Accounting for health inequities in the design of contact tracing interventions: A rapid review

COVID-19 vaccination at a hospital in Paris: Spatial analyses and inverse equity hypothesis

Background

Vaccination against SARS-CoV-2 has been deployed in France since January 2021. Without specific action for different population subgroups, the inverse equity hypothesis postulates that people in the most deprived neighbourhoods will be the last to benefit. The article aims to study whether the inverse care law has been verified in the context of vaccination against SARS-CoV-2 from a vaccination centre of a hospital in the Paris region.

Methods

We performed a spatial analysis using primary data from the vaccination centre of the Avicenne Hospital in Bobigny from January 8th to September 30th, 2021. Primary data variables include the vaccinated person's date, age, and postal address. Secondary data calculates access times between residential neighbourhoods and the vaccination centre and social deprivation index. We performed flow analysis, k-means aggregation, and mapping.

Results

32,712 people were vaccinated at the study centre. Vaccination flow to the hospital shows that people living in the most disadvantaged areas were the last to be vaccinated. The number of people immunized according to the level of social deprivation then scales out with slightly more access to the vaccination centre for the most advantaged. The furthest have travelled more than 100 km, and more than 1h45 of transport time to get to this vaccination centre.

Conclusion

The study confirms the inverse equity hypothesis and shows that vaccination preparedness strategies must consider equity issues. Public health interventions should be implemented according to proportionate universalism and use community health, health mediation, and outreach activities for more equity.

Did the design and planning of testing and contact tracing interventions for COVID-19 consider social inequalities in health? A multiple case study from Brazil, Canada, France & Mali

The COVID-19 pandemic has led to an unprecedented global crisis. It has exposed and exacerbated weaknesses in public health systems worldwide, particularly with regards to reaching the most vulnerable populations, disproportionately impacted by the pandemic. The objective of our study was to examine whether and how social inequalities in health (SIH) were considered in the design and planning of public health responses to COVID-19 in jurisdictions of Brazil, Canada, France, and Mali. This article reports on a qualitative multiple case study of testing and contact tracing interventions in regions with high COVID-19 incidence in each country, namely: Manaus (Brazil), Montréal (Canada), Île-de-France (France), and Bamako (Mali). We conducted interviews with 108 key informants involved in these interventions in the four jurisdictions, focusing on the first and second waves of the pandemic. We analyzed our data thematically using a theoretical bricolage framework. Our analysis suggests that the lack of a common understanding of SIH among all actors involved and the sense of urgency brought by the pandemic eclipsed the prioritization of SIH in the initial responses. The pandemic increased intersectoral collaboration, but decision-making power was often unequal between Ministries of Health and other actors in each jurisdiction. Various adaptations to COVID-19 interventions were implemented to reach certain population groups, therefore improving the accessibility, availability, and acceptability of testing and contact tracing. Our study contributes to identifying lessons learned from the current pandemic, namely that the ways in which SIH are understood shape how interventions are planned; that having clear guidelines on how to integrate SIH into public health interventions could lead to more inclusive pandemic responses; that for intersectoral collaboration to be fruitful, there needs to be sufficient resources and equitable decision-making power between partners; and that interventions must be flexible to respond to emerging needs while considering long-standing structural inequalities.

Supporting the Respiratory Health of Migrants and Refugees

Migrants and refugees are at risk of developing acute and chronic respiratory diseases at their destination countries. Yet, people from these populations are also least likely to access care within the current health care system across the world. Although biological, psychological, and social factors play a role in influencing risk of respiratory diseases among these populations, the influences from cultural differences on health behaviors cannot be ignored. Cultural differences are influential in affecting an individual's level of health literacy. Health professionals can contribute to the provision of equitable care to diverse communities through addressing issues related to linguistic and cultural differences.

