Health equity monitoring is essential in public health: lessons from Mozambique.

BACKGROUND: Countries must be able to describe and monitor their populations health and well-being needs in an attempt to understand and address them. The Sustainable Development Goals (SDGs) have re-emphasized the need to invest in comprehensive health information systems to monitor progress towards health equity; however, knowledge on the capacity of health information systems to be able do this, particularly in low-income countries, remains very limited. As a case study, we aimed to evaluate the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with SDG 3 (Good Health and Well Being for All at All Ages). METHODS: A data source mapping of the health information system in Mozambique was conducted. We followed the World Health Organization's methodology of assessing data sources to evaluate the information available for every equity stratifier using a three-point scale: 1 - information is available, 2 - need for more information, and 3 - an information gap. Also, for each indicator we estimated the national average inequality score. RESULTS: Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 SDG3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with SDG3 can be fully disaggregated by equity stratifiers; they either lack some information (15 indicators) or do not have information at all (nine indicators). The indicators that contain more information are related to maternal and child health. CONCLUSIONS: There are important information gaps in Mozambique's current national health information system which prevents it from being able to comprehensively measure and monitor health equity. Comprehensive national health information systems are an essential public health need. Significant policy and political challenges must also be addressed to ensure effective interventions and action towards health equity in the country.

Strategies to support culturally safe health and wellbeing evaluations in Indigenous settings in Australia and New Zealand: a concept mapping study.

BACKGROUND: In recent decades, financial investment has been made in health-related programs and services to overcome inequities and improve Indigenous people's wellbeing in Australia and New Zealand. Despite policies aiming to 'close the gap', limited evaluation evidence has informed evidence-based policy and practice. Indigenous leaders have called for evaluation stakeholders to align their practices with Indigenous approaches. METHODS: This study aimed to strengthen culturally safe evaluation practice in Indigenous settings by engaging evaluation stakeholders, in both countries, in a participatory concept mapping study. Concept maps for each country were generated from multi-dimensional scaling and hierarchical cluster analysis. RESULTS: The 12-cluster Australia map identifies four cluster regions: An Evaluation Approach that Honours Community; Respect and Reciprocity; Core Heart of the Evaluation; and Cultural Integrity of the Evaluation. The 11-cluster New Zealand map identifies four cluster regions: Authentic Evaluation Practice; Building Maori Evaluation Expertise; Integrity in Maori Evaluation; and Putting Community First. Both maps highlight the importance of cultural integrity in evaluation. Differences include the distinctiveness of the 'Respecting Language Protocols' concept in the Australia map in contrast to language being embedded within the cluster of 'Knowing Yourself as an Evaluator in a Maori Evaluation Context' in the New Zealand map. Participant ratings highlight the importance of all clusters with some relatively more difficult to achieve, in practice. Notably, the 'Funding Responsive to Community Needs and Priorities' and 'Translating Evaluation Findings to Benefit Community' clusters were rated the least achievable, in Australia. The 'Conduct of the Evaluation' and the 'Prioritising Maori Interests' clusters were rated as least achievable in New Zealand. In both countries, clusters of strategies related to commissioning were deemed least achievable. CONCLUSIONS: The results suggest that the commissioning of evaluation is crucial as it sets the stage for whether evaluations: reflect Indigenous interests, are planned in ways that align with Indigenous ways of working and are translated to benefit Indigenous communities Identified strategies align with health promotion principles and relational accountability values of Indigenous approaches to research. These findings may be relevant to the commissioning and conduct of Indigenous health program evaluations in developed nations.

[Inequality in the management of ischemic chest pain in the emergency department from a gender perspective]. / Inequidades en la atención al dolor torácico de origen isquémico en Urgencias desde una perspectiva de género.

