Social determinants and their unequal distribution: clarifying policy understandings

Genetic propensity for obesity, socioeconomic position, and trajectories of body mass index in older adults

Identifying how socioeconomic positioning and genetic factors interact in the development of obesity is imperative for population-level obesity prevention strategies. The current study investigated whether social positioning, either independently or through interaction with a polygenic score for Body Mass Index (BMI-PGS), influences BMI trajectories across older adulthood. Data were analysed from 7,183 individuals from the English Longitudinal Study of Aging (ELSA). Interactions between the BMI-PGS and; lower educational attainment, self-perceived social status (SSS), and income, on BMI trajectories over 12 years across older adulthood were investigated through linear mixed effects models. Lower educational attainment, SSS and income were each associated with a higher baseline BMI for women, but not for men. There were interaction effects between BMI-PGS and social positioning such that men aged > 65 with a lower educational attainment (β = 0.62; 95%CI 0.00 – 1.24, p < 0.05), men aged ≤ 65 of a lower income (β = − 0.72, 95%CI − 1.21 - − 0.23, p < 0.01) and women aged ≤ 65 of lower SSS (β = − 1.41; 95%CI − 2.46 – 0.36, p < 0.01) showed stronger associations between the BMI-PGS and baseline BMI. There were few associations between markers of socioeconomic position and rate of change in BMI over the follow-up period. In sum, lower socioeconomic positioning showed adverse associations with women’s BMI in older adulthood. Moreover, the expression of the BMI-PGS, or extent to which it translates to a higher BMI, was subtly influenced by socioeconomic standing in both women and in men.

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study

Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC. Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement. Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12-1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51-0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10-1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24-1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement. Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.

Socioeconomic inequities in diet quality among a nationally representative sample of adults living in Canada: an analysis of trends between 2004 and 2015

BACKGROUND

Socioeconomic inequities in diet quality are stable or widening in the United States; however, these trends have not been well characterized in other nations. Moreover, purpose-developed indices of inequities that can provide a more comprehensive and precise perspective of trends in absolute and relative dietary gaps and gradients using multiple indicators of socioeconomic position (SEP) have not yet been used, and can inform strategies to narrow dietary inequities.

OBJECTIVES

We quantified nationally representative trends in absolute and relative gaps and gradients in diet quality between 2004 and 2015 according to 3 indicators of SEP among adults in Canada.

METHODS

Adults (≥18 y old) who participated in the nationally representative, cross-sectional Canadian Community Health Survey-Nutrition in 2004 (n = 20,880) or 2015 (n = 13,970) were included. SEP was classified using household income (quintiles), education (5 categories), and neighborhood deprivation (quintiles). Dietary intake data from 24-h recalls were used to derive Healthy Eating Index-2015 (HEI-2015) scores. Dietary inequities were quantified using absolute and relative gaps (between the most and least disadvantaged) and absolute [Slope Index of Inequality (SII)] and relative gradients (Relative Index of Inequality). Overall and sex-stratified multivariable linear regression and generalized linear models examined trends in HEI-2015 scores between 2004 and 2015.

RESULTS

Mean HEI-2015 scores improved from 55.3 to 59.0 (maximum: 100); however, these trends were not consistently equitable. Whereas inequities in HEI-2015 scores were stable in the total population and in females, the absolute gap [from 1.60 (95% CI: 0.09, 3.10) to 4.27 (95% CI: 2.20, 6.34)] and gradient [from SII = 2.09 (95% CI: 0.45, 3.73) to SII = 4.84 (95% CI: 2.49, 7.20)] in HEI-2015 scores for household income, and the absolute gradient for education [from SII = 8.06 (95% CI: 6.41, 9.71) to SII = 10.52 (95% CI: 8.73, 12.31)], increased in males.

CONCLUSIONS

Absolute and relative gaps and gradients in overall diet quality remained stable or widened between 2004 and 2015 among adults in Canada.

Progress of Inequality in Age at Death in India: Role of Adult Mortality

India has seen a reduction in infant and child mortality rates for both the sexes since the early 1980s. However, a decline in mortality at adult ages is marked by significant differences in the subgroups of sex and regions. This study assesses the progress of inequality in age at death with the advances in mortality transition during 36 years period between 1981-1985 and 2012-2016 in India, using the Gini coefficients at the age of zero (G ₀ ). The Gini coefficients show that in the mid-2000s, women outpaced men in G ₀ . The reduction in inequality in age at death is a manifestation of the process of homogeneity in mortality. The low G ₀ is concomitant of high life expectancy at birth (e ₀ ) in India. The results show the dominance of adult mortality over child mortality in the medium-mortality and low-mortality regimes. Varying adult mortality in the subgroups of sex and variance in the mortality levels of regions are the predominant factors for the variation in inequality in age at death. By lowering of the mortality rates in the age group of 15-29 years, India can achieve a high e ₀ that appears at high demographic development and the narrow sex differentials in e ₀ and G ₀ in a short time. Men in the age group of 15-29 years are the most vulnerable subgroup with respect to mortality. There is an immediate need for health policies in India to prioritise the aversion of premature deaths in men aged 15-29 years.

[Work, family, resources and unequal levels of psychological distress between working men and working women : vulnerability or gendered expression of stress?]

INTRODUCTION

This study aims to compare the vulnerability hypothesis and the expression hypothesis to explain a greater level of psychological distress among working women than among working men.

METHOD

The two hypotheses were contrasted by integrating work stressors, family stressors, work-family conflicts and psychosocial resources. The conceptual models were tested by using multilevel path analyses on 2026 employees in Quebec (Canada) based in 63 work establishments.

RESULTS

Results partially supported both hypotheses. According to the vulnerability hypothesis, single parenting, child-related problems and self-esteem were indirectly involved in the variation of psychological distress among women through family-to-work, otherwise known as work-family conflict. According to the expression hypothesis, although family-to-work conflict was closely associated with more psychological distress among women, this stressor was also closely associated with higher at-risk alcohol consumption among men. Couple-related problems and a sense of control likewise played a role in the expression mechanism through family-to-work conflict.

CONCLUSION

These results underline the importance of considering that gender contributes to mental health inequalities through multiple mechanisms. They also call for a distinction between the two directions of work-family conflict as gendered mediators.

Life Course Socioeconomic Position, Intergenerational Social Mobility, and Hypertension Incidence in ELSA-Brasil

BACKGROUND

Life course epidemiology is a powerful framework to unravel the role of socioeconomic position (SEP) disparities in hypertension (HTN). This study investigated whether life course SEP is associated with HTN incidence. Specifically, to test whether cumulative low SEP throughout life and unfavorable intergenerational social mobility increased HTN incidence.

METHODS

Longitudinal analysis of 8,754 ELSA-Brasil participants without HTN or cardiovascular in visit 1 (2008-2010). The response variable was the incidence of HTN between visits 1 and 2 (2012-2014). The explanatory variables were childhood, youth, and adulthood SEP, cumulative low SEP, and intergenerational social mobility. Associations were estimated by incidence rate ratios (IRRs) obtained by generalized linear models, with Poisson distribution and logarithmic link function, after adjustment for sociodemographic, behavioral, and health factors.

RESULTS

The incidence of HTN was 43.2/1,000 person-years, being higher in males, elderly (70-74 years), self-declared black, and low SEP individuals. After considering sociodemographic factors, low SEP in childhood, youth, and adulthood remained statistically associated with increased HTN incidence. Individuals in the third (IRR: 1.26; 95% confidence interval (CI): 1.11-1.44) and fourth top quartiles (IRR: 1.29; 95% CI: 1.11-1.49) of cumulative low SEP, vs. first, as well as those with low stable intergenerational trajectory (IRR: 1.29; 95% CI: 1.16-1.43), vs. high stable, also had increased HTN incidence rates.

