Lifecourse Educational Trajectories and Hypertension in Midlife: An Application of Sequence Analysis

BACKGROUND

Higher educational attainment predicts lower hypertension. Yet, associations between non-traditional educational trajectories (e.g., interrupted degree programs) and hypertension are less well understood, particularly among structurally marginalized groups who are more likely to experience these non-traditional trajectories.

METHODS

In National Longitudinal Survey of Youth 1979 cohort data (N=6,317), we used sequence and cluster analyses to identify groups of similar educational sequences - characterized by timing and type of terminal credential - that participants followed from age 14-48. Using logistic regression, we estimated associations between the resulting 10 educational sequences and hypertension at age 50. We evaluated effect modification by individual-level indicators of structural marginalization (race, gender, race and gender, and childhood socioeconomic status (cSES)).

RESULTS

Compared to terminal high school (HS) diploma completed at traditional age, terminal GED (OR:1.32;95%CI:1.04,1.66; RR:1.21;95%CI:1.03,1.43) or Associate Degree after <HS (OR:1.93;95%CI: 1.11,3.35; RR:1.55;95%CI:1.10,2.17) was associated with higher hypertension. There was some evidence of effect modification. Hypertension associated with delayed HS diploma versus HS diploma at a traditional age (the reference) was lower for Black men than White men (interaction term:0.44;95%CI:0.21,0.91); similarly, hypertension associated with <HS versus completing HS at a traditional age was lower for people with low cSES than people with high cSES (interaction term:0.52;95%CI:0.30,0.90).

CONCLUSIONS

Both type and timing to terminal credential matter for hypertension but effects may vary by experiences of structural marginalization. Documenting the nuanced ways in which complex educational trajectories are associated with health could elucidate underlying mechanisms and inform systems-level interventions for health equity.

Census Tract Patterns and Contextual Social Determinants of Health Associated With COVID-19 in a Hispanic Population From South Texas: A Spatiotemporal Perspective

BACKGROUND

Previous studies have shown that various social determinants of health (SDOH) may have contributed to the disparities in COVID-19 incidence and mortality among minorities and underserved populations at the county or zip code level.

OBJECTIVE

This analysis was carried out at a granular spatial resolution of census tracts to explore the spatial patterns and contextual SDOH associated with COVID-19 incidence from a Hispanic population mostly consisting of a Mexican American population living in Cameron County, Texas on the border of the United States and Mexico. We performed age-stratified analysis to identify different contributing SDOH and quantify their effects by age groups.

METHODS

We included all reported COVID-19-positive cases confirmed by reverse transcription-polymerase chain reaction testing between March 18 (first case reported) and December 16, 2020, in Cameron County, Texas. Confirmed COVID-19 cases were aggregated to weekly counts by census tracts. We adopted a Bayesian spatiotemporal negative binomial model to investigate the COVID-19 incidence rate in relation to census tract demographics and SDOH obtained from the American Community Survey. Moreover, we investigated the impact of local mitigation policy on COVID-19 by creating the binary variable "shelter-in-place." The analysis was performed on all COVID-19-confirmed cases and age-stratified subgroups.

RESULTS

Our analysis revealed that the relative incidence risk (RR) of COVID-19 was higher among census tracts with a higher percentage of single-parent households (RR=1.016, 95% posterior credible intervals [CIs] 1.005, 1.027) and a higher percentage of the population with limited English proficiency (RR=1.015, 95% CI 1.003, 1.028). Lower RR was associated with lower income (RR=0.972, 95% CI 0.953, 0.993) and the percentage of the population younger than 18 years (RR=0.976, 95% CI 0.959, 0.993). The most significant association was related to the "shelter-in-place" variable, where the incidence risk of COVID-19 was reduced by over 50%, comparing the time periods when the policy was present versus absent (RR=0.506, 95% CI 0.454, 0.563). Moreover, age-stratified analyses identified different significant contributing factors and a varying magnitude of the "shelter-in-place" effect.

