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      Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews

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          Abstract

          Background

          There is increasing pressure to tackle the wider social determinants of health through the implementation of appropriate interventions. However, turning these demands for better evidence about interventions around the social determinants of health into action requires identifying what we already know and highlighting areas for further development.

          Methods

          Systematic review methodology was used to identify systematic reviews (from 2000 to 2007, developed countries only) that described the health effects of any intervention based on the wider social determinants of health: water and sanitation, agriculture and food, access to health and social care services, unemployment and welfare, working conditions, housing and living environment, education, and transport.

          Results

          Thirty systematic reviews were identified. Generally, the effects of interventions on health inequalities were unclear. However, there is suggestive systematic review evidence that certain categories of intervention may impact positively on inequalities or on the health of specific disadvantaged groups, particularly interventions in the fields of housing and the work environment.

          Conclusion

          Intervention studies that address inequalities in health are a priority area for future public health research.

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          Most cited references29

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          Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials.

          To assess the relative effectiveness of interventions to prevent falls in older adults to either a usual care group or control group. Systematic review and meta-analyses. Medline, HealthSTAR, Embase, the Cochrane Library, other health related databases, and the reference lists from review articles and systematic reviews. Components of falls intervention: multifactorial falls risk assessment with management programme, exercise, environmental modifications, or education. 40 trials were identified. A random effects analysis combining trials with risk ratio data showed a reduction in the risk of falling (risk ratio 0.88, 95% confidence interval 0.82 to 0.95), whereas combining trials with incidence rate data showed a reduction in the monthly rate of falling (incidence rate ratio 0.80, 0.72 to 0.88). The effect of individual components was assessed by meta-regression. A multifactorial falls risk assessment and management programme was the most effective component on risk of falling (0.82, 0.72 to 0.94, number needed to treat 11) and monthly fall rate (0.63, 0.49 to 0.83; 11.8 fewer falls in treatment group per 100 patients per month). Exercise interventions also had a beneficial effect on the risk of falling (0.86, 0.75 to 0.99, number needed to treat 16) and monthly fall rate (0.86, 0.73 to 1.01; 2.7). Interventions to prevent falls in older adults are effective in reducing both the risk of falling and the monthly rate of falling. The most effective intervention was a multifactorial falls risk assessment and management programme. Exercise programmes were also effective in reducing the risk of falling.
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            A typology of actions to tackle social inequalities in health.

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              Effect of insulating existing houses on health inequality: cluster randomised study in the community.

              To determine whether insulating existing houses increases indoor temperatures and improves occupants' health and wellbeing. Community based, cluster, single blinded randomised study. Seven low income communities in New Zealand. 1350 households containing 4407 participants. Installation of a standard retrofit insulation package. Indoor temperature and relative humidity, energy consumption, self reported health, wheezing, days off school and work, visits to general practitioners, and admissions to hospital. Insulation was associated with a small increase in bedroom temperatures during the winter (0.5 degrees C) and decreased relative humidity (-2.3%), despite energy consumption in insulated houses being 81% of that in uninsulated houses. Bedroom temperatures were below 10 degrees C for 1.7 fewer hours each day in insulated homes than in uninsulated ones. These changes were associated with reduced odds in the insulated homes of fair or poor self rated health (adjusted odds ratio 0.50, 95% confidence interval 0.38 to 0.68), self reports of wheezing in the past three months (0.57, 0.47 to 0.70), self reports of children taking a day off school (0.49, 0.31 to 0.80), and self reports of adults taking a day off work (0.62, 0.46 to 0.83). Visits to general practitioners were less often reported by occupants of insulated homes (0.73, 0.62 to 0.87). Hospital admissions for respiratory conditions were also reduced (0.53, 0.22 to 1.29), but this reduction was not statistically significant (P=0.16). Insulating existing houses led to a significantly warmer, drier indoor environment and resulted in improved self rated health, self reported wheezing, days off school and work, and visits to general practitioners as well as a trend for fewer hospital admissions for respiratory conditions.
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                Author and article information

                Journal
                J Epidemiol Community Health
                jech
                jech
                Journal of Epidemiology and Community Health
                BMJ Group (BMA House, Tavistock Square, London, WC1H 9JR )
                0143-005X
                1470-2738
                26 March 2010
                April 2010
                26 March 2010
                : 64
                : 4
                : 284-291
                Affiliations
                [1 ]Department of Geography, Durham University, Durham, UK
                [2 ]MRC Social and Public Health Sciences Unit, Glasgow, UK
                [3 ]Centre for Reviews and Dissemination, University of York, York, UK
                [4 ]Division of Public Health, University of Liverpool, Liverpool, UK
                [5 ]Public and Environment Health Research Unit, London School of Hygiene and Tropical Medicine, London, UK
                Author notes
                Correspondence to Clare Bambra, Department of Geography, Wolfson Research Institute, Durham University Queen's Campus, Stockton on Tees TS17 6BH, UK; clare.bambra@ 123456durham.ac.uk
                Article
                jech082743
                10.1136/jech.2008.082743
                2921286
                19692738
                873cb457-a975-4eab-8f5d-33404401a214
                © 2010, Published by the BMJ Publishing Group Limited For permission to use, (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 3 June 2009
                Categories
                Review
                1507
                Custom metadata
                editors-choice

                Public health
                social inequalities,systematic review,socioeconomic,health inequalities,evidence,interventions,social determinants,unemployment and health

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