CONCLUSIONS

Socioeconomic disparities at all phases of the life cycle appear to raise HTN incidence rates, being the individuals with greater accumulation of exposure to low SEP and with more unfavorable intergenerational mobility at greatest risk, even in a short follow-up time.

A systematic review of interventions to link families with preschool children from healthcare services to community-based support

BACKGROUND

Supporting patients to access community-based support may be a key intervention to address the wider determinants of health. There is a lack of evidence synthesis around the most effective methods for linking individuals from health services to organizations within communities, especially those aimed at supporting families with young children.

METHODS

Papers were identified from seven databases covering peer-reviewed and grey literature. The Effective Public Health Practice Project and the Critical Appraisal Skills Programme Qualitative quality appraisal tools were used to assess methodological quality. Thematic narrative data synthesis based on study quality was performed.

RESULTS

Twenty-four unique publications were included in the review with a range of study designs and variable methodological quality. A broad typology of intervention processes for undertaking linking was developed defining three distinct approaches: signposting, referral and facilitation. Active processes, such as facilitation, appeared more successful at linking families to community support.

CONCLUSIONS

This was the first systematic review to focus on interventions that link families with young children to community-based support organizations. It identified a typology for linking interventions, and whilst there were limitations in the quality of evidence available, it showed a tendency for more active interventions to be more effective in linking families to community support.

The Underreporting of Concussion: Differences Between Black and White High School Athletes Likely Stemming from Inequities

Previous studies have found that Black high school athletes have poorer knowledge about concussions and have fewer sports medicine healthcare resources than White athletes, but research on concussion disclosure by race is still needed. Therefore, the purpose of this study was to examine racial differences in concussion reporting behaviors between Black and White high school athletes. This cross-sectional study administered surveys to 577 high school athletes (64.5% Black; 72.3% males; 16.02 ± 1.2 years) from 14 schools (title I, n = 9; non-title I, n = 5). The survey included self-reported items on concussions and bell-ringers experienced during games and practices and the number of these episodes that were reported to an authoritative figure. Reasons for reporting and not reporting were also assessed. Results found that White athletes were more likely to recall experiencing a bell-ringer in games compared with Black athletes. They were also more likely to report a bell-ringer or concussion that occurred in a game. There was a significantly higher proportion of Black athletes compared with White athletes that did not report their bell-ringer experienced in games and concussions experienced in practices. White athletes were more likely than Black athletes to disclose a concussion because they thought they had a concussion, while there were no racial differences in the reasons for not reporting. The findings of this study highlight the critical role that race, as a social determinant of health, may play in concussion reporting in high school athletes. Future public health efforts should seek to further understand and overcome inequities in healthcare resources for concussion education and management.

Risk of Low Birth Weight According to Household Composition in Brussels and Montreal: Do Income Support Policies Variations Explain the Differences Observed between Both Regions?

Variations in social policy between countries provide opportunities to assess the impact of these policies on health inequities. This study compares the risk of low birth weight in Brussels and Montreal, according to household composition, and discusses the impact of income support policies. For each context, we estimated the impact of income support policies on the extent of poverty of welfare recipients, using the model family method. Based on the differences found, we tested hypotheses on the association between low birth weight and household composition, using administrative data from the birth register and social security in each region. The extent of poverty of welfare families differs according to household composition. In Quebec, the combination of low welfare benefits and larger family allowances widens the gap between households with children and those without children. The risk of LBW also differs between these two contexts according to the number of children. Compared to children born into large welfare families, first-born children are more at risk in Montreal than in Brussels. In addition to the usual comparative studies on the topic, our study highlights the importance of an evaluative perspective that considers the combination of different types of income support measures to better identify the most vulnerable households.

The Sustainable Development Goals and Technological Capacity

In order to achieve the Sustainable Development and Health Goals, it is essential to increase the technological capacity of the most disadvantaged populations. In the 21st century, the necessary technologies for this exist. The gap in technological capacity reflects the existence of a technological gradient between large- and small-scale production, due to an absence of incentives for innovation and a lack of technological dissemination in small businesses and communities. Technological change is central to development, but it is a public good that the market economy does not provide efficiently. Providing it requires the implementation of public policies aimed at technological innovation and dissemination. Reducing the technological gradient is therefore a major part of the United Nations 2030 Agenda for Sustainable Development and the Pan American Health Organization's 2018-2030 Sustainable Health Agenda for the Americas. This also applies to the development of health systems, which function as a redistribution mechanism to break poverty traps. In addition, experiences in these systems are relevant to the implementation of policies that increase technological capacities aimed at reducing poverty, improving social determinants of health, and thereby reducing the scale of the human development trap.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)-particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014-2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives

INTRODUCTION

The absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted.

METHODS

Qualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods.

RESULTS

Guiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability.

CONCLUSIONS

A harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

A community-health partnership response to mitigate the impact of the COVID-19 pandemic on Travellers and Roma in Ireland

Irish Travellers and Roma are two ethnic minorities experiencing high levels of health inequities. These communities are at greater risk of developing COVID-19 and of suffering more severe symptoms due to poor living environments and higher rates of comorbidities. This study explores the strategies adopted by community-health partnerships and NGOs to minimise the potential widening of Travellers’ and Roma’s health inequities during the initial response to the COVID-19 pandemic in Ireland. A descriptive qualitative approach was employed to provide a detailed account of three different community and partnership-led responses. Data were gathered from multiple sources and through first-hand participation in the COVID-19 responses. Data were analysed using thematic analysis. This study found that the main pandemic mitigation interventions implemented were public health measures, culturally sensitive communications, lobbying for policy change and economic and social support. These interventions, supported by the health promotion strategies of partnership, advocacy and empowerment, have proven to be extremely important to reduce potential inequities in exposure to the virus and in access to healthcare. The findings suggest that community-health partnerships between minority groups’ organizations and healthcare professionals represent a viable approach to mitigate the disproportionate effects of a pandemic on Travellers and Roma.

Disparities in all-cause mortality with potentially inappropriate medication use: Analysis of the Reasons for Geographic and Racial Differences in Stroke study

OBJECTIVES

Health disparities across different socioeconomic subgroups have been reported in previous studies. Mortality with potentially inappropriate medication (PIM) use may be subject to similar disparities. We aimed to assess the association between PIM use and all-cause mortality and the effect of disparity parameters (sex, race, income, education, and location of residence) on this relationship.

METHODS

This longitudinal cohort study included 26,399 U.S. adults aged 45 years and older from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, of which 13,475 participants were aged 65 years and older (recruited 2003-2007). PIM use and drug-drug interactions (DDIs) were identified through the 2015 Beers Criteria and a clinically significant DDIs list by the American Family Physicians, respectively. Cox regression was used to assess disparities in mortality with PIM use, iteratively adjusting for disparity parameters and other covariates. The full models included interaction terms between PIM use and other covariates. A similar method was used for the analyses of disparities in mortality with DDIs.

RESULTS

Approximately 87% of older adults used at least 1 drug listed in the Beers Criteria, and 3.8% of all participants used 2 or more drugs with DDIs. In the adjusted analysis, an increased risk of mortality was observed among whites with PIM use (hazard ratio [HR] = 1.27 [95% CI 1.10-1.47]). The higher mortality rate was observed among blacks without PIM use (1.34 [1.09-1.65]). Lower income and education were independent predictors for higher mortality.

CONCLUSION

Racial differences in all-cause mortality with PIM use were observed. Further research is needed to better understand the contributing factors of such disparities to develop appropriate interventions.

