Priorities for research on equity and health: towards an equity-focused health research agenda

Utilisation of health services and the poor: deconstructing wealth-based differences in facility-based delivery in the Philippines

BACKGROUND

Despite achieving some success, wealth-related disparities in the utilisation of maternal and child health services persist in the Philippines. The aim of this study is to decompose the principal factors driving the wealth-based utilisation gap.

METHODS

Using national representative data from the 2013 Philippines Demographic and Health Survey, we examine the extent overall differences in the utilisation of maternal health services can be explained by observable factors. We apply nonlinear Blinder-Oaxaca-type decomposition methods to quantify the effect of differences in measurable characteristics on the wealth-based coverage gap in facility-based delivery.

RESULTS

The mean coverage of facility-based deliveries was respectively 41.1 % and 74.6 % for poor and non-poor households. Between 67 and 69 % of the wealth-based coverage gap was explained by differences in observed characteristics. After controlling for factors characterising the socioeconomic status of the household (i.e. the mothers' and her partners' education and occupation), the birth order of the child was the major factor contributing to the disparity. Mothers' religion and the subjective distance to the health facility were also noteworthy.

CONCLUSIONS

This study has found moderate wealth-based disparities in the utilisation of institutional delivery in the Philippines. The results confirm the importance of recent efforts made by the Philippine government to implement equitable, pro-poor focused health programs in the most deprived geographic areas of the country. The importance of addressing the social determinants of health, particularly education, as well as developing and implementing effective strategies to encourage institutional delivery for higher order births, should be prioritised.

Analysing implementer narratives on addressing health inequity through convergent action on the social determinants of health in India

BACKGROUND

Understanding health inequity in India is a challenge, given the complexity that characterise the lives of its residents. Interpreting constructive action to address health inequity in the country is rare, though much exhorted by the global research community. We critically analysed operational understandings of inequity embedded in convergent actions to address health-related inequalities by stakeholders in varying contexts within the country.

METHODS

Two implementer groups were purposively chosen to reflect on their experiences addressing inequalities in health (and its determinants) in the public sector working in rural areas and in the private non-profit sector working in urban areas. A representing co-author from each group developed narratives around how they operationally defined, monitored, and addressed health inequality in their work. These narratives were content analysed by two other co-authors to draw out common and disparate themes characterising each action context, operational definitions, shifts and changes in strategies and definitions, and outcomes (both intended and unintended). Findings were reviewed by all authors to develop case studies.

RESULTS

We theorised that action to address health inequality converges around a unifying theme or pivot, and developed a heuristic that describes the features of this convergence. In one case, the convergence was a single decision-making platform for deliberation around myriad village development issues, while in the other, convergence brought together communities, legal, police, and health system action around one salient health issue. One case emphasized demand generation, the other was focussed on improving quality and supply of services. In both cases, the operationalization of equity broke beyond a biomedical or clinical focus. Dearth of data meant that implementers exercised various strategies to gather it, and to develop interventions - always around a core issue or population.

CONCLUSIONS

This exercise demonstrated the possibility of constructive engagement between implementers and researchers to understand and theorize action on health equity and the social determinants of health. This heuristic developed may be of use not just for further research, but also for on-going appraisal and design of policy and praxis, both sensitive to and reflective of Indian concerns and understandings.

Measurement of health equity as a driver for impacting policies

This paper proposes measurement tracks of health equity (HE) and presents practical illustrations to influence, inform and guide the uptake of equity-sensitive policies. It discusses the basic requirements that allow the effective use of the proposed measurement tracks. Egypt is used as a demonstration of this practice. The paper differentiates between the policy needs of two groups of countries. The first set of measurement tracks are specifically tailored to countries at the early stages of considering health equity, requiring support in placing HE on the policy agenda. Key messages for this group of countries are that the policy influence of measurement can be strengthened through the implementation of four self-reinforcing tracks that recognize the need to effectively use the available current databases prior to engaging in new data collection, emphasize the importance of a social justice reframing of the documented health inequities, present health inequity facts in simple visual messages and move beyond the why to what needs to be done and how. The tracks also recognizes that placing an issue on the policy agenda is a complex matter requiring reinforcement from many actors and navigation among competing forces and policy circles. For the second group of countries the paper discusses the monitoring framework. The key messages include the importance of moving toward a more comprehensive system that sustains the monitoring system which is embedded within affective participatory accountability mechanisms. The paper discusses the basic requirements and the institutional, financial, technical and human capacity-building considerations for implementing the proposed measurement tracks.