OBJECTIVE: Sex is a determining factor in the differences with which men and women are treated in the emergency room. The objective was to analyze the profile in patients with chest paint attended in emergency department, and the gender inequalities in the diagnosis and treatment. METHODS: Descriptive observational study of patients, who attended to the Miguel Servet University Hospital emergency department, with ischemic chest pain during 2017. Sociodemographic and clinical variables of treatment and evolution were analyzed. Bivariate and multivariate analysis was performed through the statistical program SPSS. RESULTS: 351 cases were registered (235 men and 116 women). The women were older (median age 75.5 years, against, 71.4 years in men, p=0.003), went to the hospital during summer time (p=0.021) and took most often of benzodiazepines (p=0.001), antidepressants (p<0.001) and diuretics drugs (p=0.039). The women had greater proportion of arterial hypertension (p=0.001). The men came more to the emergency department during autumn period (p=0.008), and had more history of ischemic heart disease (p=0.003) and percutaneous coronary intervention (p<0.001). The time of completion of the first electrocardiogram was greater in women (p<0.001), and were diagnosed with a higher frequency of atypical chest pain (p=0.003), unlike men, more diagnosed of acute coronary syndrome (p=0.028) and subjected to invasive treatment (p<0.001). CONCLUSIONS: There are differences according to sex in the antecedents, delay in performing the first electrocardiogram and use of invasive treatment. Its consideration from the emergency department, without influence of value judgments and with the determination of values disaggregated by sex, can improve the attention and evolution of these patients.

OBJETIVO: El sexo es determinante en las diferencias con que hombres y mujeres son atendidos en Urgencias. El objetivo de este estudio fue analizar el perfil clínico de los pacientes atendidos en Urgencias por dolor torácico isquémico, y la presencia de inequidades según sexo en el diagnóstico y tratamiento. METODOS: Se realizó un estudio observacional descriptivo de los pacientes que acudieron a Urgencias del Hospital Universitario Miguel Servet (Zaragoza) por dolor torácico isquémico en 2017. Se recogieron variables sociodemográficas y clínicas de tratamiento y evolución mediante la historia clínica. Se realizó análisis bivariante y multivariante mediante el paquete estadístico SPSS. RESULTADOS: Se registraron 351 casos (235 hombres, 116 mujeres). Las mujeres fueron mayores que los hombres (edad mediana de 75,5 años frente a 71,4 años en hombres, p=0,003), acudieron más durante el verano (p=0,021), tomaron con mayor frecuencia benzodiacepinas (p=0,001), antidepresivos (p<0,001) y diuréticos (p=0,039), y presentaron con mayor proporción hipertensión arterial (p=0,001). Los hombres acudieron más durante el otoño (p=0,008) y presentaron más antecedentes de cardiopatía isquémica (p=0,003) e intervención coronaria percutánea (p<0,001). El tiempo de realización del electrocardiograma fue mayor en mujeres (p<0,001), y estas fueron diagnosticadas con mayor frecuencia de dolor torácico atípico (p=0,003), a diferencia de los hombres, más diagnosticados de síndrome coronario agudo (p=0,028) y sometidos a tratamiento invasor (p<0,001). CONCLUSIONES: Existen diferencias según el sexo en los antecedentes, demora en la realización del electrocardiograma y uso de tratamiento invasor. Su consideración desde Urgencias, sin influencia de juicios de valor y con la determinación de valores desagregados por sexo, puede mejorar la atención y evolución de estos pacientes.

Compact of Free Association Migrants and Health Insurance Policies: Barriers and Solutions to Improve Health Equity.

This commentary outlines the health insurance disparities of Compact of Free Association (COFA) migrants living in the United States. Compact of Free Association migrants are citizens of the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau who can live, work, and study in the United States without a visa. Compact of Free Association migrants make up a significant proportion of the rapidly growing Pacific Islander population in the United States. This article describes the historical and current relationships between the United States and the Compact nations and examines national policy barriers constraining health insurance access for COFA migrants. In addition, the commentary describes the state-level health policies of Arkansas, Hawai'i, and Oregon, which are the states where the majority of COFA migrants reside. Finally, policy recommendations are provided to improve health equity for COFA migrants.

Race, Socioeconomic Status, and Health-Care Access Disparities in Ovarian Cancer Treatment and Mortality: Systematic Review and Meta-Analysis.