Sexual Orientation, Social Determinants of Health, and Unmet Substance Use Treatment Need: Findings from a National Survey

Background: In 2018, an estimated 89% of individuals who needed treatment for substance use did not have their need met. Compared to heterosexuals, the disparity between needing and receiving treatment is thought to be even higher for sexual minorities. Yet, few studies have investigated sexual orientation and its relationship to unmet treatment need or the association between sexual orientation and specific reasons for the inability to enter treatment. Understanding these reasons is critical to eradicating barriers to treatment for sexual minorities. Obejctives: Using pooled data from the 2015-2018 National Survey of Drug Use and Health and guided by Andersen's behavioral model of health services use, this study examined the relationship between respondents' sexual orientation and their perceptions of reasons for unmet substance use treatment need. Results: Findings indicated that sexual minorities had more than double the odds of having unmet need due to access and insurance barriers. Conclusions: While further research and larger samples are needed to understand the relationships revealed by this study more fully, it is clear that sexual minorities do not have equitable access to substance use treatment services relative to heterosexuals. Implications and directions for future research are discussed.

Los Objetivos de Desarrollo Sostenible y las capacidades tecnológicas

Para lograr los objetivos de desarrollo y salud sostenibles, es esencial incrementar las capacidades tecnológicas de las poblaciones más desfavorecidas. Entrado el siglo XXI, existen las tecnologías necesarias para ello. El déficit en capacidades tecnológicas se debe a la existencia de un gradiente tecnológico entre la producción de gran y de pequeña escalas, debido a la falta de incentivos para la innovación y la difusión en empresas y comunidades pequeñas. En estos ámbitos el cambio tecnológico, punto medular del desarrollo, es un bien público que la economía de mercado no provee eficientemente. Su provisión requiere la aplicación de políticas públicas de innovación y difusión tecnológicas. La reducción del gradiente tecnológico constituye, pues, parte medular de la Agenda 2030 para el Desarrollo Sostenible, de las Naciones Unidas, y la Agenda de Salud Sostenible para las Américas 2018-2030, de la Organización Panamericana de la Salud. Esto es aplicable, así mismo, al desarrollo de los sistemas de salud, que funcionan también como mecanismos de redistribución para romper las trampas de pobreza. Asimismo, las experiencias en esos sistemas tienen relevancia para aplicar políticas de incremento de capacidades tecnológicas que disminuyan la pobreza, mejoren los determinantes sociales de la salud y, con ello, reduzcan la magnitud de la trampa de desarrollo humano.

Beyond the map: evidencing the spatial dimension of health inequalities

Background

Spatial inequalities in health result from different exposures to health risk factors according to the features of geographical contexts, in terms of physical environment, social deprivation, and health care accessibility. Using a common geographical referential, which combines indices measuring these contextual features, could improve the comparability of studies and the understanding of the spatial dimension of health inequalities.

Methods

We developed the Geographical Classification for Health studies (GeoClasH) to distinguish French municipalities according to their ability to influence health outcomes. Ten contextual scores measuring physical and social environment as well as spatial accessibility of health care have been computed and combined to classify French municipalities through a K-means clustering. Age-standardized mortality rates according to the clusters of this classification have been calculated to assess its effectiveness.

Results

Significant lower mortality rates compared to the mainland France population were found in the Wealthy Metropolitan Areas (SMR = 0.868, 95% CI 0.863–0.873) and in the Residential Outskirts (SMR = 0.971, 95% CI 0.964–0.978), while significant excess mortality were found for Precarious Population Districts (SMR = 1.037, 95% CI 1.035–1.039), Agricultural and Industrial Plains (SMR = 1.066, 95% CI 1.063–1.070) and Rural Margins (SMR = 1.042, 95% CI 1.037–1.047).

Conclusions

Our results evidence the comprehensive contribution of the geographical context in the constitution of health inequalities. To our knowledge, GeoClasH is the first nationwide classification that combines social, environmental and health care access scores at the municipality scale. It can therefore be used as a proxy to assess the geographical context of the individuals in public health studies.

An atlas of health inequalities and health disparities research: "How is this all getting done in silos, and why?"

Research on health inequalities and health disparities has grown exponentially since the 1960s, but this expansion has not been matched by an associated sense of progress. Criticisms include claims that too much research addresses well-trodden questions and that the field has failed to gain public and policy traction. Qualitative studies have found researchers partly attribute these challenges to fragmentation resulting from disciplinary and methodological differences. Yet, empirical investigation ('research on research') is limited. This study addresses this gap, employing mixed-methods to examine, at scale, how and why this field is defined by insular research clusters. First, bibliometric analysis identifies and visualizes the 250 most-connected authors. Next, an algorithm was used to identify clustering via citation links between authors. We used researcher profiling to ascertain authors' geographical and institutional locations and disciplinary training, examining how this mapped onto clusters. Finally, causes of siloing were investigated via semi-structured interviews with 45 researchers. The resulting 'atlas' of health inequalities and health disparities research identifies eight clusters of authors with varying degrees of connectedness. No single factor neatly describes observed fragmentation, health equity scholars exhibit a diverse disciplinary backgrounds, and geographical, institutional, and historical factors appear to intersect to explain siloed citation patterns. While the configuration of research activity within clusters potentially helps render questions scientifically manageable, it affirms perceptions of the field as fragmented. We draw on Thomas Kuhn and Sheila Jasanoff to position results within theoretical pictures of scientific progress. Newcomers to the field can use our findings to orient themselves within the many streams of health equity scholarship, and existing health equity scholars can use the atlas to move beyond existing geo-disciplinary networks. However, although stronger cross-cluster engagement would be likely to improve insights, the complex nexus of factors underlying the field's structure will likely make this challenging in practice.

Values are not enough: qualitative study identifying critical elements for prioritization of health equity in health systems

Background

Health system policies and programs that reduce health inequities and improve health outcomes are essential to address unjust social gradients in health. Prioritization of health equity is fundamental to addressing health inequities but challenging to enact in health systems. Strategies are needed to support effective prioritization of health equity.

Methods

Following provincial policy recommendations to apply a health equity lens in all public health programs, we examined health equity prioritization within British Columbia health authorities during early implementation. We conducted semi-structured qualitative interviews and focus groups with 55 senior executives, public health directors, regional directors, and medical health officers from six health authorities and the Ministry of Health. We used an inductive constant comparative approach to analysis guided by complexity theory to determine critical elements for prioritization.

Results

We identified seven critical elements necessary for two fundamental shifts within health systems. 1) Prioritization through informal organization includes creating a systems value for health equity and engaging health equity champions. 2) Prioritization through formal organization requires explicit naming of health equity as a priority, designating resources for health equity, requiring health equity in decision making, building capacity and competency, and coordinating a comprehensive approach across levels of the health system and government.

Conclusions

Although creating a shared value for health equity is essential, health equity - underpinned by social justice - needs to be embedded at the structural level to support effective prioritization. Prioritization within government and ministries is necessary to facilitate prioritization at other levels. All levels within health systems should be accountable for explicitly including health equity in strategic plans and goals. Dedicated resources are needed for health equity initiatives including adequate resourcing of public health infrastructure, training, and hiring of staff with equity expertise to develop competencies and system capacity.

The Curated Food System: A Limiting Aspirational Vision of What Constitutes "Good" Food

In an effort to elucidate an aspirational vision for the food system and explore whether the characteristics of such a system inadvertently set unattainable standards for low-wealth rural communities, we applied discourse analysis to the following qualitative datasets: (1) interviews with food experts and advocates, (2) scholarly and grey literature, (3) industry websites, and (4) email exchanges between food advocates. The analysis revealed eight aspirational food system discourses: production, distribution, and infrastructure; healthy, organic, local food; behavioral health and education; sustainability; finance and investment; hunger relief; demand-side preferences; romanticized, community led transformations. Study findings reveal that of eight discourses, only three encompass the experiences of low-wealth rural residents. This aspirational food system may aggravate the lack of autonomy and powerlessness already experienced by low-wealth rural groups, perpetuate a sense of failure by groups who will be unable to reach the aspirational food vision, silence discourses that might question those that play a role in the inequitable distribution of income while sanctioning discourses that focus on personal or community solutions, and leave out other policy-based solutions that address issues located within the food system. Further research might explore how to draw attention to silenced discourses on the needs and preferences of low-wealth rural populations to ensure that the policies and programs promoted by food system experts mitigate poor diets caused by food insecurity. Further research is needed to inform policies and programs to mitigate food insecurity in low-wealth rural populations.

