finalement, je présente les impressions positives des jeunes sur ces services. CONCLUSION: Prises ensemble, les caractéristiques d'une clinique jeunesse favorisent l'accès aux soins à plusieurs niveaux pour les jeunes en matière de santé sexuelle. Mes réflexions encouragent les omnipraticiens à collaborer avec des services connexes à la médecine de famille lorsqu'il est question de la santé sexuelle des jeunes.

The Impact of COVID-19 Pandemic on Inequity in Routine Childhood Vaccination Coverage: A Systematic Review.

BACKGROUND: Routine childhood vaccination coverage rates fell in many countries during the COVID-19 pandemic, but the impact of inequity on coverage is unknown. METHODS: We synthesised evidence on inequities in routine childhood vaccination coverage (PROSPERO, CRD 42021257431). Studies reporting empirical data on routine vaccination coverage in children 0-18 years old during the COVID-19 pandemic by equity stratifiers were systematically reviewed. Nine electronic databases were searched between 1 January 2020 and 18 January 2022. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Tool for Cohort Studies. Overall, 91 of 1453 studies were selected for full paper review, and thirteen met the inclusion criteria. RESULTS: The narrative synthesis found moderate evidence for inequity in reducing the vaccination coverage of children during COVID-19 lockdowns and moderately strong evidence for an increase in inequity compared with pre-pandemic months (before March 2020). Two studies reported higher rates of inequity among children aged less than one year, and one showed higher inequity rates in middle- compared with high-income countries. CONCLUSIONS: Evidence from a limited number of studies shows the effect of the pandemic on vaccine coverage inequity. Research from more countries is required to assess the global effect on inequity in coverage.

Literacy and self-rated health: Analysis of the Longitudinal and International Study of Adults (LISA).

The relationship between education and health is well-established. The empirical literature finds that individuals with higher levels of education experience lower risks of poor health outcomes compared to individuals with less education. Outstanding to this literature is the examination of a dimension of education - literacy - and its association with health. The objective of this study was to examine the relationship between literacy (reading, numeracy) and health (self-reported health). We use data from the 2012 wave of the Canadian Longitudinal International Survey of Adults (LISA). The LISA includes rich information on health, broader sociodemographic characteristics (income, age, sex, etc.) as well as information on literacy skills from the Program for International Assessment of Adult Competencies (PIAAC). Using logistic regression, we first reaffirm the association between education and self-reported health. We then find that after controlling for measures of literacy, understood as proficiency in reading and numeracy, the magnitude of effect of education on health is reduced. Skills in literacy reduce the risk of reporting poor health, but only for the older subset of respondents (ages 40-65). Our results suggest that literacy should not be understated in empirical research on education and health, and in fact serve to sharpen our understanding of how education impacts health by drawing attention to indirect pathways.

Climate Change and Child Health Inequality: A Review of Reviews.

There is growing evidence on the observed and expected consequences of climate change on population health worldwide. There is limited understanding of its consequences for child health inequalities, between and within countries. To examine these consequences and categorize the state of knowledge in this area, we conducted a review of reviews indexed in five databases (Medline, Embase, Web of Science, PsycInfo, Sociological Abstracts). Reviews that reported the effect of climate change on child health inequalities between low- and high-income children, within or between countries (high- vs low-middle-income countries; HICs and LMICs), were included. Twenty-three reviews, published between 2007 and January 2021, were included for full-text analyses. Using thematic synthesis, we identified strong descriptive, but limited quantitative, evidence that climate change exacerbates child health inequalities. Explanatory mechanisms relating climate change to child health inequalities were proposed in some reviews; for example, children in LMICs are more susceptible to the consequences of climate change than children in HICs due to limited structural and economic resources. Geographic and intergenerational inequalities emerged as additional themes from the review. Further research with an equity focus should address the effects of climate change on adolescents/youth, mental health and inequalities within countries.

Interpreting forty-three-year trends of expenditures on public health in Canada: Long-run trends, temporal periods, and data differences.

The COVID-19 pandemic has raised concerns around public health (PH) investments. Among OECD countries, Canada devotes one of the largest shares of total health expenditures to PH. Examining retrospectively PH spending growth over a very long period may hold lessons on how to reach this high share. Further, different historical periods can be used to understand how macroeconomic conditions affect PH spending growth. Using forty-three years of data, we examine real PH spending growth per capita, comparatively between thirteen Canadian jurisdictions and with other key publicly funded healthcare sectors (physicians, hospitals, and pharmaceuticals), as well as by four periods defined by macroeconomic conditions. We find a five-fold increase on average in PH spending since 1975, a growth above physicians and hospitals, but below pharmaceuticals. However, there is substantial variation in PH growth between periods and across the country. Because concerns have been raised over PH spending data in other OECD countries, we explore differences between spending estimates reported by the national agency and ten provincial budgetary estimates, and find the former is larger. The magnitude of the difference varies between jurisdictions but not much over time. Although these differences do not challenge the presence of growth in PH spending, they show that the growth may be below that of hospitals. A better categorization of PH financing data is warranted.

Volunteer engagement to inform research on cardiovascular health awareness, Canada.

Volunteers have been extensively used in health promotion programmes. However, they have been less frequently involved in the research process. In its most recent iterations, the Cardiovascular Health Awareness Program (CHAP) integrated volunteers (i) to facilitate CHAP sessions with participating patients for data collection and (ii) to evaluate the intervention. Drawing on the patient and public involvement literature, our research team included volunteers in the data collection and evaluation of CHAP sessions as part of the programme's implementation in the province of Quebec (Canada). We sought volunteers' formal feedback through individual online and phone interviews and through focus groups for each of the four projects conducted in Quebec. We found that volunteers provide valuable insight on the research protocol as well as patient needs. Their feedback led to several modifications to the research protocol and procedures of subsequent CHAP sessions. Changes included involving volunteers at earlier stages of the research process, adding more learning modules and practice sessions during the volunteer training and defining research priorities according to patient needs. Our methodology of engaging volunteers in the research process was useful to gain important and unique insight on patient needs and for future programme planning to modify the research process.