BACKGROUND: Ovarian cancer remains a leading cause of death from gynecological malignancies. Race, socioeconomic status (SES), and access to health care are important predictors of quality treatment and survival. We provide a systematic review and meta-analysis on the role of these predictors on disparities in ovarian cancer treatment and mortality. METHODS: Using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched PubMed, EMBASE, and Scopus for relevant articles published between January 2000 and March 2017. We selected studies published in the United States that evaluated the role of race, SES, or health-care access on disparities in ovarian cancer treatment or survival. Pooled relative risk (RR) and 95% confidence intervals (CIs) were calculated for each outcome using a random-effects model. RESULTS: A total of 41 studies met the inclusion criteria for systematic review. In meta-analysis, there was a 25% decrease (RR = 0.75, 95% CI = 0.66 to 0.84) in receipt of adherent ovarian cancer treatment and 18% increased risk (RR = 1.18, 95% CI = 1.11 to 1.26) of mortality for blacks compared to whites. Receipt of adherent ovarian cancer treatment was 15% lower (RR = 0.85, 95% CI = 0.77 to 0.94) in the lowest vs highest SES group and 30% lower (RR = 0.70, 95% CI = 0.58 to 0.85) among patients at lower vs higher hospital volumes. CONCLUSION: We found consistent and strong evidence for continued lack of quality ovarian cancer treatment and higher mortality among ovarian cancer patients who are black, are of low SES, and/or have poor access to care. Interventions focused on these groups targeting specific barriers to care are needed to reduce disparities in ovarian cancer treatment and mortality.

The trend of full vaccination coverage in infants and inequalities by wealth quintile and maternal education: analysis from four recent demographic and health surveys in Nepal.

BACKGROUND: Despite policy intention to reach disadvantaged populations, inequalities in health care resource use and health outcomes persist in Nepal. The current study aimed to investigate the trend of full vaccination coverage among infants and its equity gaps between Nepal Demographic and Health Surveys (NDHS) 2001 and 2016. METHODS: Using data from NDHS conducted in 2001, 2006, 2011 and 2016, we investigated the trend of coverage of six antigens: Bacille Calmette Guerin (BCG), Diptheria, Pertussis, Tetanus (DPT), Polio, and Measles during their infancy among children aged 12-23 months. We presented trends and correlates of full vaccination coverage by different socio-demographic factors. We measured inequalities in full vaccination coverage by wealth quintile and maternal education using absolute measure (slope index of inequality) and relative measures (Relative index of inequality, concentration index) of inequalities. RESULTS: Full vaccination coverage among infants steadily increased from 65.6% in 2001 to 87.0% in 2011; however, it decreased to 77.8% in 2016. Province 2 had a significantly lower full vaccination coverage compared to Province1.Although decreasing over time, there were significant inequalities by household wealth quintiles and maternal educational status. The slope index of inequality (SII) for wealth quintiles decreased from - 32.3 [- 45.5,-19.1] in 2001 to an SII of-8.4 [- 18.6,-1.7] in 2016. Similarly, the SII for education decreased from - 61.8 [- 73.5,-50.1] in 2001 to an SII of - 30.5 [- 40.7,-20.2] in 2016. Similarly, the relative index of inequality (RII) also showed an improvement over time, indicating the narrowing equity gap. Additionally, concentration index on full vaccination coverage by wealth quintiles dropped from 0.21 (0.12-0.28) in 2001 to 0.054 (- 0.01-0.12) in 2016. Absolute and relative inequalities were persistently larger by maternal educational status compared to household wealth quintiles throughout the study period. CONCLUSION: Full vaccination coverage in Nepal increased from 2001 until 2011 but saw a significant decrement away from the national target after 2011. However, the equity gap by household wealth quintile and maternal education status has narrowed over time. National Immunization programs need to give higher emphasis to infants born to mothers with less education, those born in the poorer wealth quintile households, and those living in Province 2.

The rural-urban gap: differences in injury characteristics. / Écart entre milieu rural et milieu urbain : différences dans les caractéristiques des blessures.