CONCLUSIONS

In our study, SDOH including social environment and local emergency measures were identified in relation to COVID-19 incidence risk at the census tract level in a highly disadvantaged population with limited health care access and a high prevalence of chronic conditions. Results from our analysis provide key knowledge to design efficient testing strategies and assist local public health departments in COVID-19 control, mitigation, and implementation of vaccine strategies.

A critical exploration of nurses' perceptions of access to oncology care among Indigenous peoples: Results of a national survey

Inequities in access to oncology care among Indigenous peoples in Canada are well documented. Access to oncology care is mediated by a range of factors; however, emerging evidence suggests that healthcare providers, including nurses, play a significant role in shaping healthcare access. The purpose of this study was to critically examine access to oncology care among Indigenous peoples in Canada from the perspective of oncology nurses. Guided by postcolonial theoretical perspectives, interpretive descriptive and critical discourse analysis methodologies informed study design and data analysis. Oncology nurses were recruited from across Canada to complete an online survey (n = 78). Nurses identified a range of barriers experienced by Indigenous peoples when accessing oncology care, yet located these barriers primarily at the individual and systems levels. Nurses perceived themselves as mediators of access to oncology care; however, their efforts to facilitate access to care were constrained by the dominance of biomedicine within healthcare. Nurses' constructions of access to oncology care highlight the embedded narrative of individualism within nursing practice and the relative invisibility of racism as a determinant of equitable access to care among Indigenous peoples. This suggests a need for oncology nurses to better understand and incorporate structural determinants of health perspectives.

Is obesity a manifestation of systemic racism? A ten-point strategy for study and intervention

In the recent past, there has been rising attention to systemic racism. The ensuing discussions have largely focused on COVID-19 and policing. Despite long-standing disparities in obesity across racial and ethnic groups and obesity's important role in COVID-19 disparities, there has been minimal attention to whether obesity itself could be a manifestation of systemic racism. Nor has there been serious policy attention dedicated to alleviating obesity and its disproportionate burden on BIPOC (Black, Indigenous, and People of Color). We discuss whether obesity's disproportionate harms to BIPOC may be attributed to systemic racism, and we provide a ten-point strategy for studying and solving the core public health issues at the intersection of obesity and systemic racism.

Racism, healthcare access and health equity for people seeking asylum

People seeking asylum are at risk of receiving poorer quality healthcare due, in part, to racist and discriminatory attitudes, behaviours and policies in the health system. Despite fleeing war and conflict; exposure to torture and traumatic events and living with uncertainty; people seeking asylum are at high-risk of experiencing long-term poor physical and mental health outcomes in their host country. This article aims to raise awareness and bring attention to some common issues people seeking asylum face when seeking healthcare in high-income countries where the health system is dominated by a Western biomedical view of health. Clinical case scenarios are used to highlight instances of racist healthcare policies and practices that create and maintain ongoing health disparities; limited access to culturally and linguistically appropriate health services, and lack of trauma-informed approaches to care. Nurses and midwives can play an important role in countering racism in healthcare settings; by identifying and calling out discriminatory practice and modelling tolerance, respect and empathy in daily practice. We present recommendations for individuals, organisations and governments that can inform changes to policies and practices that will reduce racism and improve health equity for people seeking asylum.

Increasing concentration of COVID-19 by socioeconomic determinants and geography in Toronto, Canada: an observational study

BACKGROUND

Inequities in the burden of COVID-19 were observed early in Canada and around the world suggesting economically marginalized communities faced disproportionate risks. However, there has been limited systematic assessment of how heterogeneity in risks has evolved in large urban centers over time.

PURPOSE

To address this gap, we quantified the magnitude of risk heterogeneity in Toronto, Ontario from January-November, 2020 using a retrospective, population-based observational study using surveillance data.

METHODS

We generated epidemic curves by social determinants of health (SDOH) and crude Lorenz curves by neighbourhoods to visualize inequities in the distribution of COVID-19 and estimated Gini coefficients. We examined the correlation between SDOH using Pearson-correlation coefficients.