State of Mind Ireland-Higher Education: A Mixed-Methods Longitudinal Evaluation of a Positive Mental Health Intervention

Objective: This study evaluates the impact of the State of Mind Ireland-Higher Education (SOMI-HE) Mental Fitness intervention on student wellbeing, resilience, and physical activity (PA) participation. Design: A mixed-methods research design, comprising of a self-report questionnaire, and semi-structured focus group interviews at pre, post and follow-up phases were employed. Participants were a sample of 134 higher education students (29% male: 71% female; mean age range 18 to 25 years old). The quantitative outcome measures of wellbeing, resilience and PA data were analysed using SPSS version 26.0, (IBM, Armonk, NY, USA) with appropriate statistical analysis. Qualitative data were analysed using thematic analysis to capture the long-term outcomes and impact of the intervention. Results: The results indicate a significant intervention effect on participants’ wellbeing (t (120) = −4.27, p < 0.001), PA levels (t (126) = 3.91, p < 0.001) and motivational readiness for exercise change (χ2 (1, n = 131) = 6.9, p < 0.009 (2–sided). Qualitative findings suggest a sustained long-term increase in PA and resilience skills for positive mental health, and reduced stigma and barriers to positive mental health. Conclusion: The findings demonstrate the effectiveness of the SOMI-HE evidence-based intervention, and beneficial outcomes of a salutary approach to higher education student mental health.

Affirmative action, minorities, and public services in India: Charting a future research and practice agenda

The National Health Policy in India mentions equity as a key policy principle and emphasises the role of affirmative action in achieving health equity for a range of excluded groups. We conducted a scoping review of literature and three multi-stakeholder workshops to better understand the available evidence on the impact of affirmative action policies in enhancing the inclusion of ethnic and religious minorities in health, education and governance in India. We consider these public services an important mechanism to enhance the social inclusion of many excluded groups. On the whole, the available empirical evidence regarding the uptake and impact of affirmative action policies is limited. Reservation policies in higher education and electoral constituencies have had a limited positive impact in enhancing the access and representation of minorities. However, reservations in government jobs remain poorly implemented. In general, class, gender and location intersect, creating inter- and intra-group differentials in the impact of these policies. Several government initiatives aimed at enhancing the access of religious minorities to public services/institutions remain poorly evaluated. Future research and practice need to focus on neglected but relevant research themes such as the role of private sector providers in supporting the inclusion of minorities, the political aspects of policy development and implementation, and the role of social mobilisation and movements. Evidence gaps also need to be filled in relation to information systems for monitoring and assessment of social disadvantage, implementation and evaluative research on inclusive policies and understanding how the pathways to inequities can be effectively addressed.

Psychological distress inequality between employed men and women: A gendered exposure model

This study examines an exposure model in which the work and family stressors and the access to resources are gendered and contribute to explaining the psychological distress inequality between sex categories, both directly and indirectly through work-family conflict. A multilevel path analysis conducted on a random cross-sectional sample of 2026 Canadians workers from 63 establishments was performed. Our exposure model fully explains the higher level of psychological distress among working women compared to working men. Women are more exposed to work-to-family conflict, have less decision authority, are more likely to be a single parent and have less self-esteem, factors that are directly associated with a higher level of psychological distress. On the other hand, women work fewer hours, have less irregular or evening schedules and have more social resources outside of work, which contribute to lower their level of psychological distress through less work-to-family conflict. By identifying which of the differences in exposure to work and family stressors and resources explain the greater psychological distress of working women compared to working men, and by examining the mediating role of work-family conflict in this process, this study identified specific paths to reduce psychological distress inequality between women and men in the workplace.

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Women report more psychological distress than men.

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Differential exposure to stressors and access to resources are associated with psychological distress inequality.

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Gendered stressors and resources contributing to this inequality are very specific.

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Some gendered stressors and resources reduce this inequality.

Self-rated health inequalities in the intersection of gender, social class and regional development in Spain: exploring contributions of material and psychosocial factors

BACKGROUND

Inequalities in health across social class, gender and regional context in Spain are well-known; however, there is a lack of research examining how these dimensions of inequality interact. This study explores self-rated health (SRH) inequalities across intersectional positions of gender, social class and region, and the contribution of material and psychosocial factors to these inequalities.

METHODS

Participants were drawn from the cross-sectional 2015 National Living Conditions Survey of Spanish residents aged 19-88 years (N = 27,215; 77% response rate). Eight intersectional positions were formed by combining dichotomous variables of gender, social class and regional development. Poisson regression was used to estimate intersectional inequalities in SRH as prevalence ratios, and the contributions of material and psychosocial factors.

RESULTS

Results showed both cumulative and heterogeneous inequalities within and across intersectional positions. Inequalities in the intersection of social class and regional development were best explained by the joint contributions of material and psychosocial factors, while gender inequalities within non-manual social class were better explained by material factors alone.

CONCLUSIONS

The results illustrate the complexity of interacting inequalities in health and their underpinnings in Spain. Local and national policies taking this complexity into account are needed to broadly improve equity in health in Spain.

Examination of food consumption in United States adults and the prevalence of inflammatory bowel disease using National Health Interview Survey 2015

Various diets and food components have been implicated as one of the environmental factors associated with inflammatory bowel disease (IBD). Patients are often recommended nutritional guidelines to manage disease symptoms. However, the current food consumption pattern of US adults with IBD that are nationally representative is unclear. A secondary analysis of National Health Interview Survey 2015 was performed to characterize the estimated US adults with IBD and their food intake and consumption frequency using bivariate and multivariate logistic regression. Fries were consumed by a greater number of people with IBD. IBD population drank less 100% fruit juice and ate more cheese and cookies than non-IBD population. Intake of fries (OR 1.60, 95% CI 1.14-2.25) and sports and energy drinks (OR 1.46, 95% CI 1.07-1.97) and more frequent drinking of regular soda were significantly associated with the likelihood of having been told one have IBD, while popcorn (OR 0.73, 95% CI 0.548-0.971) and milk (OR 0.70, 95% CI 0.497-0.998) were associated with smaller odds, adjusting for covariates. Foods typically labeled as junk food were positively associated with IBD. Nonetheless, of the assessed 26 foods, we found eating patterns between IBD and non-IBD population to be mostly analogous. It is unclear whether the results reflect potential change in food intake in IBD population long before the survey interview. Understanding the role of food intake in IBD risk/prevalence would benefit from identifying other environmental factors (i.e. food desert), food processing (i.e. frying), and potential bioactive food components that can induce intestinal inflammation that can increase the individual's susceptibility to IBD.