Public health agenda setting in a global context: the International Labor Organization's decent work agenda

We drew on two agenda-setting theories usually applied at the state or national level to assess their utility at the global level: Kingdon's multiple streams theory and Baumgartner and Jones's punctuated equilibrium theory. We illustrate our analysis with findings from a qualitative study of the International Labor Organization's Decent Work Agenda. We found that both theories help explain the agenda-setting mechanisms that operate in the global context, including how windows of opportunity open and what role institutions play as policy entrepreneurs. Future application of these theories could help characterize power struggles between global actors, whose voices are heard or silenced, and their impact on global policy agenda setting.

Training needs for research in health inequities among health and demographic researchers from eight African and Asian countries

Background

To support equity focussed public health policy in low and middle income countries, more evidence and analysis of the social determinants of health inequalities is needed. This requires specific know how among researchers. The INDEPTH Training and Research Centres of Excellence (INTREC) collaboration will develop and provide training on the social determinants of health approach for health researchers from the International Network for the Demographic Evaluation of Populations and Their Health in Low- and Middle-Income Countries (INDEPTH) in Africa and Asia. To identify learning needs among the potential target group, this qualitative study explored what INDEPTH researchers from Ghana, Tanzania, South Africa, Kenya, Indonesia, India, Vietnam, and Bangladesh feel that they want to learn to be able to conduct research on the causes of health inequalities in their country.

Methods

Using an inductive method, online concept-mapping, participants were asked to generate statements in response to the question what background knowledge they would need to conduct research on the causes of health inequalities in their country, to sort those statements into thematic groups, and to rate them in terms of how important it would be for the INTREC program to offer instruction on each of the statements. Statistical techniques were used to structure statements into a thematic cluster map and average importance ratings of statements/clusters were calculated.

Results

Of the 150 invited researchers, 82 participated in the study: 54 from Africa; 28 from Asia. Participants generated 59 statements and sorted them into 6 broader thematic clusters: “assessing health inequalities”; “research design and methods”; “research and policy”; “demography and health inequalities”; “social determinants of health” and “interventions”. African participants assigned the highest importance to further training on methods for assessing health inequalities. Asian participants assigned the highest importance to training on research and policy.

Conclusion

The identified thematic clusters and statements provide a detailed understanding of what INDEPTH researchers want to learn in order to be able to conduct research on the social determinants of health inequalities. This offers a framework for developing capacity building programs in this emerging field of public health research.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-1254) contains supplementary material, which is available to authorized users.

A literary analysis of global female identity, health, and equity

Females' experiences of identity, health, and equity share similar features around the world. This literary analysis describes the narratives of 4 female protagonists from popular fiction novels to identify similarities between their personal and contextualized experiences. The impact these private realities and public structures have on female health will be used to demonstrate the universal ecological threats to women's health. In conclusion, we offer suggestions on how to incorporate the shared female movement from domination and separation toward liberation and connection into modern health care practices that emphasize shared decision making, open communication, and social activism.

What interventions are effective on reducing inequalities in maternal and child health in low- and middle-income settings? A systematic review

BACKGROUND

The deadline for achieving Millennium Development Goals 4 and 5 is approaching, but inequalities between disadvantaged and other populations is a significant barrier for progress towards achieving these goals. This systematic review aims to collect evidence about the differential effects of interventions on different sociodemographic groups in order to identify interventions that were effective in reducing maternal or child health inequalities.

METHODS

We searched the PubMed, EMBASE and other relevant databases. The reference lists of included reviews were also screened to find more eligible studies. We included experimental or observational studies that assessed the effects of interventions on maternal and child health, but only studies that report quantitative inequality outcomes were finally included for analysis.

