Health inequalities, fundamental causes and power: towards the practice of good theory

Evaluating neurosurgical society award recipients: Realising inclusivity in neurosurgical awards

This article evaluates disparities in neurosurgical awards, focusing on the underrepresentation of women and racial minorities. It underscores the need for transparent award selection processes and diverse judging panels to foster inclusivity. The article also highlights the importance of mentorship programs in addressing systemic biases. It calls for further research into institutional factors, including education and geographic disparities, that contribute to inequitable representation. By implementing these reforms, the field of neurosurgery can ensure a more diverse and innovative future, ultimately improving patient care and outcomes.

An ecosystem of accepting life with chronic pain: A meta-ethnography

Background

Chronic pain is a highly prevalent long-term condition, experienced unequally, impacting both the individual living with pain, and wider society. 'Acceptance' of chronic pain is relevant to improved consultations in pain care, and navigating an approach towards evidence-based, long-term management and associated improvements in health. However, the concept proves difficult to measure, and primary qualitative studies of lived experiences show complexity related to our socio-cultural-political worlds, healthcare experiences, and difficulties with language and meaning. We framed acceptance of chronic pain as socially constructed and aimed to conceptualise the lived experiences of acceptance of chronic pain in adults.

Methods

We conducted a systematic search and screening process, followed by qualitative, interpretive, literature synthesis using Meta-ethnography. We included qualitative studies using chronic pain as the primary condition, where the study included an aim to research the acceptance concept. We conducted each stage of the synthesis with co-researchers of differing disciplinary backgrounds, and with lived experiences of chronic pain.

Findings

We included 10 qualitative studies from Canada, Sweden, The Netherlands, Ireland, UK, Australia and New Zealand. Our 'lines of argument' include a fluid and continuous journey with fluctuating states of acceptance; language and meaning of acceptance and chronic pain, a challenge to identity in a capitalist, ableist society and the limits to individualism; a caring, supportive and coherent system. The conceptual framework of the meta-ethnography is represented by a rosebush with interconnected branches, holding both roses and thorns, such is the nature of accepting life with chronic pain.

Conclusion

Our findings broaden conceptualisation of 'acceptance of chronic pain' beyond an individual factor, to a fluid and continuous journey, interconnected with our socio-cultural-political worlds; an ecosystem.

Social transition, socioeconomic status and self-rated health in China: evidence from a national cross-sectional survey (CGSS)

Background

Social transition is one of the multi-level mechanisms that influence health disparities. However, it has received less attention as one of the non-traditional social determinants of health. A few studies have examined China's social transition and its impact on health inequality in self-rated health (SRH). Therefore, this study explores the impact of China's market-oriented reforms-social transition and socioeconomic status (SES)-on residents' SRH.

Methods

Using the cross-sectional data from the Chinese General Social Survey (CGSS) in 2017, we analyzed the effects of social transition and SES on the SRH of Chinese residents using the RIF (Recentered influence function) method. The RIF decomposition method investigated health differences among different populations and their determinants.

Results

Social transition and SES have significant positive effects on the SRH of Chinese residents. The correlation between SES and the SRH of Chinese residents is moderated by social transition, implying that social transition can weaken the correlation between SES and the SRH of Chinese residents. The impacts of SES and social transition on SRH vary across populations.

Conclusion

Promoting social transition and favoring disadvantaged groups with more resources are urgently needed to promote equitable health outcomes.

Assessing the effects of population-level political, economic and social exposures, interventions and policies on inclusive economy outcomes for health equity in high-income countries: a systematic review of reviews

BACKGROUND

A fairer economy is increasingly recognised as crucial for tackling widening social, economic and health inequalities within society. However, which actions have been evaluated for their impact on inclusive economy outcomes is yet unknown.

OBJECTIVE

Identify the effects of political, economic and social exposures, interventions and policies on inclusive economy (IE) outcomes in high-income countries, by systematically reviewing the review-level evidence.

METHODS

We conducted a review of reviews; searching databases (May 2020) EconLit, Web of Science, Sociological Abstracts, ASSIA, International Bibliography of the Social Sciences, Public Health Database, Embase and MEDLINE; and registries PROSPERO, Campbell Collaboration and EPPI Centre (February 2021) and grey literature (August/September 2020). We aimed to identify reviews which examined social, political and/or economic exposures, interventions and policies in relation to two IE outcome domains: (i) equitable distribution of the benefits of the economy and (ii) equitable access to the resources needed to participate in the economy. Reviews had to include primary studies which compared IE outcomes within or between groups. Quality was assessed using a modified version of AMSTAR-2 and data synthesised informed by SWiM principles.

RESULTS

We identified 19 reviews for inclusion, most of which were low quality, as was the underlying primary evidence. Most reviews (n = 14) had outcomes relating to the benefits of the economy (rather than access to resources) and examined a limited set of interventions, primarily active labour market programmes and social security. There was limited high-quality review evidence to draw upon to identify effects on IE outcomes. Most reviews focused on disadvantaged groups and did not consider equity impacts.

CONCLUSIONS

Review-level evidence is sparse and focuses on 'corrective' approaches. Future reviews should examine a diverse set of 'upstream' actions intended to be inclusive 'by design' and consider a wider range of outcomes, with particular attention to socioeconomic inequalities.

