Perinatal substance use among United States veterans and servicemembers: A scoping review of the literature.

Making use of opportunities for health promotion and disease prevention when people seek healthcare is critical to increasing the impact of healthcare on population health. Only 10–20% of what makes people healthy is attributable to the treatment of illness, while 30% has to do with individuals’ health behaviours []. According to recent reports of the World Health Organization, 22.3% of the world’s population use tobacco, 27.5% of the adult population do not meet the recommended level of physical activity, and 42.6% of the population are current consumers of alcohol []. In Alberta, 18% of the population smoke cigarettes, 28% engage in greater than low risk levels of alcohol drinking, and 70% do not get enough physical activity, as defined by the Canadian guidelines for a healthy lifestyle []. Tobacco consumption, alcohol misuse, and physical inactivity are leading modifiable risk factors for preventable chronic diseases (e.g., cancer, cardiovascular disease, respiratory diseases) and poor outcomes (e.g., complications and increased healthcare use or costs) []. According to the Canadian Population Attributable Riskfor Cancer study, in 2015, 28% of new cancer cases diagnosed in Canada were attributable to tobacco use, 5% to drinking alcohol, and 9% to physical inactivity []. Together, the three risk factors account for approximately 20% of total healthcare expenditures []. Importantly, these risk factors are modifiable by raising awareness and encouraging behaviour change; these negative impacts could be prevented or reduced by supporting patients’ health behaviour change []. Of the estimated 40% of cancers that are preventable, the greatest proportion are attributable to modifiable risk factors, including tobacco and alcohol use and insufficient physical activity []. Although incorporating screening for behavioural health risk factors and promoting healthy behaviour change are important goals for primary care, there are also compelling reasons to incorporate health promoting interventions within hospital-based care. Hospital settings provide opportunities to support a large proportion of patients to modify their risk to prevent chronic diseases and improve treatment outcomes. Tobacco and alcohol use and physical inactivity are common (43%–90%) among patients attending hospitals []. Also, these risk factors are common among diverse subpopulations (e.g., some minority populations and socioeconomically disadvantaged people). These subpopulations, who often lack access to family physicians and primary care, are over-represented in the hospital settings. Healthcare providers are a trusted source of information about health risks, and patients who are currently experiencing ill health are more responsive to health advice for lifestyle behaviour change []. Significantly, a large proportion of total healthcare costs are driven by the costs of hospital care related to diseases associated with these factors []. Although general medicine guidelines recommend counselling on these risk factors as standard practice, it is not reliably integrated into hospital care routines. The health promoting hospitals and health services (HPH) concept, developed by the World Health Organization over 30 years ago based on the principles of the WHO Ottawa Charter for Health Promotion, aims to reorient health services from a solely curative focus toward more holistic health care that includes health promotion []. In Alberta, Canada, our Cancer Prevention and Screening Innovation group has implemented several initiatives during the last 10 years to integrate screening, brief intervention, and referral (SBIR), pertaining to modifiable risk factors for cancer, as an approach for health promotion in hospital settings []. Our earlier health promotion pilots evaluated the implementation feasibility of SBIR using a paper-based guidance and documentation approach [] However, these pilot initiatives as well as the existing global literature have lacked rigorous measurement of the health and healthcare impacts of this kind of HPH initiative as well as evidence-based guidance to support spread and scale out of implementation []. Research evidence on the effectiveness of HPH is limited, particularly in Canada, with no high quality peer reviewed studies yet published in English []. Most existing studies relied on surveys, interviews, and case studies to explore the enablers and barriers of HPHS projects. However, they offered limited evaluation of intervention implementation processes, impacts, mechanisms of impact, and contextual factors, and often lacked the use of appropriate study designs []. To enable large-scale integration of health promotion activities into routine hospital care, clinical leaders and decision makers need both good evidence of their effectiveness as well as evidence-informed implementation guidance pertinent to regular clinical settings. There is a clear need for more rigorous evaluation with focus on effectiveness and implemen