How Equity-Oriented Health Care Affects Health: Key Mechanisms and Implications for Primary Health Care Practice and Policy

Policy Points A consensus regarding the need to orient health systems to address inequities is emerging, with much of this discussion targeting population health interventions and indicators. We know less about applying these approaches to primary health care. This study empirically demonstrates that providing more equity-oriented health care (EOHC) in primary health care, including trauma- and violence-informed, culturally safe, and contextually tailored care, predicts improved health outcomes across time for people living in marginalizing conditions. This is achieved by enhancing patients’ comfort and confidence in their care and their own confidence in preventing and managing health problems. This promising new evidence suggests that equity-oriented interventions at the point of care can begin to shift inequities in health outcomes for those with the greatest need. Context: Significant attention has been directed toward addressing health inequities at the population health and systems levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary health care context. Although the provision of equity-oriented health care (EOHC) is widely assumed to lead to improvements in patients’ health outcomes, little empirical evidence supports this claim. To remedy this, we tested whether more EOHC predicts more positive patient health outcomes and identified selected mediators of this relationship. Methods: Our analysis uses longitudinal data from 395 patients recruited from 4 primary health care clinics serving people living in marginalizing conditions. The participants completed 4 structured interviews composed of self-report measures and survey questions over a 2-year period. Using path analysis techniques, we tested a hypothesized model of the process through which patients’ perceptions of EOHC led to improvements in self-reported health outcomes (quality of life, chronic pain disability, and posttraumatic stress [PTSD] and depressive symptoms), including particular covariates of health outcomes (age, gender, financial strain, experiences of discrimination). Findings: Over a 24-month period, higher levels of EOHC predicted greater patient comfort and confidence in the health care patients received, leading to increased confidence to prevent and manage their health problems, which, in turn, improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life). In addition, financial strain and experiences of discrimination had significant negative effects on all health outcomes. Conclusions: This study is among the first to demonstrate empirically that providing more EOHC predicts better patient health outcomes over time. At a policy level, this research supports investments in equity-focused organizational and provider-level processes in primary health care as a means of improving patients’ health, particularly for those living in marginalizing conditions. Whether these results are robust in different patient groups and across a broader range of health care contexts requires further study

Optimal seismic upgrade timing in seaports with increasing throughput demand via real options

A real options (RO) formulation is proposed for decision-making on the timing to upgrade the seismic performance of existing seaports with increasing throughput demand in earthquake prone areas. The pay-off of the seismic upgrade investment option is estimated based on projected net earnings, repair cost, and downtime for a damaging reference seismic event having a pre-specified annual probability of occurrence. These projections inform a discrete-time RO binomial tree, following the American option valuation framework, which propagates the probability of the reference seismic event assuming Poisson temporal distribution of earthquake occurrence. The net present value of the expected annual payoff of the considered investment is used as an index supporting risk-informed decision-making discounted by the weighted average cost of capital (WACC). Numerical examples pertaining to decision makers with different capital cost, namely port authorities and terminal operators, operating in different economic environments typical of developed and developing countries are furnished to illustrate the applicability of the proposed RO formulation. It is found that high WACC and/or low throughput growth bring the optimal seismic upgrade timing forward, while earthquake consequences and upgrade cost have almost no influence on this timing

The minimum energy expenditure shortest path method

This article discusses the addition of an energy parameter to the shortest path execution process; namely, the energy expenditure by a character during execution of the path. Given a simple environment in which a character has the ability to perform actions related to locomotion, such as walking and stair stepping, current techniques execute the shortest path based on the length of the extracted root trajectory. However, actual humans acting in constrained environments do not plan only according to shortest path criterion, they conceptually measure the path that minimizes the amount of energy expenditure. On this basis, it seems that virtual characters should also execute their paths according to the minimization of actual energy expenditure as well. In this article, a simple method that uses a formula for computing vanadium dioxide ($VO_2$) levels, which is a proxy for the energy expenditure by humans during various activities, is presented. The presented solution could be beneficial in any situation requiring a sophisticated perspective of the path-execution process. Moreover, it can be implemented in almost every path-planning method that has the ability to measure stepping actions or other actions of a virtual character

The cell envelope subtilisin-like proteinase is a virulence determinant for Streptococcus suis