Social capital and utilization of immunization service: A multilevel analysis in rural Uttar Pradesh, India

The National Health Policy (2017) of India advocates Universal Health Coverage through inclusive growth, decentralization, and rebuilding a cohesive community through a participatory process. To achieve this goal, understanding social organization, and community relationships - defined as social capital - is critical. This study aimed to explore the influence of individual and community-level social capital on a critical health system performance indicator, three-doses of diphtheria-pertussis-tetanus (DPT3) immunization among 12-59 month children, in rural Uttar Pradesh (UP), India. The analysis is based on a cross-sectional survey from two districts of UP, which included 2239 children 12-59 months of age (level 1) from 1749 households (level 2) nested within 346 communities (level 3). We used multilevel confirmatory factor analysis to generate standardized factor scores of social capital constructs (Organizational Participation, Social Support, Trust and Social Cohesion) of the household heads and mothers both at individual and community level, which were then used in the multilevel logistic regressions to explore the independent and contextual effect of social capital on a child's DPT3 immunization status. The result showed only community-level Social Cohesion of the mothers was associated with a child's DPT3 immunization status (Adjusted odds ratio = 1.25, 95% confidence interval = 1.12-1.54; p = 0.04). Beyond its independent effect on utilization of immunization service, the collective Social Cohesion of the mothers significantly modified the relationship of child age, mother's knowledge of immunization, community wealth, and communities' contact with frontline workers with immunization status of the child. With a strong theoretical underpinning, the result substantially contributes to understanding the individual and contextual predictors of immunization service utilization and further advancing the literature of social capital in India. This study can serve as a starting point to catalyze social capital within the health interventions for achieving wellbeing and the collective development of society.

Public health management: systemic analysis of social determinants of health in Brazilian municipalities

The health sector is considered extremely important by governments and multilateral international organisms, due to its implication to life, as well as material and human struggling involved. This study adopts a systematical approach in order to question if the mortality outcomes in medium Brazilian cities explain or may be explained by factors considered external to the public health service, expressed by health social determinants. Therefore, this study aims to investigate health conditions in public health management in medium Brazilian cities. The scenario adopted contains 192 cities with a population contingent between 100 000 and 500 000 inhabitants, between the years 2007 and 2011. The database produced, containing 30 indicators representing conceptual models referenced, allowed the elaboration of an operational model of health social determinants from a Bayesian network. As result, we elaborated a model of health system formed by six factors, showing associations that allow a better comprehension about relations among health social determinants and health conditions, producing contextualized information, able to subsidize the formulation of strategies by managers of Sistema Único de Saúde.

The experiences of pregnant women attending a specialist service and using methamphetamine

BACKGROUND

Pregnant women attending the Specialist Drug and Alcohol Service in Perth use methamphetamine as their primary drug of choice. This is the only tertiary service for pregnant and postnatal women with complex Alcohol and Other Drug Use in Western Australia. It is a midwifery-led multidisciplinary team. Many of the women struggle with addiction, polysubstance use, co-occurring mental health, family and domestic violence, complex trauma and fear of Child Protection and infant removal. Therefore, the aim of this study was to understand the impact of methamphetamine use of pregnant women attending the service and explore and highlight the potential barriers to engagement and follow-up.

METHODS

A qualitative study informed by phenomenological methods was undertaken using semi-structured interviews with 20 women with methamphetamine use attending the service in order to explore and understand the experience of using methamphetamine in pregnancy and the postpartum period. A thematic analysis was undertaken with data from the women in the study (n=20) to identify key themes.

RESULTS

Key themes that emerged from the women's experiences detail their resilience and experience with methamphetamine and the impact that methamphetamine has on their life. A key concern for women regarding methamphetamine use and engagement with specialist services was the welfare of their child(ren). Agencies charged with child protection was a barrier to treatment because women feared disclosure of methamphetamine use would result in loss of child custody. Themes highlighted the multiple layers of adversities, and trauma from childhood to adulthood including, co-occurring drug use, mental health and life histories of trauma (abuse, violence, and neglect; intergenerational trauma; intergenerational drug and alcohol use, and child removal), the omnipresence of methamphetamine, and the impact on pregnancy and mothering.

CONCLUSION

We conclude that understanding the experiences of women and the impact methamphetamine use has on their life is paramount to providing effective and appropriate care to support pregnant women in a trauma-informed and woman-centred approach. Poor engagement in pregnancy care for women with methamphetamine use has significant impacts on mother and infant.

Uncovering social and psychosocial health factors through participatory qualitative research with low-income adults in a suburb of Montreal, Quebec

OBJECTIVES

The association between social status and health is well established, but the psychosocial factors and mechanisms underlying this association are not fully understood. This study aims to identify and describe social and psychosocial factors that may harm the health of low-income adults.

DESIGN

Participatory qualitative research using a problem-posing method based on Freire's pedagogy.

SETTING

Community organisation in a low-income district in the metropolitan area of Montreal, in the province of Quebec, Canada.

PARTICIPANTS

Eight low-income adults using food bank services provided by the community organisation. Participants had to reside in the community organisation's service area, have insufficient income to cover living expenses, be aged 18 years or older, and be able to participate in group sessions.

METHODS

Eight weekly group sessions (average of 2.5 hours per session) were held using problem-posing method, which included activities such as presentation of representative stories or images and role-playing. Five additional sessions were held for thematic data analysis with participants.

RESULTS

A main factor identified as harming the health of participants was the dissonance between perceived current circumstances and the ideal of circumstances conceived early in life. This dissonance follows a loss or a failure to achieve the ideal of circumstances and generates profound malaise. Other main factors identified were the current circumstances as a social trap and the lack of love and support from an early age.

CONCLUSIONS

This study identifies a new psychosocial factor, namely, the dissonance between perceived current circumstances and the ideal of circumstances conceived early in life. Larger studies should examine the influence of this factor on health.

Structural equation modeling of psychosocial determinants of health for the empowerment of Iranian women in reproductive decision making

BACKGROUND

Women's empowerment is a process wherein females are afforded power over their own lives as well as their participation in the communities and larger societies to which they belong. An important aspect of such empowerment is the right to make decisions regarding fertility-an entitlement affected by the social health determinants that contribute to the social conditions under which humans live and work throughout their lives. As one such determinant, psychosocial factors play an essential role in the development of women's empowerment. Correspondingly, this study conducted a structural equation modeling of these determinants to examine the empowerment of Iranian women in reproductive decision making.

METHODS

This cross-sectional study involved 400 women who were referred to clinical centers of the Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using six questionnaires, namely, demographic, socioeconomic, and social support questionnaires, the Rosenberg self-esteem scale, a marital satisfaction questionnaire, and an empowerment survey. The data were analyzed using SPSS software version 17, and the structural equation modeling was carried out using EQS software version 6.1.

RESULTS

The Iranian women had an average level of empowerment with respect to reproductive decision making, and such empowerment was related to all the psychosocial factors examined (p = 0.001). The final model appropriately fit the data (comparative fit index = 0.92, root mean square error of approximation = 0.06). The psychosocial factors served as intermediate social determinants of the women's empowerment in reproductive decision making (β = 0.78, p = 0.001). This empowerment was indirectly affected by socioeconomic situation as a structural factor (β = 0.44, p = 0.001).

CONCLUSIONS

Socioeconomic factors, through the mechanism of psychosocial determinants, may significantly affect women's empowerment in making decisions regarding reproductive health. Conditions associated with these factors should be improved to ensure that women claim and exercise their right to have mastery over their reproductive health.

Modelo conceitual aplicável a estudos sobre determinantes sociais da saúde em municípios brasileiros

Resumo Os modelos conceituais de determinantes sociais da saúde (DSS) disponíveis na literatura, embora úteis para compreensão dos mecanismos que afetam os resultados do sistema de saúde sobre as condições de vida das populações, apresentam limitações quanto à sua aplicação em estudos empíricos e, consequentemente, na orientação da gestão de políticas públicas de saúde. Isso ocorre porque as categorias adotadas por esses modelos não são adequadamente representadas por indicadores ou variáveis homogêneas, sujeitas a manipulações matemáticas ou estatísticas em um sistema simples de relacionamentos. Este estudo tem por objetivo contribuir para o preenchimento dessa lacuna, ao propor um modelo conceitual de DSS passível de aplicação operacional, ou seja, de ser reproduzido em modelos matemáticos ou estatísticos, a fim de subsidiar estudos e definir estratégias de saúde pública. O esforço recorre à literatura para revisar modelos conceituais consagrados, identificar um conjunto de DSS e apresentar recomendações e critérios de escolha. Na sequência, identifica fontes de dados confiáveis que disponibilizem indicadores e variáveis dispostos em séries históricas e propõe o desenho de um modelo conceitual aplicável, cuja operacionalização requer métodos e ferramentas próprios de uma abordagem sistêmica.