RESULTS

22 articles about the effectiveness of interventions on equity in maternal and child health were finally included. These studies covered five kinds of interventions: immunization campaigns, nutrition supplement programs, health care provision improvement interventions, demand side interventions, and mixed interventions. The outcome indicators covered all MDG 4 and three MDG 5 outcomes. None of the included studies looked at equity in maternal mortality, adolescent birth rate and unmet need for family planning. The included studies reported inequalities based on gender, income, education level or comprehensive socioeconomic status. Stronger or moderate evidence showed that all kinds of the included interventions may be more effective in improving maternal or child health for those from disadvantaged groups.

CONCLUSION

Studies about the effectiveness of interventions on equity in maternal or child health are limited. The limited evidence showed that the interventions that were effective in reducing inequity included the improvement of health care delivery by outreach methods, using human resources in local areas or provided at the community level nearest to residents and the provision of financial or knowledge support to demand side.

Indicators for tracking programmes to strengthen health research capacity in lower- and middle-income countries: a qualitative synthesis

BACKGROUND

The monitoring and evaluation of health research capacity strengthening (health RCS) commonly involves documenting activities and outputs using indicators or metrics. We sought to catalogue the types of indicators being used to evaluate health RCS and to assess potential gaps in quality and coverage.

METHODS

We purposively selected twelve evaluations to maximize diversity in health RCS, funders, countries, and approaches to evaluation. We explored the quality of the indicators and extracted them into a matrix across individual, institutional, and national/regional/network levels, based on a matrix in the ESSENCE Planning, Monitoring and Evaluation framework. We synthesized across potential impact pathways (activities to outputs to outcomes) and iteratively checked our findings with key health RCS evaluation stakeholders.

RESULTS

Evaluations varied remarkably in the strengths of their evaluation designs. The validity of indicators and potential biases were documented in a minority of reports. Indicators were primarily of activities, outputs, or outcomes, with little on their inter-relationships. Individual level indicators tended to be more quantitative, comparable, and attentive to equity considerations. Institutional and national-international level indicators were extremely diverse. Although linkage of activities through outputs to outcomes within evaluations was limited, across the evaluations we were able to construct potential pathways of change and assemble corresponding indicators.

CONCLUSIONS

Opportunities for improving health RCS evaluations include work on indicator measurement properties and development of indicators which better encompass relationships with knowledge users. Greater attention to evaluation design, prospective indicator measurement, and systematic linkage of indicators in keeping with theories of change could provide more robust evidence on outcomes of health RCS.

The challenges of including sex/gender analysis in systematic reviews: a qualitative survey

BACKGROUND

Systematic review methodology includes the rigorous collection, selection, and evaluation of data in order to synthesize the best available evidence for health practice, health technology assessments, and health policy. Despite evidence that sex and gender matter to health outcomes, data and analysis related to sex and gender are frequently absent in systematic reviews, raising concerns about the quality and applicability of reviews. Few studies have focused on challenges to implementing sex/gender analysis within systematic reviews.

METHODS

A multidisciplinary group of systematic reviewers, methodologists, biomedical and social science researchers, health practitioners, and other health sector professionals completed an open-ended survey prior to a two-day workshop focused on sex/gender, equity, and bias in systematic reviews. Respondents were asked to identify challenging or 'thorny' issues associated with integrating sex and gender in systematic reviews and indicate how they address these in their work. Data were analysed using interpretive description. A summary of the findings was presented and discussed with workshop participants.

RESULTS

Respondents identified conceptual challenges, such as defining sex and gender, methodological challenges in measuring and analysing sex and gender, challenges related to availability of data and data quality, and practical and policy challenges. No respondents discussed how they addressed these challenges, but all proposed ways to address sex/gender analysis in the future.

CONCLUSIONS

Respondents identified a wide range of interrelated challenges to implementing sex/gender considerations within systematic reviews. To our knowledge, this paper is the first to identify these challenges from the perspectives of those conducting and using systematic reviews. A framework and methods to integrate sex/gender analysis in systematic reviews are in the early stages of development. A number of priority items and collaborative initiatives to guide systematic reviewers in sex/gender analysis are provided, based on the survey results and subsequent workshop discussions. An emerging 'community of practice' is committed to enhancing the quality and applicability of systematic reviews by integrating considerations of sex/gender into the review process, with the goals of improving health outcomes and ensuring health equity for all persons.