RESULTS

Gini coefficient of cumulative cases by population size was 0.41 (95% confidence interval [CI]:0.36-0.47) and estimated for: household income (0.20, 95%CI: 0.14-0.28); visible minority (0.21, 95%CI:0.16-0.28); recent immigration (0.12, 95%CI:0.09-0.16); suitable housing (0.21, 95%CI:0.14-0.30); multi-generational households (0.19, 95%CI:0.15-0.23); and essential workers (0.28, 95%CI:0.23-0.34).

CONCLUSIONS

There was rapid epidemiologic transition from higher to lower income neighbourhoods with Lorenz curve transitioning from below to above the line of equality across SDOH. Moving forward necessitates integrating programs and policies addressing socioeconomic inequities and structural racism into COVID-19 prevention and vaccination programs.

Racial-ethnic disparities in pain intensity and interference among middle-aged and older U.S. adults

BACKGROUND

This study aims to better understand differing pain experiences across U.S. racial/ethnic subgroups by estimating racial-ethnic disparities in both pain intensity and domain-specific pain-related interference. To address this issue, we use a nationally-representative sample of non-Hispanic White, non-Hispanic Black, and Hispanic adults ages 50+ who report recently experiencing pain.

METHODS

Using data from the 2010 wave of the Health and Retirement Study (HRS; N=684), we conducted a series of multivariate analyses to assess possible racial/ethnic disparities in pain intensity and seven domains of pain interference, controlling for relevant sociodemographic variables and other health problems.

RESULTS

Black and Hispanic participants reported higher pain intensity than White participants after controlling for socioeconomic status (SES) and other health conditions. Both Black and Hispanic individuals reported more domain-specific pain interference in bivariate analyses. In multivariate analyses, Black (vs. White) participants reported significantly higher levels of pain interference with family-home responsibilities, occupation, sexual behavior, and daily self-care. We did not find significant Hispanic-White differences in the seven pain interference domains, nor did we find Black-White differences in three domains (recreation, social activities, and essential activities).

CONCLUSIONS

Our findings highlight the need for using multi-dimensional measures of pain when assessing for possible pain disparities with respect to race/ethnicity. Future studies on pain interventions should consider contextualizing the pain experience across different racial subgroups to help pain patients with diverse needs, with the ultimate goal of reducing racial/ethnic disparities in pain.

Reflection on modern methods: statistical, policy and ethical implications of using age-standardized health indicators to quantify inequities

Methods for calculating health indicators profoundly influence understanding of and action on population health and inequities. Age-standardization can be useful and is commonly applied to account for differences in age structures when comparing health indicators across groups. Age-standardized rates have well-acknowledged limitations, including that they are relative indices for comparison, and not accurate measures of actual rates where the age structures of groups diverge. This paper explores these limitations, and demonstrates alternative approaches through a case study quantifying mortality rates within the Aboriginal and Torres Strait Islander (Indigenous) population of Australia and inequities compared with the non-Indigenous population, over 2001–16. Applying the Australian Standard Population, the Aboriginal and Torres Strait Islander age-standardized mortality rate was more than double the crude mortality rate in 2001 and 2016, inflated through high weighting of older age groups. Despite divergent population age structures, age-standardized mortality rates remain a key policy metric for measuring progress in reducing Indigenous-non-Indigenous inequities in Australia. Focusing on outcomes age-standardized to the total population can obscure inequities, and denies Aboriginal and Torres Strait Islander peoples and communities valid, actionable information about their health and well-being. Age-specific statistics convey the true magnitude of health risks and highlight high-risk subgroups. When requiring standardization, standardizing to a population-specific standard (here, an Indigenous standard) generates metrics centred around and reflective of reality for the population of focus, supporting communities’ self-determination to identify priorities and informing resource allocation and service delivery. The principles outlined here apply across populations, including Indigenous and other populations internationally.

Occurrence of fatal police violence during pregnancy and hazard of preterm birth in California

BACKGROUND

Exposure to fatal police violence may play a role in population-level inequities in risk for preterm delivery.