The legacy of the Home Owners' Loan Corporation and the political ecology of urban trees and air pollution in the United States

This study examines the persistent impacts of historical racebased discriminatory housing policies on contemporary urban environments in the United States. Specifically, we examine the relationships between Home Owners' Loan Corporation (HOLC) grades assigned to neighborhoods in the 1930s and the current distribution of tree canopy and level of exposure to air pollution hazards. Our results indicate a clear gradient in tree canopy by HOLC grade, with better neighborhood grades associated with significantly higher percentage of tree canopy coverage. The pattern also exists for airborne carcinogens and respiratory hazards, with worse neighborhood grades associated with significantly higher hazards exposure. Our findings indicate that early 20th century discriminatory housing policies exert a contemporary influence on patterns of green space exposure in American cities, with implications for health and health inequities. Our findings suggest that, in order to achieve equitable access to the benefits of urban greenspace, we must acknowledge these historical influences and consider policies and practices that directly counter these influences, for example, through targeted greenspace development in areas historically identified as unfit for investment.

Cash transfers and the social determinants of health: a conceptual framework

Cash transfers (CTs) can play a significant role in tackling the social determinants of health (SDoH), but to date there is a lack of conceptual framework for understanding CTs linkages to the SDoH. This article proposes a framework that identifies the linkages between CTs and SDoH, discusses its implications, and argues for active involvement of health promoters in CT design, implementation and evaluation. The development of the framework followed two stages: evidence review and stakeholder involvement. The evidence review entailed a systematic literature search to identify published and unpublished impact evaluation studies of CTs in sub-Saharan Africa. Critical reflection on the evidence synthesized from the literature formed the basis for the development of the framework. Interviews with CT policy makers, managers and development partners were also carried out to help refine the framework. Interviews were audio-recorded and transcripts were analysed using thematic framework analysis. The study finds that there is limited recognition of SDoH in CT policy making and implementation. The evidence reviewed, however, points to strong impacts of CTs on SDoH. The framework thus conceptualizes how CTs work to influence a broad range of SDoH and health inequities. It also highlights how CT architecture and contexts may influence program impacts. The proposed framework can be used by policy makers to guide CT design, adaptation and operations, and by program managers and researchers to inform CTs' evaluations, respectively. The framework suggests that to optimize CT impact on SDoH and reduce health inequities, health promoters should be actively engaged in terms of the programs design, implementation and evaluation.

Measuring Health Vulnerability: An Interdisciplinary Indicator Applied to Mainland Portugal

Health promotion and inequality reduction are specific goals of the United Nations 2030 Agenda, which are interconnected with several dimensions of life. This work proposes a composite index SEHVI-socioeconomic health vulnerability index-to address Portuguese population socioeconomic determinants that affect health outcomes. Variables composing SEHVI are aligned with the sustainable development goals considering data and times series availability to enable progress monitoring, and variables adequacy to translate populations' life conditions affecting health outcomes. Data for 35 variables and three periods were collected from official national databases. All variables are part of one of the groups: Health determinants (social, economic, cultural, and environmental factors) and health outcomes (mortality indicators). Variables were standardized and normalized by "Distance to a reference" method and then aggregated into the SEHVI formula. Several statistical procedures for validation of SEHVI revealed the internal consistency of the index. For all municipalities, SEHVI was calculated and cartographically represented. Results were analyzed by statistical tests and compared for three years and territory typologies. SEHVI differences were found as a function of population density, suggesting inequalities of communities' life conditions and in vulnerability to health.

Pathways to inequalities in child health

From birth, children living in disadvantaged socioeconomic circumstances (SECs) suffer from worse health than their more advantaged peers. The pathways through which SECs influence children's health are complex and inter-related, but in general are driven by differences in the distribution of power and resources that determine the economic, material and psychosocial conditions in which children grow up. A better understanding of why children from more disadvantaged backgrounds have worse health and how interventions work, for whom and in what contexts, will help to reduce these unfair differences. Macro-level change is also required, including the reduction of child poverty through improved social security systems and employment opportunities, and continued investment in high-quality and accessible services (eg, childcare, key workers, children's centres and healthy school environments). Child health professionals can play a crucial role by being mindful of the social determinants of health in their daily practice, and through advocating for more equitable and child-focussed resource allocation.

Reconceptualising precision public health

As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalisation, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalisation within research and practice. Social position shapes individuals' unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualisations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalising these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to the identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualised thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.As currently conceived, precision public health is at risk of becoming precision medicine at a population level. This paper outlines a framework for precision public health that, in contrast to its current operationalization, is consistent with public health principles because it integrates factors at all levels, while illuminating social position as a fundamental determinant of health and health inequities. We review conceptual foundations of public health, outline a proposed framework for precision public health and describe its operationalization within research and practice. Social position shapes individuals' unequal experiences of the social determinants of health. Thus, in our formulation, precision public health investigates how multiple dimensions of social position interact to confer health risk differently for precisely defined population subgroups according to the social contexts in which they are embedded, while considering relevant biological and behavioural factors. It leverages this information to uncover the precise and intersecting social structures that pattern health outcomes, and to identify actionable interventions within the social contexts of affected groups. We contend that studies informed by this framework offer greater potential to improve health than current conceptualizations of precision public health that do not address root causes. Moreover, expanding beyond master categories of social position and operationalizing these categories in more precise ways across time and place can enrich public health research through greater attention to the heterogeneity of social positions, their causes and health effects, leading to identification of points of intervention that are specific enough to be useful in reducing health inequities. Failure to attend to this level of particularity may mask the true nature of health risk, the causal mechanisms at play and appropriate interventions. Conceptualized thus, precision public health is a research endeavour with much to offer by way of understanding and intervening on the causes of poor health and health inequities.

Evaluation of data availability on population health indicators at the regional level across the European Union

BACKGROUND

The ability to measure regional health inequalities across Europe and to build adequate population health indices depends significantly on the availability of reliable and comparable data at the regional level. Within the scope of the EU-funded project EURO-HEALTHY, a Population Health Index (PHI) was built. This model aggregates 39 indicators considered relevant by experts and stakeholders to evaluate and monitor population health on the regional level within the European Union (269 regions). The aim of this research was to assess the data availability for those indicators. As a subsequent aim, an adequate protocol to overcome issues arising from missing data will be presented, as well as key messages for both national and European statistical authorities meant to improve data collection on population health.

METHODS

The methodology for the study includes three consecutive phases: (i) assessing the data availability for the respective indicators at the regional level for the last year available (ii) applying a protocol for missing data and completing the database and (iii) developing a scoring system ranging from 0 (no data available; worst) to 1 (all data available; best) to evaluate the availability of data by indicator and EU region.

RESULTS

Although the missing data on the set of the PHI indicators was significant, the mean availability score for the EURO-HEALTHY PHI indicators is 0.8 and the regional availability score is 0.7, which reveal the strength of the indicators as well as the data completeness protocol for missing data.

CONCLUSIONS

This study provides a comprehensive data availability assessment for population health indicators from multiple areas of concern, at the EU regional level. The results highlight that the data completeness protocol and availability scores are suitable tools to apply on any indicator's data source mapping. It also raises awareness to the urgent need for sub-national data in several domains and for closing the data gaps between and within countries. This will require policies clearly focused on improving equity between regions and a coordinated effort from the producers of data (the EU28 national statistics offices and EUROSTAT) and the stakeholders who design policies at EU, regional and local level.