Screening primary-care patients forgoing health care for economic reasons

BACKGROUND

Growing social inequities have made it important for general practitioners to verify if patients can afford treatment and procedures. Incorporating social conditions into clinical decision-making allows general practitioners to address mismatches between patients' health-care needs and financial resources.

OBJECTIVES

Identify a screening question to, indirectly, rule out patients' social risk of forgoing health care for economic reasons, and estimate prevalence of forgoing health care and the influence of physicians' attitudes toward deprivation.

DESIGN

Multicenter cross-sectional survey.

PARTICIPANTS

Forty-seven general practitioners working in the French-speaking part of Switzerland enrolled a random sample of patients attending their private practices.

MAIN MEASURES

Patients who had forgone health care were defined as those reporting a household member (including themselves) having forgone treatment for economic reasons during the previous 12 months, through a self-administered questionnaire. Patients were also asked about education and income levels, self-perceived social position, and deprivation levels.

KEY RESULTS

Overall, 2,026 patients were included in the analysis; 10.7% (CI95% 9.4-12.1) reported a member of their household to have forgone health care during the 12 previous months. The question "Did you have difficulties paying your household bills during the last 12 months" performed better in identifying patients at risk of forgoing health care than a combination of four objective measures of socio-economic status (gender, age, education level, and income) (R(2) = 0.184 vs. 0.083). This question effectively ruled out that patients had forgone health care, with a negative predictive value of 96%. Furthermore, for physicians who felt powerless in the face of deprivation, we observed an increase in the odds of patients forgoing health care of 1.5 times.

CONCLUSION

General practitioners should systematically evaluate the socio-economic status of their patients. Asking patients whether they experience any difficulties in paying their bills is an effective means of identifying patients who might forgo health care.

Equity in access to fortified maize flour and corn meal

Mass fortification of maize flour and corn meal with a single or multiple micronutrients is a public health intervention that aims to improve vitamin and mineral intake, micronutrient nutritional status, health, and development of the general population. Micronutrient malnutrition is unevenly distributed among population groups and is importantly determined by social factors, such as living conditions, socioeconomic position, gender, cultural norms, health systems, and the socioeconomic and political context in which people access food. Efforts trying to make fortified foods accessible to the population groups that most need them require acknowledgment of the role of these determinants. Using a perspective of social determinants of health, this article presents a conceptual framework to approach equity in access to fortified maize flour and corn meal, and provides nonexhaustive examples that illustrate the different levels included in the framework. Key monitoring areas and issues to consider in order to expand and guarantee a more equitable access to maize flour and corn meal are described.

Beyond Accreditation: A Multi-Track Quality-Enhancing Strategy for Primary Health Care in Low-and Middle-Income Countries

Many define an equitable health care system as one that provides logistical and financial access to “quality” care to the population. Realizing that fact, many low- and middle-income countries started investing in enhancing the quality of care in their health care systems, recently in primary health care. Unfortunately, in many instance, these investments have been exclusively focused on accreditation due to available guidelines and existing accrediting structures. A multi-track quality-enhancing strategy (MTQES) is proposed that includes, in addition to promoting resource-sensitive accreditation, other quality initiatives such as clinical guidelines, performance indicators, benchmarking activities, annual quality-enhancing projects, and annual quality summit/meeting. These complementary approaches are presented to synergistically enhance a continuous quality improvement culture in the primary health care sector, taking into consideration limited resources available, especially in low- and middle-income countries. In addition, an implementation framework depicting MTQES in three-phase interlinked packages is presented; each matches existing resources and quality infrastructure. Health care policymakers and managers need to think about accreditation as a beginning rather than an end to their quest for quality. Improvements in the structure of a health delivery organization or in the processes of care have little value if they do not translate to reduced disparities in access to “quality” care, and not merely access to care.

Gender inequalities in health: exploring the contribution of living conditions in the intersection of social class

BACKGROUND

Women experience poorer health than men despite their longer life expectancy, due to a higher prevalence of non-fatal chronic illnesses. This paper aims to explore whether the unequal gender distribution of roles and resources can account for inequalities in general self-rated health (SRH) by gender, across social classes, in a Southern European population.