BACKGROUND: Injuries are among the top 10 leading causes of death in Canada. However, the types and rates of injuries vary between rural versus urban settings. Injury rates increase with rurality, particularly those related to motor vehicle collisions. Factors such as type of work, hazardous environments and longer driving distances contribute to the difference in rural and urban injury rates. Further examination of injuries comparing rural and urban settings with increased granularity in the nature of injuries and severity is needed. METHODS: The study population consisted of records from the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP) from between 2011 and July 2017. Rural and urban status was determined based on postal codes as defined by Canada Post. Proportionate injury ratios (PIRs) were calculated to compare rural and urban injury rates by nature and severity of injury and sex, among other factors. RESULTS: Rural injuries were more likely to involve multiple injuries (PIR = 1.66 for 3 injuries) and crush injuries (PIR = 1.72). More modestly elevated PIRs for rural settings were found for animal bites (1.14), burns (1.22), eye injuries (1.32), fractures (1.20) and muscle or soft tissue injuries (1.11). Injuries in rural areas were more severe, with a higher likelihood of cases being admitted to hospital (1.97), and they were more likely to be due to a motor vehicle collision (2.12). CONCLUSION: The nature of injuries in rural settings differ from those in urban settings. This suggests a need to evaluate current injury prevention efforts in rural settings with the aim to close the gap between rural and urban injury rates.

Protecting our future generation: study protocol for a randomized controlled trial evaluating a sexual health self-care intervention with Native American youth and young adults.

BACKGROUND: Disparities in sexually transmitted infections (STI) are an urgent problem among Native American youth and young adults which are not fully explained by different sexual or related behaviors. These sexual health disparities are more likely attributed to social environments and structural determinants such as a shortage of sexual healthcare providers, lower socioeconomic status, and access barriers to STI screening and treatment, including geographic isolation and confidentiality concerns. Innovative, non-clinic based alternatives to promote STI screening and treatment are essential for alleviating these disparities. Self-care, or the care taken by individuals towards their own health and well-being may be such a strategy. This study will assess the efficacy of a self-care intervention, called Protecting Our Future Generation, for increasing uptake of STI screening and impacting sexual risk and protective behaviors among Native American youth and young adults living in a reservation-based community in the Southwestern United States. METHODS: The proposed study is a randomized controlled trial to test the efficacy of a self-care intervention compared to a control condition. Participants will be Native Americans ages 14-26 years old who have had vaginal or anal sex at least once in their lifetime. Participants will be randomized to the intervention which includes: 1) a sexual health self-assessment with embedded clinical prediction tool predicting STI positivity, and 2) personalized messaging with key steps to lower risk for STIs, or the control condition which includes: 1) a self-assessment about water, soda and sugar sweetened beverage consumption, and 2) personalized messaging to meet recommended daily intake. All participants will be offered a self-administered STI test. Participants will complete assessments at baseline, 3- and 6-months follow-up. The primary outcome measure is completion of STI screening. DISCUSSION: Protecting Our Future Generation is among the first self-care interventions uniquely focused on sexual health among a Native American population, who endure significant sexual health disparities and are under-represented in research. If efficacious, the intervention will be a model of sexual health self-care for Native American youth and young adults adaptable for use in healthcare and community-based settings. TRIAL REGISTRATION: Clinical Trials: http://clinicaltrials.gov; NCT03895320; Registered 03/28/2019.

Inequality of health stock and the relation to national wealth.

BACKGROUND: The decline in global and between-country health inequality is a major challenge to overcome. However, few studies have systematically investigated the relationship between inequality of health stock and national wealth. From an economic perspective, health can be viewed as a durable capital stock that produces an output of healthy time. Therefore, in this paper, we focused on health capital to investigate the relationship between inequalities of national health and national wealth. METHODS: Based on health stock data from 1990 to 2015 for 140 countries, we estimated Gini coefficients of health stock to investigate associations with a well-known economic flow indicator, Gross Domestic Product (GDP), stock-based national wealth indicator, Inclusive Wealth Index (IWI), and firm-level net income. RESULTS: The estimated Gini coefficient of global health stock shows that health stock has experienced a global decline. The Gini coefficient for low-income countries (LICs) showed the fastest decline in health stock, dropping from 0.69 to 0.66 in 25 years. Next, rapid population growth and the rise in the youth share of the working-age population in LICs were most likely contributing factors to the decline in inequality. Most countries that experienced positive health stock growth also indicated a strong positive relationship with GDP and IWI. However, some countries showed a negative relationship with natural capital, which is a part of IWI. In addition, firm-level net income showed no obvious associations with health stock, GDP and IWI. CONCLUSIONS: We argue that a negative relationship between health stock and natural capital is a sign of unstable development because sustainable development involves maintaining not only GDP but also IWI, as it is a collective set of assets or wealth comprising human, produced and natural capital. Moreover, in our analysis of firm-level income data, we also discuss that income will be influenced by other factors, such as innovations, human resources, organization culture and strategy. Therefore, the paper concludes that health stock is a vital component in measuring health inequality and health-related Sustainable Development Goals (SDGs). Thus, IWI is more comprehensive in measuring national wealth and can complement GDP in measuring progress toward sustainable development.