Hospital Resilience to the COVID-19 Pandemic in Five Countries: A Multiple Case Study

Since the beginning of the pandemic, hospitals have been central to the COVID-19 response, often experiencing severe financial, material, and human constraints. In this special issue, we present some of the findings of the HoSPiCOVID research project. One of its main objectives was to compare hospital responses to the first and second waves of the COVID-19 pandemic in Brazil, Canada, France, Japan, and Mali. Studying and comparing how nine different hospitals coped with the pandemic in terms of preparedness and response allowed us to: 1) identify strengths and weaknesses of their responses, including challenges for hospital professionals; and 2) produce lessons learned, using a systematic approach to reflect and analyze their potential of resilience to the crisis. In the five countries, research teams conducted in-depth qualitative studies focused on nine large hospitals, using observation sessions, semistructured interviews with hospital professionals, and lessons learned workshops. The empirical work was supported by an original analytical framework on hospital resilience and a heuristic tool focused on configurations. The studies demonstrate that the hospitals were able to absorb and/or adapt to the crisis by deploying different coping mechanisms, which often required extensive involvement of hospital professionals. More extended study periods would be needed to assess the sustainability of these coping mechanisms and discern whether they have transformative potential. These international comparisons of hospital resilience, based on studies of contrasting contexts and epidemiological situations, allowed researchers to identify lessons learned to support hospital decision-makers in thinking more deeply about managing future health crises.

Considering social inequalities in health in COVID-19 response: insights from a French case study

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation.

Widening or narrowing inequalities? The equity implications of digital tools to support COVID-19 contact tracing: A qualitative study

BACKGROUND

As digital tools are increasingly used to support COVID-19 contact tracing, the equity implications must be considered. As part of a study to understand the public's views of digital contact tracing tools developed for the national 'Test and Protect' programme in Scotland, we aimed to explore the views of groups often excluded from such discussions. This paper reports on their views about the potential for contact tracing to exacerbate inequalities.

METHODS

A qualitative study was carried out; interviews were conducted with key informants from organizations supporting people in marginalized situations, followed by interviews and focus groups with people recruited from these groups. Participants included, or represented, minority ethnic groups, asylum seekers and refugees and those experiencing multiple disadvantage including severe and enduring poverty.

RESULTS

A total of 42 people participated: 13 key informants and 29 members of the public. While public participants were supportive of contact tracing, key informants raised concerns. Both sets of participants spoke about how contact tracing, and its associated digital tools, might increase inequalities. Barriers included finances (inability to afford smartphones or the data to ensure access to the internet); language (digital tools were available only in English and required a degree of literacy, even for English speakers); and trust (many marginalized groups distrusted statutory organizations and there were concerns that data may be passed to other organizations). One strength was that NHS Scotland, the data guardian, is seen as a generally trustworthy organization. Poverty was recognized as a barrier to people's ability to self-isolate. Some participants were concerned about giving contact details of individuals who might struggle to self-isolate for financial reasons.

CONCLUSIONS

The impact of contact tracing and associated digital tools on marginalized populations needs careful monitoring. This should include the contact tracing process and the ability of people to self-isolate. Regular clear messaging from trusted groups and community members could help maintain trust and participation in the programme.

PATIENT AND PUBLIC CONTRIBUTION

Our patient and public involvement coapplicant, L. L., was involved in all aspects of the study including coauthorship. Interim results were presented to our local Public and Patient Involvement and Engagement Group, who commented on interpretation and made suggestions about further recruitment.

Outcomes of a Community Engagement and Information Gathering Program to Support Telephone-Based COVID-19 Contact Tracing: Descriptive Analysis

BACKGROUND

Contact tracing is an important public health tool for curbing the spread of infectious diseases. Effective and efficient contact tracing involves the rapid identification of individuals with infection and their exposed contacts and ensuring their isolation or quarantine, respectively. Manual contact tracing via telephone call and digital proximity app technology have been key strategies in mitigating the spread of COVID-19. However, many people are not reached for COVID-19 contact tracing due to missing telephone numbers or nonresponse to telephone calls. The New York City COVID-19 Trace program augmented the efforts of telephone-based contact tracers with information gatherers (IGs) to search and obtain telephone numbers or residential addresses, and community engagement specialists (CESs) made home visits to individuals that were not contacted via telephone calls.

OBJECTIVE

The aim of this study was to assess the contribution of information gathering and home visits to the yields of COVID-19 contact tracing in New York City.

METHODS

IGs looked for phone numbers or addresses when records were missing phone numbers to locate case-patients or contacts. CESs made home visits to case-patients and contacts with no phone numbers or those who were not reached by telephone-based tracers. Contact tracing management software was used to triage and queue assignments for the telephone-based tracers, IGs, and CESs. We measured the outcomes of contact tracing-related tasks performed by the IGs and CESs from July 2020 to June 2021.