METHODS

Cross-sectional study of residents in Catalonia aged 25-64, using data from the 2006 population living conditions survey (n=5,817). Poisson regression models were used to calculate the fair/poor SRH prevalence ratio (PR) by gender and to estimate the contribution of variables assessing several dimensions of living conditions as the reduction in the PR after their inclusion in the model. Analyses were stratified by social class (non-manual and manual).

RESULTS

SRH was poorer for women among both non-manual (PR 1.39, 95% CI 1.09-1.76) and manual social classes (PR 1.36, 95% CI 1.20-1.56). Adjustment for individual income alone eliminated the association between sex and SRH, especially among manual classes (PR 1.01, 95% CI 0.85-1.19; among non-manual 1.19, 0.92-1.54). The association was also reduced when adjusting by employment conditions among manual classes, and household material and economic situation, time in household chores and residential environment among non-manual classes.

DISCUSSION

Gender inequalities in individual income appear to contribute largely to women's poorer health. Individual income may indicate the availability of economic resources, but also the history of access to the labour market and potentially the degree of independence and power within the household. Policies to facilitate women's labour market participation, to close the gender pay gap, or to raise non-contributory pensions may be helpful to improve women's health.

Social and material deprivation and the cost-effectiveness of an intervention to promote physical activity: cohort study and Markov model

Background

We developed a method to model the cost-effectiveness at different levels of deprivation of an intervention to promote physical activity.

Methods

The cost-effectiveness of a brief intervention in primary care was estimated by means of a Markov model stratified by deprivation quintile. Estimates for disease incidence, mortality, depression prevalence and health service utilization were obtained from 282 887 participants in the UK Clinical Practice Research Datalink with linked deprivation scores. Discounted results were compared for least deprived and most deprived quintiles.

Results

An effective intervention to promote physical activity continuing for 5 years gave an increase in life years free from disease: least deprived 54.9 (95% interval 17.5–93.5) per 1000 participants entering model; most deprived 74.5 (22.8–128.0) per 1000. The overall incremental quality adjusted life years were: least deprived, 3.7 per 1000 and most deprived, 6.1 per 1000 with probability cost-effective at £30 000 per QALY being 52.5 and 63.3%, respectively. When the intervention was modelled to be 30% less effective in the most deprived than the least deprived quintile, the probability cost-effective was least deprived 52.9% and most deprived 55.9%.

Conclusion

Physical activity interventions may generate greater health benefits in deprived populations. When intervention effectiveness is attenuated in deprived groups, cost-effectiveness may sometimes still be similar to that in the most affluent groups. Even with favourable assumptions, evidence was insufficient to support wider use of presently available brief primary care interventions in a universal strategy for primary prevention.

Promoting social responsibility amongst health care users: medical tourists' perspectives on an information sheet regarding ethical concerns in medical tourism

BACKGROUND

Medical tourists, persons that travel across international borders with the intention to access non-emergency medical care, may not be adequately informed of safety and ethical concerns related to the practice of medical tourism. Researchers indicate that the sources of information frequently used by medical tourists during their decision-making process may be biased and/or lack comprehensive information regarding individual safety and treatment outcomes, as well as potential impacts of the medical tourism industry on third parties. This paper explores the feedback from former Canadian medical tourists regarding the use of an information sheet to address this knowledge gap and raise awareness of the safety and ethical concerns related to medical tourism.

RESULTS

According to feedback provided in interviews with former Canadian medical tourists, the majority of participants responded positively to the information sheet and indicated that this document prompted them to engage in further consideration of these issues. Participants indicated some frustration after reading the information sheet regarding a lack of know-how in terms of learning more about the concerns discussed in the document and changing their decision-making. This frustration was due to participants' desperation for medical care, a topic which participants frequently discussed regarding ethical concerns related to health care provision.

CONCLUSIONS

The overall perceptions of former medical tourists indicate that an information sheet may promote further consideration of ethical concerns of medical tourism. However, given that these interviews were performed with former medical tourists, it remains unknown whether such a document might impact upon the decision-making of prospective medical tourists. Furthermore, participants indicated a need for an additional tool such as a website for continued discussion about these concerns. As such, along with dissemination of the information sheet, future research implications should include the development of a website for ongoing discussion that could contribute to a raised awareness of these concerns and potentially increase social responsibility in the medical tourism industry.