<p>Abstract</p> <p>Background</p> <p><it>Streptococcus suis </it>is a major swine pathogen and zoonotic agent that mainly causes septicemia, meningitis, and endocarditis. It has recently been suggested that proteinases produced by <it>S. suis </it>(serotype 2) are potential virulence determinants. In the present study, we screened a <it>S. suis </it>mutant library created by the insertion of Tn<it>917 </it>transposon in order to isolate a mutant deficient in a cell surface proteinase. We characterized the gene and assessed the proteinase for its potential as a virulence factor.</p> <p>Results</p> <p>Two mutants (G6G and M3G) possessing a single Tn<it>917 </it>insertion were isolated. The affected gene coded for a protein (SSU0757) that shared a high degree of identity with <it>Streptococccus thermophilus </it>PrtS (95.9%) and, to a lesser extent, with <it>Streptococcus agalactiae </it>CspA (49.5%), which are cell surface serine proteinases. The SSU0757 protein had a calculated molecular mass of 169.6 kDa and contained the catalytic triad characteristic of subtilisin family proteinases: motif I (Asp₂₀₀), motif II (His₂₃₉), and motif III (Ser₅₆₈). SSU0757 also had the Gram-positive cell wall anchoring motif (Leu-Pro-X-Thr-Gly) at the carboxy-terminus, which was followed by a hydrophobic domain. All the <it>S. suis </it>isolates tested, which belonged to different serotypes, possessed the gene encoding the SSU0757 protein. The two mutants devoid of subtilisin-like proteinase activity had longer generation times and were more susceptible to killing by whole blood than the wild-type parent strain P1/7. The virulence of the G6G and M3G mutants was compared to the wild-type strain in the CD1 mouse model. Significant differences in mortality rates were noted between the P1/7 group and the M3G and G6G groups (<it>p </it>< 0.001).</p> <p>Conclusion</p> <p>In summary, we identified a gene coding for a cell surface subtilisin-like serine proteinase that is widely distributed in <it>S. suis</it>. Evidences were brought for the involvement of this proteinase in <it>S. suis </it>virulence.</p

Aboriginal Children and Their Caregivers Living with Low Income: Outcomes from a Two-Generation Preschool Program

The development of preschool children of Aboriginal heritage is jeopardized by the inter-generational transmission of risk that has created, and continues to create, social disadvantage. Early intervention programs are intended to mitigate the impact of social disadvantage. Yet, evidence of the effectiveness of these programs for children of Aboriginal heritage is limited. The purpose of this study was to examine the effects of a two-generation, multi-cultural preschool program on 45 children of Aboriginal heritage and their caregivers. We used a single-group, pretest (program intake)/posttest (program exit) design with follow-up when the children were 7 years old. We used an observational measure of child receptive language (Peabody Picture Vocabulary Test–III) and caregiver-reported measures of child development (Nipissing District Developmental Screen), risk for child maltreatment (Adult-Adolescent Parenting Inventory; AAPI), parenting stress (Parenting Stress Index; PSI), self-esteem (Rosenberg Self-Esteem scale; RSE), and life skills (Community Life Skills scale; CLS). Using paired t-tests we found statistically significant increases in child receptive language scores between intake and exit, and repeated-measures ANOVA showed that these improvements were maintained up to age 7 years. For caregivers, Pearson’s correlations demonstrated that risk for child maltreatment, parenting stress, self-esteem, and life skills were stable over time. Results of this study suggest that children of Aboriginal heritage can benefit from participation in a two-generation, multi-cultural preschool program. Their caregivers may have received greater benefit if issues of intergenerational transmission of the negative influences of residential schools were addressed as part of programming

Gender, age and the MBA: An analysis of extrinsic and intrinsic career benefits

Against the background of an earlier UK study, this paper presents the findings of a Canadian based survey of career benefits from the MBA. Results indicate firstly that gender and age interact to influence perceptions of career outcomes (young men gain most in terms of extrinsic benefits of career change and pay), and secondly that both men and women gain intrinsic benefits from the MBA. However, intrinsic benefits vary by gender: men in the study were more likely to say they gained confidence from having a fuller skill set while women were more likely to say they gained confidence from feelings of self worth; men emphasised how they had learned to give up control while women argued that they had gained a ‘voice’ in the organization. The role of the MBA in career self- management and the acquisition of key skills are examined as well as the implications for the design of programmes in meeting the varied need of men and women in different age groups

A new experimental snow avalanche test site at Seehore peak in Aosta Valley (NW Italian Alps) - Part II: Engineering aspects