OBJECTIVE

To evaluate whether exposure to fatal police violence during pregnancy affects the hazard of preterm delivery and whether associations differ by race/ethnicity and fetal sex.

METHODS

We leveraged temporal variation in incidents of fatal police violence within census tracts to assess whether occurrence of fatal police violence in a person's tract during pregnancy was associated with increased hazard of extremely (20-27 weeks), early (28-31 weeks), moderate (32-33 weeks), and late (32-36 weeks) preterm delivery in California from 2007 to 2015. We used both death records and the Fatal Encounters database to identify incidents of fatal police violence. We estimated hazard ratios (HR) using time-varying Cox proportional hazard models stratified by census tract, controlling for age, race/ethnicity, educational attainment, health insurance type, parity, and the year and season of conception. We further stratified by race/ethnicity and infant sex to evaluate whether there were differential effects by these characteristics.

RESULTS

Exposure to an incident of fatal police violence was associated with a small increase in the hazard of late preterm birth using both the death records (N = 376,029; hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.00, 1.10) and the Fatal Encounters data (N = 938,814; HR 1.03, 95% CI 1.00, 1.06). We also observed an association for moderate preterm birth in the Fatal Encounters data (HR 1.06, 95% CI 0.98, 1.15). We did not observe associations for early or extremely preterm birth in either data source. Larger relative hazards of moderate (HR 1.25, 95% CI 0.93, 1.68) and late preterm delivery (HR 1.18, 95% CI 1.05, 1.33) were observed among Black birth parents with female births in the Fatal Encounters data.

CONCLUSIONS

Preventing police use of lethal force may reduce preterm delivery in communities where such violence occurs.

Understanding and Promoting Racial Diversity in Healthcare Settings to Address Disparities in Pandemic Crisis Management

Background:

Health disparities have become apparent since the beginning of the COVID-19 pandemic. When observing racial discrimination in healthcare, self-reported incidences, and perceptions among minority groups in the United States suggest that, the most socioeconomically underrepresented groups will suffer disproportionately in COVID-19 due to synergistic mechanisms. This study reports racially-stratified data regarding the experiences and impacts of different groups availing the healthcare system to identify disparities in outcomes of minority and majority groups in the United States.

Methods:

Studies were identified utilizing PubMed, Embase, CINAHL Plus, and PsycINFO search engines without date and language restrictions. The following keywords were used: Healthcare, raci*, ethnic*, discriminant, hosti*, harass*, insur*, education, income, psychiat*, COVID-19, incidence, mortality, mechanical ventilation. Statistical analysis was conducted in Review Manager (RevMan V.5.4). Unadjusted Odds Ratios, P-values, and 95% confidence intervals were presented.

Results:

Discrimination in the United States is evident among racial groups regarding medical care portraying mental risk behaviors as having serious outcomes in the health of minority groups. The perceived health inequity had a low association to the majority group as compared to the minority group (OR = 0.41; 95% CI = 0.22 to 0.78; P = .007), and the association of mental health problems to the Caucasian-American majority group was low (OR = 0.51; 95% CI = 0.45 to 0.58; P < .001).

Conclusion:

As the pandemic continues into its next stage, efforts should be taken to address the gaps in clinical training and education, and medical practice to avoid the recurring patterns of racial health disparities that become especially prominent in community health emergencies. A standardized tool to assess racial discrimination and inequity will potentially improve pandemic healthcare delivery.

Characterizing 'health equity' as a national health sector priority for maternal, newborn, and child health in Ethiopia

Background: The pursuit of health equity is a priority in Ethiopia, especially with regards to maternal, newborn, and child health (MNCH). To date, there has been little characterization of the ‘problem’ of health inequity, and the normative assumptions implicit in the representation of the problem. Yet, such insights have implications for shaping the framing, incentivization, and implementation of health policies and their wider impact.

Objective: In this article, we characterize how health (in)equity is represented as a policy issue, how this representation came about, and the underlying assumptions.

Methods: We draw from Bacchi’s ‘what is the problem represented to be’ approach to explore how national-level actors in the health sector constitute the problem. The data for our analysis encompass 23 key informant interviews with national health sector actors working in leadership positions on MNCH in Ethiopia, and six policy documents. Findings were derived from thematic and content analysis.