Equity-focused knowledge translation: a framework for "reasonable action" on health inequities

OBJECTIVES

To identify gaps in procedural approaches to knowledge translation and outline a more relational approach that addresses health inequities based on creating collaborative environments for reasonable action.

METHODS

A literature review encompassing approaches to critical inquiry of the institutional conditions in which knowledge is created combined with a process for encouraging reflexive professional practice provide the conceptual foundation for our approach, called equity-focused knowledge translation (EqKT).

RESULTS

The EqKT approach creates a matrix through which teams of knowledge stakeholders (researchers, practitioners, and policymakers) can set common ground for taking collaborative action on health inequities.

CONCLUSIONS

Our approach can contribute to the call by the WHO Commission on the Social Determinants of Healths for more reasonable action on health inequities by being incorporated into numerous public health settings and processes. Further steps include empirical applications and evaluations of EqKT in real world applications.

Improving average health and persisting health inequities--towards a justice and fairness platform for health policy making in Asia

BACKGROUND

Following a period of rapid economic and social change across Asia in the 1980s and 1990s, there have been persisting reports of public sector health systems decline and worsening health inequities within countries. Many studies and analyses in the region have indicated that these inequities are socially determined, leading to questions regarding the adequacy of current health policy approaches towards addressing the challenge of persisting health inequities.

METHODS

Utilizing published data from Demographic Health Surveys (DHS) and case studies and reviews on health inequity in the Asian region, this article aims to describe the existing patterns of inequity of health access both within and between countries, focusing on immunization, maternal health access, nutritional outcomes and child mortality, with a view to recommending health policy options for addressing these health inequities. We compare the gap in access and outcomes between the highest and the lowest wealth quintiles, as well as cross-reference these findings with case studies and surveys on health inequities in the region.

RESULTS

In Asia, while in terms of aggregate health more of the poor are being reached, the reduction in the gap between social groups in some cases is stagnating, particularly for maternal health access and childhood stunting. Inequity gaps for immunization are persisting, and remain very wide in large population countries. For child mortality, more of the poor are surviving, although the rate of mortality decline is more rapid in higher than lower socio-economic groupings.

CONCLUSIONS

Both a strategic shift towards public health critique of social and political policy and operational shifts in health management and practice will be required to attain improvements in distributive health in Asia.

Who cares about health inequalities? Cross-country evidence from the World Health Survey

Reduction of health inequalities within and between countries is a global health priority, but little is known about the determinants of popular support for this goal. We used data from the World Health Survey to assess individual preferences for prioritizing reductions in health and health care inequalities. We used descriptive tables and regression analysis to study the determinants of preferences for reducing health inequalities as the primary health system goal. Determinants included individual socio-demographic characteristics (age, sex, urban residence, education, marital status, household income, self-rated health, health care use, satisfaction with health care system) and country-level characteristics [gross domestic product (GDP) per capita, disability-free life expectancy, equality in child mortality, income inequality, health and public health expenditures]. We used logistic regression to assess the likelihood that individuals ranked minimizing inequalities first, and rank-ordered logistic regression to compare the ranking of other priorities against minimizing health inequalities. Individuals tended to prioritize health system goals related to overall improvement (improving population health and health care responsiveness) over those related to equality and fairness (minimizing inequalities in health and responsiveness, and promoting fairness of financial contribution). Individuals in countries with higher GDP per capita, life expectancy, and equality in child mortality were more likely to prioritize minimizing health inequalities.

Consideration of ethnicity in guidelines and systematic reviews promoting lifestyle interventions: a thematic analysis

BACKGROUND

There is a growing body of evidence supporting lifestyle interventions for the prevention of chronic disease. However, it is unclear to what extent these evidence-derived recommendations are applicable to ethnic minority populations. We sought to assess the degree of consideration of ethnicity in systematic reviews and guidelines for lifestyle interventions.