Advancing health equity and access using telemedicine: a geospatial assessment

INTRODUCTION

Health disparity affects both urban and rural residents, with evidence showing that rural residents have significantly lower health status than urban residents. Health equity is the commitment to reducing disparities in health and in its determinants, including social determinants.

OBJECTIVE

This article evaluates the reach and context of a virtual urgent care (VUC) program on health equity and accessibility with a focus on the rural underserved population.

MATERIALS AND METHODS

We studied a total of 5343 patient activation records and 2195 unique encounters collected from a VUC during the first 4 quarters of operation. Zip codes served as the analysis unit and geospatial analysis and informatics quantified the results.

RESULTS

The reach and context were assessed using a mean accumulated score based on 11 health equity and accessibility determinants calculated for each zip code. Results were compared among VUC users, North Carolina (NC), rural NC, and urban NC averages.

CONCLUSIONS

The study concluded that patients facing inequities from rural areas were enabled better healthcare access by utilizing the VUC. Through geospatial analysis, recommendations are outlined to help improve healthcare access to rural underserved populations.

Community-Based Efforts to Prevent and Manage Diabetes in Women Living in Vulnerable Communities

Social determinants of health likely play a significant role in the development of type 2 diabetes for women in vulnerable communities. Adult African American women diagnosed with or at-risk for diabetes in Inkster, Michigan (n = 113) and a group of demographically similar women in Flint, Michigan (n = 48) participated in programs aimed at increasing diabetes-related self-management behaviors through peer coaching, health literacy training, and social support. Participants completed surveys to measure changes in health, health behaviors, health literacy, and social support. We found that these diabetes programs with a focus on increasing women's capacity to practice health management behaviors, navigate the health care system, and connect with social support, led to an increase in healthy behaviors and a reported increase in both overall and diabetes-specific health over an 18 month period. Overall health, general diet and specific diet improved significantly (p < 0.05) from baseline to follow-up, when controlled for age, diabetes status and site. Exercise also improved, but the change was not statistically significant. Women who participated in the intervention changed health behaviors, and increased their sense of health literacy and social support. Improvement in women's access to and use of community preventive services, and the provision of outreach support using community health workers (CHWs) and peer mentorship was an integral part of creating these changes. Although this study found that a variety of diabetes prevention and management programs provided opportunities for positive health changes, findings also suggest that it is critical to address the burdens women from vulnerable communities face in order to participate in these programs.

A Review of Housing and Food Intersections: Implications for Nurses and Nursing Research

Study Background

Quality, accessibility, and affordability of housing and food are public health and nursing concerns. Yet, intersections between housing and food security are relatively understudied.

Purpose

The purpose of this article is to examine the evidence describing the relationship between food security and housing interventions, and second, describing specific opportunities for targeted strategies for nursing practice and research.

Methods

Arksey and O’Malley’s scoping review method was followed to search housing and food security research. A database search identified 46 studies that were mapped onto a social ecological theory to understand the micro, meso, exo, and macro interventions.

Results

Three major recommendations were identified. Micro-system recommendations include primary care screening for low-income groups. Meso- and exo-system recommendations focus on creating partnerships in research and enhancing social housing. Lastly, macro-system recommendations focus on challenging housing affordability standards. The major gap in the literature is addressing healthy housing.

Conclusion

Broadening housing interventions to include comprehensive approaches to meeting individuals’ needs offers more than simply packaging two interventions together. There is a significant moment in nursing in which nurses are witness to a paradigmatic shift in the ways to approach housing and food security.

Glossary of health equity concepts for public health action in the Canadian context

Despite increased interest in addressing health equity through public health initiatives, practitioner and decision maker comprehension of core concepts is limited and inconsistent. Absence of a shared understanding of equity and related terminology contributes to lack of coordinated solutions as practitioners focus on individual level issues, unrelated to social justice. Taking action to decrease population health inequities requires a comprehension of where inequities are rooted, who is affected and interventions that consider the complexity of inequities being addressed. Public health decision making would be strengthened with greater common understanding of health equity concepts and terminology as an initial step to collaborative action. This glossary defines key concepts related to health equity in public health practice as well as broad-level approaches for taking action on health inequities at a population health level. Exploring terminology in this way supports going beyond individual practitioner responsibility and shifts towards organisational accountability for action.

Qualitative exploration of sociocultural determinants of health inequities of Dalit population in Dhaka City, Bangladesh

OBJECTIVES

In recent years, Bangladesh has made remarkable advances in health outcomes; however, the benefits of these gains are unequally shared among citizens and population groups. Dalits (jaat sweepers), a marginalised traditional working community, have relatively poor access to healthcare services. This study sought to explore the sociopolitical and cultural factors associated with health inequalities among Dalits in an urban setting.

DESIGN

An exploratory qualitative study design was adopted. Fourteen in-depth interviews, five focus group discussions and seven key informant interviews were conducted. The acquired data were analysed using an iterative approach which incorporated deductive and inductive methods in identifying codes and themes.

SETTINGS

This study was conducted in two sweeper communities in Dhaka city.

PARTICIPANTS

Participants were Dalit men and women (in-depth interviews, mean age±SD 30±10; and focus group discussions), and the community leaders and non-governmental organisation workers (key informant interviews).

RESULTS

The health status of members of these Dalit groups is determined by an array of social, economic and political factors. Dalits (untouchables) are typically considered to fall outside the caste-based social structure and existing vulnerabilities are embedded and reinforced by this identity. Dalits' experience of precarious access to healthcare or poor healthcare is an important manifestation of these inequalities and has implications for the economic and social life of Dalit populations living together in geographically constrained spaces.

CONCLUSIONS

The provision of clinical healthcare services alone is insufficient to mitigate the negative effects of discriminations and to improve the health status of Dalits. A better understanding of the precise influences of sociocultural determinants of health inequalities is needed, together with the identification of the strategies and programmes needed to address these determinants with the aim of developing more inclusive health service delivery systems.

Rethinking the Theory of Change for Health in All Policies Comment on "Health Promotion at Local Level in Norway: The Use of Public Health Coordinators and Health Overviews to Promote Fair Distribution Among Social Groups"

This commentary discusses the interesting and surprising findings by Hagen and colleagues, focusing on the role of the public health coordinator as a Health in All Policies (HiAP) tool. The original article finds a negative association between the employment of public health coordinators in Norwegian municipalities and consideration of a fair distribution of social and economic resources between social groups in local policymaking and planning. The commentary contemplates whether this surprising negative association should be interpreted as a failure of implementation, as suggested by the authors, or whether it might be the theory of change that has failed. On this basis, it is suggested that the very notion of HiAP could be flawed by the assumption that health should function as an overarching aim across government sectors. Potentially, the social determinants of health (SDH) might be more efficiently addressed by means of sectoral action by the corresponding sectors, emphasizing equity rather than health.

Widening health inequalities between the employed and the unemployed: A decomposition of trends in Canada (2000-2014)

Recent developments in the social epidemiological literature indicate that health inequalities between the employed and the unemployed are widening in many advanced capitalist countries. At present, we know relatively little about why these inequalities are worsening. Drawing on nationally-representative data from the largest health survey in Canada, we explored this question by analyzing changes in self-rated health inequalities between employed and unemployed Canadians from 2000 to 2014. Using a regression-based method that decomposes a given inequality into its component sources, we investigated the extent to which risk factors that account for unemployment-related health inequalities at a single point in time can also explain the extent and direction of change in these unemployment-related health inequalities over time. Our results indicate that relative and absolute health inequalities between employed and unemployed Canadians widened over the study period. Between 2000 and 2014, the prevalence of poor self-rated health among unemployed Canadians increased from 10.8% to 14.6%, while rates among employed Canadians were stable at around 6%. Our findings suggest that the demographic, socioeconomic, and proximal risk factors that are routinely used to explain unemployment-related health inequalities may not be as powerful for explaining how and why these inequalities change over time. In the case of unemployment-related health inequalities in Canada, these risk factors explain neither the increasing prevalence of poor self-rated health among the unemployed nor the growing gap between the unemployed and their employed counterparts. We provide several possible explanations for these puzzling findings. We conclude by suggesting that widening health inequalities may be driven by macrosocial trends (e.g. widening income inequality and declining social safety nets) which have changed the meaning and context of unemployment, as well as its associated risk factors, in ways that are not easy to capture using routinely available survey data.