Results: Health inequity is a normalized and inevitable concern that is regarded as actionable (can be altered) but not fully resolvable (can never be fully achieved). Operationally, health equity is viewed as a technocratic matter, reflected in the widespread use of metrics to motivate and measure progress. These representations are shaped by Ethiopia’s rapid expansion of health services into rural areas during the 2000s leading to the positive international attention and funding the country received for improved MNCH indicators. Expanding the coverage and efficiency of health service provision, especially in rural areas, is associated with economic productivity.

Conclusion: The metrication of health equity may detract from the fairness, justice, and morality underpinnings of the concept. The findings of this study point to the implications of global pressures in terms of maximizing health investments, and call into question how social, political, and economic determinants of health are addressed through broader development agendas.

Compounding Risks Caused by Heat Exposure and COVID-19 in New York City: A Review of Policies, Tools, and Pilot Survey Results

The Coronavirus Disease 2019 (COVID-19) pandemic changed many social, economic, environmental, and healthcare determinants of health in New York City (NYC) and worldwide. COVID-19 potentially heightened the risk of heat-related health impacts in NYC, particularly on the most vulnerable communities, who often lack equitable access to adequate cooling mechanisms such as air conditioning (AC) and good quality green space. Here, we review some of the policies and tools which have been developed to reduce vulnerability to heat in NYC. We then present results from an online pilot survey of members of the environmental justice organization WE ACT for Environmental Justice (WE ACT) between July 11 and August 8, 2020, which asked questions to evaluate how those in Northern Manhattan coped with elevated summer heat in the midst of the COVID-19 pandemic. We also make some policy recommendations based on our initial findings. Results of our pilot survey suggest that people stayed indoors more due to COVID-19 and relied more on AC units to stay cool. Survey responses also indicated that some avoided visiting green spaces due to concerns around overcrowding and did not regularly frequent them due to the distance from their homes. The responses also demonstrate a potential racial disparity in AC access; AC ownership and access was highest amongst white and lowest amongst Latino/a/x and Black respondents. The impacts of COVID-19 have highlighted the need to accelerate efforts to improve preparedness for extreme heat like the City of New York's AC and cooling center programs, heat ventilation and air conditioning (HVAC) retrofitting, equitable green space expansion, and stronger environmental justice community networks and feedback mechanisms to hear from affected residents. Conducting a survey of this kind annually may provide an additional effective component of evaluating cooling initiatives in NYC.

Syndemics & syndemogenesis in COVID-19 and rheumatic and musculoskeletal diseases: old challenges, new era

People with rheumatic and musculoskeletal diseases (RMDs) are facing several challenges during the COVID-19 pandemic, such as poor access to regular health services and drug shortages, particularly in developing countries. COVID-19 represents a syndemic, synergistic condition that interacts with and exacerbates pre-existing diseases such as RMDs, other co-morbidities and social conditions. The emerging evidence on both biological and non-biological factors implicated in worse outcomes in people with RMDs affected by the COVID-19 pandemic, whether infected by the virus or not, calls for the need to use more novel and holistic frameworks for studying disease. In this context, the use of a syndemic framework becomes particularly relevant. We appeal for a focus on the identification of barriers and facilitators to optimal care of RMDs in the context of the COVID-19 pandemic, in order to tackle both the pandemic itself and the health inequities inherent to it.