Healthy People 2020: Rural Areas Lag In Achieving Targets For Major Causes Of Death.

For the period 2007-17 rural death rates were higher than urban rates for the seven major causes of death analyzed, and disparities widened for five of the seven. In 2017 urban areas had met national targets for three of the seven causes, while rural areas had met none of the targets.

Rural-Urban Differences In Severe Maternal Morbidity And Mortality In The US, 2007-15.

In the United States, severe maternal morbidity and mortality is climbing-a reality that is especially challenging for rural communities, which face declining access to obstetric services. Severe maternal morbidity refers to potentially life-threatening complications or the need to undergo a lifesaving procedure during or immediately following childbirth. Using data for 2007-15 from the National Inpatient Sample, we analyzed severe maternal morbidity and mortality during childbirth hospitalizations among rural and urban residents. We found that severe maternal morbidity and mortality increased among both rural and urban residents in the study period, from 109 per 10,000 childbirth hospitalizations in 2007 to 152 per 10,000 in 2015. When we controlled for sociodemographic factors and clinical conditions, we found that rural residents had a 9 percent greater probability of severe maternal morbidity and mortality, compared with urban residents. Attention to the challenges faced by rural patients and health care facilities is crucial to the success of efforts to reduce maternal morbidity and mortality in rural areas. These challenges include both clinical factors (workforce shortages, low patient volume, and the opioid epidemic) and social determinants of health (transportation, housing, poverty, food security, racism, violence, and trauma).

The Potential for Plant-Based Diets to Promote Health Among Blacks Living in the United States.

Plant-based diets are associated with reduced risks of various chronic diseases in the general population. However, it is unclear how these benefits translate to Blacks living in the United States, who are disproportionately burdened with heart disease, cancer, diabetes, obesity, and chronic kidney disease. The objectives of this study were to: (1) review the general evidence of plant-based diets and health outcomes; (2) discuss how this evidence translates to Blacks following a plant-based diet; and (3) provide recommendations and considerations for future studies in this area. Interestingly, although the evidence supporting plant-based diets in the general population is robust, little research has been done on Blacks specifically. However, the available data suggests that following a plant-based diet may reduce the risk of heart disease and possibly cancer in this population. More research is needed on cardiovascular disease risk factors, cancer subtypes, and other chronic diseases. Further, attention must be given to the unique individual, familial, communal, and environmental needs that Blacks who follow plant-based diets may have. Interventions must be culturally appropriate in order to achieve long-term success, and providing low-cost, flavorful, and nutritious options will be important.

Disparity on Unplanned Readmission in Melanoma Patients: A National Cancer Database Analysis.

BACKGROUND/AIM: This study aimed to analyze associated factors of 30-day hospital readmission after surgery for melanoma. PATIENTS AND METHODS: We conducted a retrospective analysis of postoperative 30-day unplanned readmission in patients with melanoma in the National Cancer Database (NCDB). RESULTS: Higher odds of unplanned readmission were found in non-white patients compared to white, uninsured patients compared to those with private insurance, tumors with invasive behavior compared to in situ, presence of ulceration, American Joint Committee on Cancer stages greater than II, and location in the extremities. Lower odds of unplanned readmission were found in women living in areas where the percentage of adults who did not graduate from high school was below 13.0% with an annual income of $38,000 or more, who were treated in Academic/Research Programs or Integrated Network Cancer Programs. CONCLUSION: Non-white patients and low-income zip-codes were associated with unplanned readmission.

Social determinants of health and their impact on postcolectomy surgery readmissions: a multistate analysis, 2009-2014.