"It's a tradition of naming injustice": An oral history of the social determinants of health - Canadian reflections, 1960s-present

The ‘social determinants of health’ (SDOH) approach in Canada is widely acknowledged as having emerged through contributions such as the 1974 Lalonde Report or 1986 Ottawa Charter. Drawing on original oral histories, I consider this history through the reflections of past and present leaders in Canadian public health. Through this rich information, I identified three phases in the recent history of the SDOH, from a social awareness (1960s-1970s, when participants underwent training and gained exposure to social and health inequities), to a loose collection of theoretical and empirical concepts (1970s–1990s, when the evidence base on health inequities and the mechanisms behind them began to solidify), to a distinct research approach (2000s-present, when high profile events led to acceptance of the SDOH approach) that encompassed the spirit of its previous iterations. This paper will be of interest to health researchers and professionals, decision-makers, and trainees as they contemplate their own role in this ongoing history.

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Social justice has remained core to SDOH history since the 1960s.

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Canada has contributed to a rhetoric supportive of the SDOH that helped shape this history.

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A generation of public health leaders committed to reducing health inequities emerged from the Canadian setting.

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The SDOH will continue to evolve as trainees learn from and build on its history.

Social inequality and fractures-secular trends in the Danish population: a case-control study

We examined links between markers of social inequality and fracture risk in the Danish population, demonstrating that high income and being married are associated with a significantly lower risk.

INTRODUCTION

We explored whether the risk of hip, humerus, and wrist fracture was associated with markers of inequality using data from Danish health registries.

METHODS

All patients 50 years or older with a primary hip (ICD10 S720, S721, S722, and S729) humerus (ICD10 S422, S423, S424, S425, S426, and S427), or wrist (ICD10: S52) fracture were identified from 1/1/1995 to 31/12/2011. Fracture patients were matched 1:1 by age, sex, and year of fracture, to a non-fracture control. Markers of inequality were as follows: income (fifths); marital status (married, divorced, widowed, or unmarried); area of residence (remote, rural, intermediate, or urban). Conditional logistic regression was used to investigate associations between these exposures, and risk of fracture, adjusting for covariates (smoking, alcohol, and Charlson co-morbidity). Interactions were fitted between exposure and covariates where appropriate.

RESULTS

A total of 189,838 fracture patients (37,500 hip, 45,602 humerus, and 106,736 wrist) and 189,838 controls were included. Mean age was 73.9 years (hip), 67.5 years (humerus), and 65.3 years (wrist). High income (5th quintile) was significantly associated with a lower odds ratio of all three fractures, compared to average income (3rd quintile). Married subjects had a significantly decreased odds ratio across all three fractures. However, no overall secular difference was observed regarding the influence of the markers of inequality.

CONCLUSION

In conclusion, we have demonstrated important, stable associations between social inequality, assessed using income, marital status, and area of residence, and fracture at the population level. These findings can inform approaches to healthcare, and suggest that much thought should be given to novel interventions aimed especially at those living alone, and ideally societal measures to reduce social inequality.

Oral Health Disparities in Children: A Canary in the Coalmine?

Despite being largely preventable, oral diseases are still a major public health problem in child populations in many parts of the world. Increasingly, however, oral diseases disproportionately affect socially disadvantaged groups in society. It is unjust and unfair that children and families from disadvantaged backgrounds experience high levels of oral diseases. This article analyzes oral diseases through a health disparities lens. Action to combat oral health disparities requires a radical multifaceted strategy that addresses the shared underlying root causes of oral diseases, the social determinants of health inequality.

Towards an understanding of the multilevel factors associated with maternal health care utilization in Uttar Pradesh, India

BACKGROUND

This paper explores the multilevel factors associated with maternal health utilization in India's most populous state, Uttar Pradesh. 3 key utilization practices: registration of pregnancy, receipt of antenatal care, and delivery at home are examined for district and individual level predictors. The data is based on 5666 household surveys conducted as part of a baseline evaluation of the Uttar Pradesh Technical Support Unit (UPTSU.) program.

OBJECTIVES

This intervention aims to assist the Government of Uttar Pradesh in increasing the efficiency, effectiveness, and equity of service delivery across a continuum of reproductive, maternal, new-born, child, and adolescent health (RMNCH+A) outcomes.

METHODS

The paper employs multilevel models that control for individuals being nested within districts in order to understand the predictors of maternal health care utilization.

RESULTS

The study identifies several individual-level predictors of health care utilization, including: literacy of the woman, the husband's schooling, age at marriage, and socio-economic factors. Key predictors of pregnancy registration include husband's schooling (OR 1.49, 95% CI 1.26-1.76), having a bank account (OR 1.36, 95% CI 1.11-1.68), and owning a house (OR 2.28, 95% CI 1.85-2.80). Factors affecting antenatal care include the woman's literacy (OR 1.49, 95% CI 1.28-1.73), the respondent having had a job in the last year (OR 1.39, 95% CI 1.10-1.77), and owning a house (OR 2.83, 95% CI 2.27-3.53). Home delivery tends to be associated with woman's literacy (OR 0.62, 95% CI 0.54-0.72) and marriage age of 15 and younger (OR 1.48, 95% CI 1.26-1.73).

CONCLUSIONS

Interventions having equity considerations need to disrupt existing patterns of the health gradient. Successful implementation of such interventions, necessitate understanding the mechanisms that can disrupt the unequal utilization patterns and target domains of disadvantage. Knowledge of key predictors of utilization can aid in the implementation of such complex interventions.

Evaluating the effect of income support policies on social health inequalities (SHIs) at birth in Montreal and Brussels using a contextualised comparative approach and model family method: a study protocol

INTRODUCTION

Assessing the effects of social policies on social health inequalities (SHIs) is a complex issue. Variations in social policy between countries or regions provide natural experiments in policy implementation to perform comparative research. Comparisons are most enlightening when: the object of the evaluation is well defined (types of policies, population groups); the context of policy is analysed (history, implementation); the impact of policy on household poverty is outlined in detail; the influence of various factors (other than poverty) on SHI is taken into consideration.

METHODS AND ANALYSIS

This study aims to understand how income support policies (ISPs) in Brussels and Montreal influence the poverty level of households receiving social assistance, and how they are associated with SHI at birth. Two cases studies will be carried out from a comparative perspective. The analysis includes four stages : (1) The model family method will be used to compare ISPs and their impact on disposable income and poverty of households receiving social assistance in both regions. (2) Statistical analysis of administrative databases will enable the description and comparison of SHI in adverse pregnancy outcomes across the two regions. (3) Analysis of databases and documents will allow for description of various factors which are likely to interact with poverty and influence SHI at birth. (4) Based on the Diderichsen model, results from the previous stages will be used to formulate hypotheses about the mechanisms by which ISPs contribute to increasing or reducing SHI at birth in both regions.

ETHICS AND DISSEMINATION

This research was approved by the Human Research Ethics Committee for Health research of Université de Montréal. In Belgium, the access to linked databases was approved by the Commission for the Protection of Privacy. Databases de-identified according to Belgian and Canadian legislation will be used. Results will be disseminated in scientific publications and will be shared with policy makers and field actors through collaborations with local organisations in Brussels and Montreal.