RESULTS

Of 659,484 cases and 861,566 contact records in the Trace system, 28% (185,485) of cases and 35% (303,550) of contacts were referred to IGs. IGs obtained new phone numbers for 33% (61,804) of case-patients and 11% (31,951) of contacts; 50% (31,019) of the case-patients and 46% (14,604) of the contacts with new phone numbers completed interviews; 25% (167,815) of case-patients and 8% (72,437) of contacts were referred to CESs. CESs attempted 80% (132,781) of case and 69% (49,846) of contact investigations, of which 47% (62,733) and 50% (25,015) respectively, completed interviews. An additional 12,192 contacts were identified following IG investigations and 13,507 following CES interventions.

CONCLUSIONS

Gathering new or missing locating information and making home visits increased the number of case-patients and contacts interviewed for contact tracing and resulted in additional contacts. When possible, contact tracing programs should add information gathering and home visiting strategies to increase COVID-19 contact tracing coverage and yields as well as promote equity in the delivery of this public health intervention.

Knowledge of COVID-19 and the impact on indigents' access to healthcare in Burkina Faso

BACKGROUND

COVID-19 constitutes a global health emergency of unprecedented proportions. Preventive measures, however, have run up against certain difficulties in low and middle-income countries. This is the case in socially and geographically marginalized communities, which are excluded from information about preventive measures. This study contains a dual objective, i) to assess knowledge of COVID-19 and the preventive measures associated with it concerning indigents in the villages of Diebougou's district in Burkina Faso. The aim is to understand if determinants of this understanding exist, and ii) to describe how their pathways to healthcare changed from 2019 to 2020 during the COVID-19 pandemic.

METHODS

The study was conducted in the Diebougou healthcare district, in the south-west region of Burkina Faso. We relied on a cross-sectional design and used data from the fourth round of a panel survey conducted among a sample of ultra-poor people that had been monitored since 2015. Data were collected in August 2020 and included a total of 259 ultra-poor people. A multivariate logistic regression to determine the factors associated with the respondents' knowledge of COVID-19 was used.

RESULTS

Half of indigents in the district said they had heard about COVID-19. Only 29% knew what the symptoms of the disease were. The majority claimed that they protected themselves from the virus by using preventive measures. This level of knowledge of the disease can be observed with no differences between the villages. Half of the indigents who expressed themselves agreed with government measures except for the closure of markets. An increase of over 11% can be seen in indigents without the opportunity for getting healthcare compared with before the pandemic.

CONCLUSIONS

This research indicates that COVID-19 is partially known and that prevention measures are not universally understood. The study contributes to reducing the fragmentation of knowledge, in particular on vulnerable and marginalized populations. Results should be useful for future interventions for the control of epidemics that aim to leave no one behind.

[The comeback of "one health" and global health: let us not make the same mistakes again]

The COVID-19 pandemic has led to a rediscovery of the concept of "One Health" and the idea that animals, humans and the environment are intimately linked. This is not a new concept, but it is still labile, contributing to inevitable confusion. There is still a lack of action on the ground, and "One Health" fails to integrate all three dimensions. This editorial aims to share six challenges for implementing the "One Health" approach in order to avoid the pitfalls of other global health initiatives. One Health programmes cannot be relevant and sustainable without the active involvement of communities. This deployment implies the necessary decolonisation of health, i.e. a rethinking of how programmes are governed, financed, formulated, implemented and evaluated, with and for the citizens and countries concerned. It cannot be done without addressing social inequalities in health and power issues. This approach leads to questioning the exploitation models of both agricultural and natural resources. Thinking about "One Health" implies thinking about issues and interventions from an intersectoral, inclusive and participatory perspective, from an interdisciplinary, if not transdisciplinary perspective, and understanding the resulting complexity. Finally, research findings should be taken into account to build public actions. Considering these different challenges and adopting a systemic and interdisciplinary perspective anchored in local contexts according to a participatory and inclusive approach thus seems essential to us to respond in an appropriate, relevant and sustainable manner to the issues associated with "One Health".

Considering social inequalities in health in large-scale testing for COVID-19 in Montréal: a qualitative case study

BACKGROUND

Evidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada).

METHODS

Part of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo.

RESULTS

Our findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population.

CONCLUSIONS

These findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health.