The telemedical imperative

Technology presents a means of improving health outcomes for vast numbers of individuals. It has historically been deployed to streamline healthcare delivery and reach those who would previously have faced obstacles to accessing services. It has also enabled improved health education and management. Telemedicine can be employed in everything from primary care consultations to the monitoring of chronic diseases. Despite recommendation by the World Health Organization, countries have been slow to embrace such technology in the health sector. Nonetheless, it is expected to become more prevalent with increased digitization. Further, amidst the COVID-19 pandemic, there was a rush to implement forms of telemedicine where possible to prevent patients breaking social distancing rules. In this paper, I present and defend what I term the 'telemedical imperative'. The telemedical imperative represents a duty for healthcare systems to implement remote access to services where possible, thereby furthering the mission of equity in access to healthcare. It is intended as an addition to in-person services rather than a replacement. After highlighting the benefits of telemedicine, I provide four criteria that must be met for the telemedical imperative to arise. The first three-safety, effectiveness, and acceptability-are consistent and essential. The fourth adapts to the service in question and requires that there be no other obstacles specific to that service that cannot reasonably be overcome. Finally, I address several potential objections to the telemedical imperative based on more general concerns around the implementation of telemedicine.

[Do We Need More Indigenous Nurses?]

Data collected over the past four decades show the life expectancy of indigenous Taiwanese to be 8 to 10 years lower than the general, predominantly Han Chinese, population. This suggests the persistence of inequities in the public health system in Taiwan. Several facets of this issue, including lack of consideration of the characteristics and lifestyle of ethnic populations in health policy planning and implementation work and the continued location-based focus of medical care resource distribution policies, are being actively discussed. However, investigations of factors related to the relatively poor health status of indigenous Taiwanese have not considered the traumatic and lingering effects of colonisation. This article briefly introduces the health status of indigenous Taiwanese and the indigenous nursing workforce and then presents a review of the literature on factors related to the under-representation of indigenous Taiwanese in nursing programs and the nursing workforce. Indigenous Taiwanese were found to be absent from public-health policymaking. Moreover, indigenous-related traditional knowledge and values are not being effectively transmitted to younger generations. A diverse nursing workforce should reflect and respond to not only indigenous peoples but also the general population in Taiwan.

Prescribing Phones to Address Health Equity Needs in the COVID-19 Era: The PHONE-CONNECT Program

Vulnerable populations have been identified as having higher infection rates and poorer COVID-19–related outcomes, likely due to their inability to readily access primary care, follow public health directives, and adhere to self-isolation guidelines. As a response to the COVID-19 pandemic, many health care services have adopted new digital solutions, which rely on phone and internet connectivity. However, persons who are digitally inaccessible, such as those experiencing poverty or homelessness, are often unable to use these services. In response to this newly highlighted social disparity known as “digital health inequity,” emergency physicians at the University Health Network in Toronto, Canada, initiated a program called PHONE-CONNECT (Phones for Healthier Ontarians iN EDs – COvid NEeds met by Cellular Telephone). This novel approach attempts to improve patients’ access to health care, information, and social services, as well as improve their ability to adhere to public health directives (social isolation and contact tracing). Although similar programs addressing the same emerging issues have been recently described in the media, this is the first time phones have been provided as a health care intervention in an emergency department. This innovative emergency department point-of-care intervention may have a significant impact on improving health outcomes for vulnerable people during the COVID-19 pandemic and beyond.

Effects of Parenting and Perceived Stress on BMI in African American Adolescents

OBJECTIVE

This study set out to examine the role of parenting practices in protecting or exacerbating the negative effects of parent and adolescent stress on adolescent body mass index (BMI) over time. Separate longitudinal models were conducted to evaluate how parenting practices interacted with parental perceived stress and adolescent perceived stress in predicting adolescent BMI.

METHODS

Baseline data were collected from 148 African American adolescents (Mage = 12.93, SD = 1.75; Mz-BMI = 0.78, SD = 0.50; MBMI%-ile = 96.7, SD = 3.90) and their caregivers (Mage = 44.45, SD = 8.65; MBMI = 37.63, SD = 8.21) enrolled in the Families Improving Together for Weight Loss trial. Adolescents self-reported their perceptions of caregiver parenting style and feeding practices. Both caregivers and adolescents self-reported their perceptions of chronic stress. BMI for parents and adolescents was assessed objectively at baseline and 16 weeks post-intervention.

RESULTS

Hierarchical regression models predicting adolescent BMI z-score (z-BMI) indicated a significant interaction between parental perceived stress and parental pressure to eat. Simple slopes analyses demonstrated that for those parents that exhibit higher pressure to eat, parent stress was positively associated with adolescent z-BMI.