METHODS

Two reviewers systematically searched seven databases to identify systematic reviews (n = 111) and UK evidence-based guidelines (n = 15) on smoking cessation, increasing physical activity and promoting healthy diet, which were then scrutinized for ethnicity-related considerations. Evidence statements were independently extracted and thematically analysed.

RESULTS

Forty-one of 111 (37%) systematic reviews and 12 of 15 (80%) guidelines provided an evidence statement relating to ethnicity; however, these were often cursory and focused mainly on the need for better evidence. Five major themes emerged: (i) acknowledging the importance of diversity and how risk factors vary by ethnicity; (ii) noting evidence gaps in the effectiveness and cost-effectiveness of interventions for ethnic minorities; (iii) observing differential effects of interventions where these have been trialled with ethnic minority populations; (iv) suggesting adaptation of interventions for ethnic minority groups; (v) proposing improvements in research on interventions involving ethnic minority populations.

CONCLUSIONS

Despite increasing recognition of the challenges posed by ethnic health inequalities, there remains a lack of guidance on the extent to which generic recommendations are applicable to, and how best to promote lifestyle changes in, ethnic minority populations. These important evidence gaps need to be bridged and tools developed to ensure that equity and population context is appropriately considered within evidence syntheses.

Disparities in child mortality trends: what is the evidence from disadvantaged states in India? the case of Orissa and Madhya Pradesh

Introduction

The Millennium Development Goals prompted renewed international efforts to reduce under-five mortality and measure national progress. However, scant evidence exists about the distribution of child mortality at low sub-national levels, which in diverse and decentralized countries like India are required to inform policy-making. This study estimates changes in child mortality across a range of markers of inequalities in Orissa and Madhya Pradesh, two of India’s largest, poorest, and most disadvantaged states.

Methods

Estimates of under-five and neonatal mortality rates were computed using seven datasets from three available sources – sample registration system, summary birth histories in surveys, and complete birth histories. Inequalities were gauged by comparison of mortality rates within four sub-state populations defined by the following characteristics: rural–urban location, ethnicity, wealth, and district.

Results

Trend estimates suggest that progress has been made in mortality rates at the state levels. However, reduction rates have been modest, particularly for neonatal mortality. Different mortality rates are observed across all the equity markers, although there is a pattern of convergence between rural and urban areas, largely due to inadequate progress in urban settings. Inter-district disparities and differences between socioeconomic groups are also evident.

Conclusions

Although child mortality rates continue to decline at the national level, our evidence shows that considerable disparities persist. While progress in reducing under-five and neonatal mortality rates in urban areas appears to be levelling off, polices targeting rural populations and scheduled caste and tribe groups appear to have achieved some success in reducing mortality differentials. The results of this study thus add weight to recent government initiatives targeting these groups. Equitable progress, particularly for neonatal mortality, requires continuing efforts to strengthen health systems and overcome barriers to identify and reach vulnerable groups.

Socioeconomic differences in purchases of more vs. less healthy foods and beverages: analysis of over 25,000 British households in 2010

Socioeconomic inequalities in diet-related health outcomes are well-recognised, but are not fully explained by observational studies of consumption. We provide a novel analysis to identify purchasing patterns more precisely, based on data for take-home food and beverage purchases from 25,674 British households in 2010. To examine socioeconomic differences (measured by occupation), we conducted regression analyses on the proportion of energy purchased from (a) each of 43 food or beverage categories and (b) major nutrients. Results showed numerous small category-level socioeconomic differences. Aggregation of the categories showed lower SES groups generally purchased a greater proportion of energy from less healthy foods and beverages than those in higher SES groups (65% and 60%, respectively), while higher SES groups purchased a greater proportion of energy from healthier food and beverages (28% vs. 24%). At the nutrient-level, socioeconomic differences were less marked, although higher SES was associated with purchasing greater proportions of fibre, protein and total sugars, and smaller proportions of sodium. The observed pattern of purchasing across SES groups contributes to the explanation of observed health differences between groups and highlights targets for interventions to reduce health inequalities.

Inequity in India: the case of maternal and reproductive health

Background

Millennium Development Goal (MDG) 5 is focused on reducing maternal mortality and achieving universal access to reproductive health care. India has made extensive efforts to achieve MDG 5 and in some regions much progress has been achieved. Progress has been uneven and inequitable however, and many women still lack access to maternal and reproductive health care.