Aim: To examine the effect of race/ethnicity, insurance status and median household income on postoperative readmissions following colectomy. Patients & methods: Multivariate analysis of hospital discharge data from California, Florida, Maryland and New York from 2009 to 2014. Primary outcomes included adjusted odds of 30- and 90-day readmissions following colectomy by race, insurance status and median income quartile. Results: Total 330,840 discharges included. All 30-day readmissions were higher for black patients (adjusted odds ratio [aOR]: 1.07). Both 30- and 90-day readmissions were higher for Medicaid (aOR: 1.30 and 1.26) and Medicare (aOR: 1.30 and 1.29). The 30- and 90-day readmissions were lower in the highest income quartiles. Conclusion: Race, insurance status and median household income are all independent predictors of disparity in readmissions following colectomy.

Health literacy as a mediator of the relationship between socioeconomic status and health: A cross-sectional study in a population-based sample in Florence.

BACKGROUND: Health literacy(HL) has recently been proposed as a potential mediator in the pathway through which socio-economic status(SES) affects health. However, empirical research investigating the contribution of HL in this relationship remains scarce. This study investigated whether functional HL mediates the association between SES and self-reported health(SRH) in an adult population-based sample. METHODS: The study adopted a cross-sectional design. Education level and financial status were used as measures of SES, while functional HL was assessed with the Newest Vital Sign. Moderated mediation analyses were conducted using SES variables as independent variables, SRH as dependent variable and functional HL as mediator variable. Furthermore, age, sex and chronic diseases were tested as moderators of the effect mediated by functional HL. RESULTS: 452 subjects completed the study (58,8% female; mean age 53,25±11,7). Results showed that functional HL mediates on average 18.5% of the association between education and SRH (p = 0.02) and 12.9% (p = 0.01) of the association between financial status and SRH. Furthermore, the proportion of effect mediated by functional HL was found to be higher in lower socio-economic classes for both SES variables considered. No significant moderation effects of age, sex or chronic diseases were observed for both SES variables. CONCLUSION: Findings suggest that functional HL may serve as a pathway by which SES affects health status, especially in lower SES groups. HL may be a valuable and actionable intermediate target for addressing health inequalities. However, further studies are needed to better define the mediating role of HL across socio-economic classes.

[Inequalities in access to services, basis for policies to reduce the health gap]. / Desigualdades en el acceso a servicios, base de las políticas para la reducción de la brecha en salud.

OBJECTIVE: To estimate inequalities in access to health services among Mexican population living in localities of 100 000 or less inhabitants. MATERIALS AND METHODS: Cross-sectional analysis using the National Health and Nu- trition Survey 100k 2018 survey data. Access was estimated using health insurance and care for the last health condition. As inequality measure, we estimated the concentration index using an imputation of household per capita income. RESULTS: Among studied population, health insurance was 82.42% and access to care 60.03%. We identified inequalities in both indicators; marginal and pro-poor for insurance and pro-rich for access to care. CONCLUSIONS: In Mexico, even within the popuation living in poverty there are inequalities in access to health care. More granular public interventions are needed to address inequalities in an effective way.

OBJETIVO: Estimar la desigualdad en acceso a servicios de salud en poblaciones de localidades menores de 100 000 habitantes en México. MATERIAL Y MÉTODOS: Análisis de la Encuesta Nacional de Salud y Nutrición 100k 2018. Se estimó el acceso con base en la afiliación a un esquema de aseguramiento (acceso potencial) y la atención para el más reciente problema de salud (acceso a atención) mediante el índice de concentración, utilizando una imputación del ingreso per cápita. RESULTADOS: La afiliación a algún esquema de ase- guramiento en salud fue de 82.42% y el acceso a atención de 60.03%. Se identificaron desigualdades en ambos indicadores, marginales para acceso potencial y con mayor concentración entre la población de menor ingreso; para acceso a atención se encontró desigualdad con mayor concentración entre la población de mayor ingreso. CONCLUSIONES: En México prevalecen desigualdades en acceso a servicios de salud para la población en condiciones de pobreza. Es necesario desarrollar intervenciones públicas con mayor granularidad para incidir de forma efectiva en la desigualdad.

Community pharmacy interventions for health promotion: effects on professional practice and health outcomes.