CONCLUSIONS

These findings provide preliminary support suggesting that certain parenting practices interact with chronic stress on adolescent weight-related outcomes and that future interventions may consider integrating these factors.

Exposing health inequities: Surreal snapshots from the Grand Canyon to global COVID-19 pandemic

The story presented here is central to social work because it is about crisis. Across diverse fields of practice, social workers regularly engage in crisis intervention. The story that follows is about crisis in the area of health and healthcare. Specifically, it's about exposing health/care inequities on Indigenous tribal land in the Grand Canyon and in the global COVID-19 pandemic.

Health equity considerations in COVID-19: geospatial network analysis of the COVID-19 outbreak in the migrant population in Singapore

BACKGROUND

Low-wage dormitory-dwelling migrant workers in Singapore were disproportionately affected by coronavirus disease 2019 (COVID-19) infection. This was attributed to communal living in high-density and unhygienic dormitory settings and a lack of inclusive protection systems. However, little is known about the roles of social and geospatial networks in COVID-19 transmission. The study examined the networks of non-work-related activities among migrant workers to inform the development of lockdown exit strategies and future pandemic preparedness.

METHODS

A population-based survey was conducted with 509 migrant workers across the nation, and it assessed dormitory attributes, social ties, physical and mental health status, COVID-19-related variables and mobility patterns using a grid-based network questionnaire. Mobility paths from dormitories were presented based on purposes of visit. Two-mode social networks examined the structures and positions of networks between workers and visit areas with individual attributes.

RESULTS

COVID-19 risk exposure was associated with the density of dormitory, social ties and visit areas. The migrant worker hub in the city centre was the most frequently visited for essential services of grocery shopping and remittance, followed by south central areas mainly for social gathering. The hub was positioned as the core with the highest degree of centrality with a cluster of workers exposed to COVID-19.

CONCLUSIONS

Social and geospatial networks of migrant workers should be considered in the implementation of lockdown exit strategies while addressing the improvement of living conditions and monitoring systems. Essential services, like remittance and grocery shopping at affordable prices, need to be provided near to dormitories to minimize excess gatherings.

Perspectives on access and usage of assistive technology by people with intellectual disabilities in the Western Cape province of South Africa: Where to from here?

BACKGROUND

Whilst assistive technology (AT) can play an important role to improve quality of life, health inequity regarding access to appropriate AT for people with intellectual disabilities (ID) is still very much present especially in low resource countries.

OBJECTIVES

This study focused on exploring factors that influence access to and continued use of AT by people with ID in the Western Cape province of South Africa and to suggest potential implications of these findings and actions required to promote access to AT.

METHOD

A qualitative approach was used to explore the experiences of people with ID and providers of AT. Face-to-face interviews with 20 adults with mild to profound ID, and 17 providers of AT were conducted and the data were analysed thematically.

RESULTS

People with ID within the study setting faced many challenges when trying to access AT and for those who managed to acquire AT, its continued usage was influenced by both personal characteristics of the user and environmental factors. Important factors that influence AT access and use for people with ID found in this study were (1) attitudes from the community, (2) knowledge and awareness to identify AT need and (3) AT training and instructions to support the user and care network.

CONCLUSION

With the perspectives of both the providers and users of AT, this study identified priority factors, which could be addressed to improve AT access and use for people with ID in the Western Cape province.

Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy

The COVID-19 pandemic precipitated catastrophic job loss, unprecedented unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g., social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends, and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic Whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of pandemic control strategies to mitigate COVID-19 spread and death.

Regional Disparity and Patients Mobility: Benefits and Spillover Effects of the Spatial Network Structure of the Health Services in China

BACKGROUND

The distribution of medical resources in China is seriously imbalanced due to imbalanced economic development in the country; unbalanced distribution of medical resources makes patients try to seek better health services. Against this backdrop, this study aims to analyze the spatial network characteristics and spatial effects of China's health economy, and then find evidence that affects patient mobility.