Objective

In this review, a framework developed by the Commission on Social Determinants of Health (CSDH) is used to categorize and explain determinants of inequity in maternal and reproductive health in India.

Design

A review of peer-reviewed, published literature was conducted using the electronic databases PubMed and Popline. The search was performed using a carefully developed list of search terms designed to capture published papers from India on: 1) maternal and reproductive health, and 2) equity, including disadvantaged populations. A matrix was developed to sort the relevant information, which was extracted and categorized based on the CSDH framework. In this way, the main sources of inequity in maternal and reproductive health in India and their inter-relationships were determined.

Results

Five main structural determinants emerged from the analysis as important in understanding equity in India: economic status, gender, education, social status (registered caste or tribe), and age (adolescents). These five determinants were found to be closely interrelated, a feature which was reflected in the literature.

Conclusion

In India, economic status, gender, and social status are all closely interrelated when influencing use of and access to maternal and reproductive health care. Appropriate attention should be given to how these social determinants interplay in generating and sustaining inequity when designing policies and programs to reach equitable progress toward improved maternal and reproductive health.

Bringing evidence to policy to achieve health-related MDGs for all: justification and design of the EPI-4 project in China, India, Indonesia, and Vietnam

BACKGROUND

The Millennium Development Goals (MDGs) are monitored using national-level statistics, which have shown substantial improvements in many countries. These statistics may be misleading, however, and may divert resources from disadvantaged populations within the same countries that are showing progress. The purpose of this article is to set out the relevance and design of the "Evidence for Policy and Implementation project (EPI-4)". EPI-4 aims to contribute to the reduction of inequities in the achievement of health-related MDGs in China, India, Indonesia and Vietnam through the promotion of research-informed policymaking.

METHODS

Using a framework provided by the Commission on the Social Determinants of Health (CSDH), we compare national-level MDG targets and results, as well as their social and structural determinants, in China, India, Indonesia and Vietnam.

RESULTS

To understand country-level MDG achievements it is useful to analyze their social and structural determinants. This analysis is not sufficient, however, to understand within-country inequities. Specialized analyses are required for this purpose, as is discussion and debate of the results with policymakers, which is the aim of the EPI-4 project.

CONCLUSION

Reducing health inequities requires sophisticated analyses to identify disadvantaged populations within and between countries, and to determine evidence-based solutions that will make a difference. The EPI-4 project hopes to contribute to this goal.

Stagnant neonatal mortality and persistent health inequality in middle-income countries: a case study of the Philippines

BACKGROUND

The probability of survival through childhood continues to be unequal in middle-income countries. This study uses data from the Philippines to assess trends in the prevalence and distribution of child mortality and to evaluate the country's socioeconomic-related child health inequality.

METHODOLOGY

Using data from four Demographic and Health Surveys we estimated levels and trends of neonatal, infant, and under-five mortality from 1990 to 2007. Mortality estimates at national and subnational levels were produced using both direct and indirect methods. Concentration indices were computed to measure child health inequality by wealth status. Multivariate regression analyses were used to assess the contribution of interventions and socioeconomic factors to wealth-related inequality.

FINDINGS

Despite substantial reductions in national under-five and infant mortality rates in the early 1990s, the rates of declines have slowed in recent years and neonatal mortality rates remain stubbornly high. Substantial variations across urban-rural, regional, and wealth equity-markers are evident, and suggest that the gaps between the best and worst performing sub-populations will either be maintained or widen in the future. Of the variables tested, recent wealth-related inequalities are found to be strongly associated with social factors (e.g. maternal education), regional location, and access to health services, such as facility-based delivery.

CONCLUSION

The Philippines has achieved substantial progress towards Millennium Development Goal 4, but this success masks substantial inequalities and stagnating neonatal mortality trends. This analysis supports a focus on health interventions of high quality--that is, not just facility-based delivery, but delivery by trained staff at well-functioning facilities and supported by a strong referral system--to re-start the long term decline in neonatal mortality and to reduce persistent within-country inequalities in child health.

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