BACKGROUND: Community pharmacies are an easily accessible and cost-effective platform for delivering health care worldwide, and the range of services provided has undergone rapid expansion in recent years. Thus, in addition to dispensing medication, pharmacy workers within community pharmacies now give advice on a range of health-promoting behaviours that aim to improve health and to optimise the management of long-term conditions. However, it remains uncertain whether these health-promotion interventions can change the professional practice of pharmacy workers, improve health behaviours and outcomes for pharmacy users and have the potential to address health inequalities. OBJECTIVES: To assess the effectiveness and safety of health-promotion interventions to change community pharmacy workers' professional practice and improve outcomes for users of community pharmacies. SEARCH METHODS: We searched MEDLINE, Embase, CENTRAL, six other databases and two trials registers to 6 February 2018. We also conducted reference checking, citation searches and contacted study authors to identify any additional studies. SELECTION CRITERIA: We included randomised trials of health-promotion interventions in community pharmacies targeted at, or delivered by, pharmacy workers that aimed to improve the health-related behaviour of people attending the pharmacy compared to no treatment, or usual treatment received in the community pharmacy. We excluded interventions where there was no interaction between pharmacy workers and pharmacy users, and those that focused on medication use only. DATA COLLECTION AND ANALYSIS: We used standard procedures recommended by Cochrane and the Effective Practice and Organisation of Care review group for both data collection and analysis. We compared intervention to no intervention or to usual treatment using standardised mean differences (SMD) and 95% confidence intervals (95% CI) (higher scores represent better outcomes for pharmacy user health-related behaviour and quality of life, and lower scores represent better outcomes for clinical outcomes, costs and adverse events). Interpretation of effect sizes (SMD) was in line with Cochrane recommendations. MAIN RESULTS: We included 57 randomised trials with 16,220 participants, described in 83 reports. Forty-nine studies were conducted in high-income countries, and eight in middle-income countries. We found no studies that had been conducted in low-income countries. Most interventions were educational, or incorporated skills training. Interventions were directed at pharmacy workers (n = 8), pharmacy users (n = 13), or both (n = 36). The clinical areas most frequently studied were diabetes, hypertension, asthma, and modification of cardiovascular risk. Duration of follow-up of interventions was often unclear. Only five studies gave details about the theoretical basis for the intervention, and studies did not provide sufficient data to comment on health inequalities. The most common sources of bias were lack of protection against contamination - mainly in individually randomised studies - and inadequate blinding of participants. The certainty of the evidence for all outcomes was moderate. We downgraded the certainty because of the heterogeneity across studies and evidence of potential publication bias. Professional practice outcomes We conducted a narrative analysis for pharmacy worker behaviour due to high heterogeneity in the results. Health-promotion interventions probably improve pharmacy workers' behaviour (2944 participants; 9 studies; moderate-certainty evidence) when compared to no intervention. These studies typically assessed behaviour using a simulated patient (mystery shopper) methodology. Pharmacy user outcomes Health-promotion interventions probably lead to a slight improvement in health-related behaviours of pharmacy users when compared to usual treatment (SMD 0.43, 95% CI 0.14 to 0.72; I2 = 89%; 10 trials; 2138 participants; moderate-certainty evidence). These interventions probably also lead to a slight improvement in intermediate clinical outcomes, such as levels of cholesterol or glycated haemoglobin, for pharmacy users (SMD -0.43, 95% CI -0.65 to -0.21; I2 = 90%; 20 trials; 3971 participants; moderate-certainty evidence). We identified no studies that evaluated the impact of health-promotion interventions on event-based clinical outcomes, such as stroke or myocardial infarction, or the psychological well-being of pharmacy users. Health-promotion interventions probably lead to a slight improvement in quality of life for pharmacy users (SMD 0.29, 95% CI 0.08 to 0.50; I2= 82%; 10 trials, 2687 participants; moderate-certainty evidence). Adverse events No studies reported adverse events for either pharmacy workers or pharmacy users. Costs We found that health-promotion interventions are likely to be cost-effective, based on moderate-certainty evidence from five of seven studies that reported an economic evaluation. AUTHORS' CONCLUSIONS: Health-promotion interventions in the community pharmacy context probably improve pharmacy workers' behaviour and probably have a slight beneficial effect on health-related behaviour, intermediate clinical outcomes, and quality of life for pharmacy users. Such interventions are likely to be cost-effective and the effects are seen across a range of clinical conditions and health-related behaviours. Nevertheless the magnitude of the effects varies between conditions, and more effective interventions might be developed if greater consideration were given to the theoretical basis of the intervention and mechanisms for effecting behaviour change.