METHODS

Data for this study were drawn from the China Health Statistical Yearbooks and China Statistical Books. The gravitational value of China's health spatial network was calculated to establish a network of gravitational relationships. The social network analysis method was used for centrality analysis and spillover effect analysis.

RESULTS

A gravity correlation matrix was constructed among provinces by calculating the gravitational value, indicating the spatial relationships of different provinces in the health economic network. Economically developed provinces, such as Shanghai and Jiangsu, are at the center of the health economic network (centrality degree = 93.333). These provinces also play a strong intermediary role in the network and have connections with other provinces. In the CONCOR analysis, 31 provinces are divided into four blocks. The spillover effect of the blocks indicates provinces with medical resource centers have beneficial effects, while provinces with insufficient resources have obvious spillover effects.

CONCLUSION

There is a significant gap in the geographical distribution of medical resources, and the health economic spatial network structure needs to be improved. Most medical resources are concentrated in economically developed provinces, and these provinces' positions in the health economic spatial network are becoming more centralized. By contrast, economically underdeveloped regions are at the edge of the network, causing patients to move to provinces with medical resource centers. There are health risks of the increasing pressure to seek medical treatment in developed provinces with abundant medical resources.

Household Energy Insecurity and COVID-19 Have Independent and Synergistic Health Effects on Vulnerable Populations

Household energy insecurity (HEINS) is detrimental to the health of the poor and most vulnerable in resource-poor settings. However, this effect amidst the COVID-19 pandemic and the uneven implementation of restrictions can create a synergistic burden of diseases and health risks for the most vulnerable in low- and middle-income countries, exacerbating the health equity gap. Based on existing literature, this paper develops three key arguments: (1) COVID-19 increases the health risks of energy insecurity; (2) HEINS increases the risk of spreading COVID-19; and (3) the co-occurrence of COVID-19 and HEINS will have compounding health effects. These arguments make context-specific interventions, rather than a generic global health approach without recourse to existing vulnerabilities critical in reducing the spread of COVID-19 and mitigating the effects of energy insecurity. Targeted international efforts aimed at financing and supporting resource security, effective testing, contact tracing, and the equitable distribution of vaccines and personal protective equipment have the potential to ameliorate the synergistic effects of HEINS and COVID-19 in resource-poor countries.

Toward an Intersectional Approach to Health Justice

Despite unprecedented global wealth creation, health inequity-the unjust health inequality between classes and groups among and within countries-persists, reviving the relevance of social justice as a lens to understand and as an instrument to intervene in these issues. However, the theoretical aspects and polysemous character of social justice as applied in the field of public health are often assumed rather than explicitly explained. An intersectional justice approach to understanding health inequality, inequity, and injustice might be useful. It argues that preexisting class-, race/ethnicity-, and gender-based health injustice and the socially differentiated impacts of the COVID-19 pandemic are shaped, interconnectedly, by economic maldistribution, cultural misrecognition, and political misrepresentation. Pursuing health justice requires analyses, strategies, and interventions that integrate the economic, cultural, and political spheres of redistribution, recognition, and representation, respectively. Such an intersectional approach to health justice is even more relevant and compelling in light of the COVID-19 pandemic. This article is broadly about class, race/ethnicity, and gender political economy of public health-but with a narrower focus on maldistribution, misrecognition, and misrepresentation, shaping social and health injustices.

Addressing health inequity through strategic planning and management

Substantial progress has been made to improve health in India in terms of availability, accessibility, cost-effectiveness, and quality. However, there are major health inequalities between and within the states. Strategic planning of health programs is required to address inequities in health. Need of the hour is to address this using a simplified strategic approach; who is left out, why are they left out, what causes are responsible for it and what are the determinants of inequality. The basic steps of strategic management, including strategic assessment, objectives, strategy formulation, and implementation, can be used to address the health equity. This article cites the examples of Serbia immunization programme, Government of India programme on Mission Indradhanush, and Thailand's universal health coverage to get better understanding to use strategic management to address health inequity. This approach is crucial in achieving sustainable development goals.