1. “Mind the gap” Which Manitoba health outcomes show increased or decreased inequity over time, and what programs are associated with these? Speaker: Patricia J. Martens PhD Director: Manitoba Centre for Health Policy; CIHR/PHAC Applied Public Health Chair; Associate Professor, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba ABSTRACT AUTHORS: Martens PJ, Fransoo R, The Need To Know Team, Burland E, Prior H, Burchill C, Romphf L.

2. What Works? A first look at evaluating Manitoba’s regional health programs and policies at the population level. Authors of report: Patricia Martens, Randy Fransoo, The Need To Know Team, Elaine Burland, Heather Prior, Charles Burchill, Linda Romphf, Dan Chateau, Angela Bailly, Carole Ouelette. Plus a massive Working Group!! Chapters 7, 10 and 11

3. CIHR’s The Need To Know Team CIHR-funded, through the Community Alliances for Health Research (CAHR) program 2001-2007; CIHR KT Award (2007/08); CIHR/PHAC Applied Public Health Chair (2008-2013) MCHP, RHAs, Manitoba Health

4. Do upstream systems approaches really work to reduce inequity?

5. Methods The Population Health Research Data Repository, housed at MCHP, contains anonymized administrative data for all Manitobans. Three health outcomes measured: –Breastfeeding initiation: % newborns breastfeeding on hospital discharge (1988/89-2003/04) –Mammography tests: % women aged 50-69 receiving 1+ mammography within 2 years (1994/96-2002/04) –Cervical cancer screening: % women aged 18-69 receiving 1+ Pap test within 3 years (1986/89-2001/04) Regional age- and sex-adjusted rates and time trends: regression modelling (negative binomial, poisson or logistic regression)

6. Measure of ‘inequity’ Geographical “inequity” at earliest and latest time period: –subtracting highest and lowest aggregate area rates = rate difference (RD) –aggregate areas: non-Winnipeg areas (Brandon, Rural South, Mid, North); three Winnipeg areas (most healthy, average, least healthy).

7. “North” = Nor-Man, Burntwood, Churchill “South” = Assiniboine, Central, South Eastman “Mid” = Parkland, Interlake, North Eastman

9. Figure 7.5: Trends in Non-Winnipeg Breastfeeding Initiation Rates Maternal age-adjusted percent of newborns breastfeeding at hospital discharge 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1988/891989/901990/911991/921992/931993/941994/951995/961996/971997/981998/991999/002000/012001/022002/032003/04 Time period South Mid North Brandon Manitoba Source: Manitoba Centre for Health Policy, 2007 RD 13.9% RD 19.8%

10. Figure 7.6: Trends in Winnipeg Breastfeeding Initiation Rates Maternal age-adjusted percent of newborns breastfeeding at hospital discharge 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1988/891989/901990/911991/921992/931993/941994/951995/961996/971997/981998/991999/002000/012001/022002/032003/04 Time Period Wpg Most Healthy Wpg Average Health Wpg Least Healthy Winnipeg Manitoba source: Manitoba Centre for Health Policy, 2007 Canada Prenatal Nutrition Programs, Healthy Baby and Family First RD 16.0% RD 11.7% Significant “jump” at program onset, p<.003

11. Figure 10.5: Trends in Non-Winnipeg Mammography Rates Age-adjusted percentage of women age 50-69 receiving at least one mammogram in two years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1984/861986/881988/901990/921992/941994/961996/981998/20002000/022002/04 Time period South Mid North Brandon Manitoba Source: Manitoba Centre for Health Policy, 2008 RD 47.0% RD 9.1% Mid-1990s: Beginning of notification and rural Mobile Screening Program

12. Figure 10.6: Trends in Winnipeg Mammography Rates Age-adjusted percentage of women age 50-69 receiving at least one mammogram in two years 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1984/861986/881988/901990/921992/941994/961996/981998/20002000/022002/04 Time Period Wpg Most Healthy Wpg Average Health Wpg Least Healthy Winnipeg Manitoba Source: Manitoba Centre for Health Policy, 2008 RD 21.1% RD 24.3%

13. Figure 11.5: Trends in Non-Winnipeg Cervical Cancer Screening Rates Age-adjusted percent of women age 18-69 with one or more Pap smears in a three-year period, excluding those who have had a hysterectomy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1986/891989/921992/951995/981998/20012001/04 Time period South Mid North Brandon Manitoba Source: Manitoba Centre for Health Policy, 2008 RD 18.2% RD 31.8%

14. Figure 11.6: Trends in Winnipeg Cervical Cancer Screening Rates Age-adjusted percent of women age 18-69 with one or more Pap smears in a three-year period, excluding those who have had a hysterectomy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 1986/891989/921992/951995/981998/20012001/04 Time Period Wpg Most Healthy Wpg Average Health Wpg Least Healthy Winnipeg Manitoba source: Manitoba Centre for Health Policy, 2008 RD 8.2% RD 12.9%

15. Key Results BREASTFEEDING RATES: Winnipeg’s breastfeeding rates showed decreased inequity, associated with national (CPNP) and provincial perinatal core-area initiatives. MAMMOGRAPHY RATES: mammography gap increased slightly in Winnipeg, but decreased dramatically outside Winnipeg. Provincial notification and rural mobile screening began in mid-1990s. PAP TEST RATES: Pap tests showed increased inequity over time, both within Winnipeg, and more so outside Winnipeg. There was no cervical cancer provincial screening program.

16. Internal validity Low High Cross-sectional Pre-experimental Anecdote/case study Time series with comparison Observational (prospective, historical prospective) Case-control Time series with qualitative layer Randomized Controlled Trials RCT Quasi-experimental comparison group studies Associated, not causal!

17. "Le mieux est l'ennemi du bien.", from Voltaire's Dictionnaire Philosophique (1764) "The best is the enemy of good.“ More commonly cited as: "The perfect is the enemy of the good."

18. John B. McKinlay, 1998

19. Time series! (plus “systems” approach)

21. Key Message “Upstream systems approaches” –Greater health inequity reductions were associated with federal or provincial programs to increase access. “Making the right choice the easy choice”

22. M anitoba C entre for H ealth P olicy M C H P www.umanitoba.ca/medicine/units/mchp/

23. Important to read the whole report!