The estimate of the effects produced by the impact of a snow avalanche against an obstacle is of the utmost importance in designing safe mountain constructions. For this purpose, an ad-hoc instrumented obstacle was designed and built in order to measure impact forces of small and medium snow avalanches at Seehore peak (NW Italian Alps). The structural design had to consider several specific and unusual demands dictated by the difficult environment. In this article, the new test facility is described from the engineering point of view, discussing the most important aspects of the analyzed problems which were solved before and after the construction. The performance of the instrumented obstacle in the first two operating seasons, and some proposals for future upgrading are eventually illustrate

Youth’s narratives about family members smoking: parenting the parent- it’s not fair!

<p>Abstract</p> <p>Background</p> <p>Successful cancer prevention policies and programming for youth must be based on a solid understanding of youth’s conceptualization of cancer and cancer prevention. Accordingly, a qualitative study examining youth’s perspectives of cancer and its prevention was undertaken. Not surprisingly, smoking (i.e., tobacco cigarette smoking) was one of the dominant lines of discourse in the youth’s narratives. This paper reports findings of how youth conceptualize smoking with attention to their perspectives on parental and family-related smoking issues and experiences.</p> <p>Methods</p> <p>Seventy-five Canadian youth ranging in age from 11–19 years participated in the study. Six of the 75 youth had a history of smoking and 29 had parents with a history of smoking. Youth were involved in traditional ethnographic methods of interviewing and photovoice. Data analysis involved multiple levels of analysis congruent with ethnography.</p> <p>Results</p> <p>Youth’s perspectives of parents and other family members’ cigarette smoking around them was salient as represented by the theme: <it>It’s not fair.</it> Youth struggled to make sense of why parents would smoke around their children and perceived their smoking as an unjust act. The theme was supported by four subthemes: <it>1) parenting the parent about the dangers of smoking; 2) the good/bad parent; 3) distancing family relationships; and 4) the prisoner</it>. Instead of being <it>talked to</it> about smoking it was more common for youth to share stories of <it>talking to</it> their parents about the dangers of smoking. Parents who did not smoke were seen by youth as the good parent, as opposed to the bad parent who smoked. Smoking was an agent that altered relationships with parents and other family members. Youth who lived in homes where they were exposed to cigarette smoke felt like a trapped prisoner.</p> <p>Conclusions</p> <p>Further research is needed to investigate youth’s perceptions about parental cigarette smoking as well as possible linkages between youth exposed to second hand smoke in their home environment and emotional and lifestyle-related health difficulties. Results emphasize the relational impact of smoking when developing anti-tobacco and cancer prevention campaigns. Recognizing the potential toll that second-hand smoke can have on youth’s emotional well-being, health care professionals are encouraged to give youth positive messages in coping with their parents’ smoking behaviour.</p

Modelling the impact of compliance with dietary recommendations on cancer and cardiovascular disease mortality in Canada

Abstract: Objectives: Despite strong evidence indicating that unbalanced diets relate to chronic diseases and mortality, most adults do not comply with dietary recommendations. To help determine which recommendations could yield the most benefits, we estimated the number of deaths attributable to cardiovascular diseases and cancer that could be delayed or averted in Canada if adults changed their diet to adhere to recommendations. Study Design: Macrosimulation based on national population-based survey and vital statistics data. Methods: We used a macrosimulation model to draw age- and sex-specific changes in relative risks based on the results of meta-analyses of relationship between food components and risk of cardiovascular disease and diet-related cancers. Inputs in the model included Canadian recommendations (fruit and vegetable, fiber, salt, and total-, monounsaturated-, polyunsaturated-, saturated-, and trans-fats), average dietary intake (from 35 107 participants with 24-h recall), and mortality from specific causes (from Canadian Vital Statistics). Monte Carlo analyses were used to compute 95% credible intervals (CI). Results: Our estimates suggest that 30 540 deaths (95% CI: 24 953, 34 989) per year could be averted or delayed if Canadians adhered to their dietary recommendations. By itself, the recommendation for fruit and vegetable intake could save as many as 72% (55-87%) of these deaths. It is followed by recommendations for fibers (29%, 13-43%) and salt (10%, 9-12%). Conclusions: A considerable number of lives could be saved if Canadians adhered to the national dietary intake recommendations. Given the scarce resources available to promote guideline adhesion, priority should be given to recommendations for fruit and vegetable intake