'Ageing well': Discursive constructions of ageing and health in the public reach of a national longitudinal study on ageing

Established in 2006, the Irish Longitudinal Study on Ageing (TILDA) investigates the health, economic and social circumstances of a nationally-representative sample of people aged fifty years and older in a series of biennial data collection waves. Irish newspapers have been reporting the results of TILDA for over a decade and a half, and their texts represent reports of scientific research distilled through the pen of journalists. In their totality, their texts constitute a public discourse on ageing and health. Using critical discourse analysis, we examined the discourse within the texts of a purposive sample of two national daily newspapers. As sites of public discourse, newspapers reflect social life and are influential in forming and legitimating public attitudes. Like other sites of discourse, their language-in-use is contextually located, is rarely neutral and may employ strategies to discursively construct, sustain and privilege particular social identities, including ageing identities. Discursively constructed as 'ageing well', our analysis of newspaper texts revealed a discernible meta-discourse on ageing and health in which ageing was framed as a life course stage that may be cultivated, diligently self-nurtured and exploited for its positive aspects. When considered in light of literature on health and social inequalities, the consequences of this broadly positive ageing discourse can, somewhat perversely, frame older adults in unintended negative ways, including homogenising them and attributing to them capacities for ageing well that they may not possess. Discursively constructing older adults as a social and economic resource can also impose unrealistic expectations on them and may legitimise exploitation and demonstrate how normative ideologies of ageism and ableism are conveyed through legitimising language. Despite these potentially unintended consequences, the available media resources associated with TILDA may represent one of the most important contributions of the study, in terms of informing positive public attitudes towards ageing.

What is missing from how we measure and understand the experience of poverty and deprivation in population health analyses?

BACKGROUND

Explaining why some populations are healthier than others is a core task of epidemiology. Socioeconomic position (SEP), encompassing a broad range of exposures relating to economic circumstances, social class and deprivation, is an important explanation, but lacks a comprehensive framework for understanding the range of relevant exposures it encompasses.

METHODS

We reviewed existing literature on experiential accounts of poverty through database searching and the identification of relevant material by experts. We mapped relevant concepts into a complex systems diagram. We developed this diagram through a process of consultation with academic experts and experts with direct experience of poverty. Finally, we categorized concepts on the basis of whether they have previously been measured, their importance to the causal flow of the diagram, and their importance to those consulted, creating a list of priorities for future measurement.

RESULTS

There are a great many aspects of SEP which are not frequently measured or used in epidemiological research and, for some of these, work is needed to better conceptualize and develop measures. Potentially important missing aspects include stigma, social class processes, access to education, sense of lost potential, neighbourhoods, fairness and justice, emotional labour, masking poverty, being (in)visible, costs, and experiences of power.

CONCLUSIONS

Analyses seeking to understand the extent to which SEP exposures explain differences in the health of populations are likely to benefit from a comprehensive understanding of the range and inter-relationships between different aspects of SEP. More research to better conceptualize and measure these aspects is now needed.

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action

INTRODUCTION

It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.

METHODS

Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.

FINDINGS

Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.

CONCLUSION

Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these.

PUBLIC CONTRIBUTION

An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

Understanding the role of the state in dietary public health policymaking: a critical scoping review

Despite evidence that dietary population health interventions are effective and widely accepted, they remain the topic of intense debate centring on the appropriate role of the state. This review sought to identify how the role of the state in intervening in individuals' food practices is conceptualized across a wide range of literatures. We searched 10 databases and 4 journals for texts that debated dietary population health interventions designed to affect individuals' health-affecting food practices. Two co-authors independently screened these texts for eligibility relative to inclusion and exclusion criteria. Thirty-five texts formed our final corpus. Through critical reflexive thematic analysis (TA), we generated 6 themes and 2 subthemes concerning choice, responsibility for health, balancing benefits and burdens of intervention, the use of evidence, fairness, and the legitimacy of the state's actions. Our analysis found that narratives that aim to prevent effective regulation are entrenched in academic literatures. Discourses that emphasized liberty and personal responsibility framed poor health as the result of 'lifestyle choices'. Utilitarian, cost-benefit rationales pervaded arguments about how to best balance the benefits and burdens of state intervention. Claims about fairness and freedom were used to evoke powerful common meanings, and evidence was used politically to bolster interests, particularly those of the food industry. This review identifies and critically analyses key arguments for and against population dietary public health policies. Our findings should motivate public health researchers and practitioners to avoid unreflexively embracing framings that draw on the languages and logics of free market economics.

Intersectionality as a theoretical framework for researching health inequities in chronic pain

Chronic pain is experienced unequally by different population groups; we outline examples from the pain literature of inequities related to gender, ethnicity, socioeconomic and migration status. Health inequities are systematic, avoidable and unfair differences in health outcomes between groups of people, with the fundamental 'causes of causes' recognised as unequal distribution of income, power and wealth. Intersectionality can add further theory to health inequities literature; collective social identities including class/socioeconomic status, race/ethnicity, gender, migration status, age, sexuality and disabled status intersect in multiple interconnected systems of power leading to differing experiences of privilege and oppression which can be understood as axes of health inequities. The process of knowledge creation in pain research is shaped by these interconnected systems of power, and may perpetuate inequities in pain care as it is largely based on majority white, middle class, Eurocentric populations. Intersectionality can inform research epistemology (ways of knowing), priorities, methodology and methods. We give examples from the literature where intersectionality has informed a justice oriented approach across different research methods and we offer suggestions for further development. The use of a reductionist frame can force unachievable objectivity on to complex health concepts, and we note increasing realisation in the field of the need to understand the individuals within their social world, and recognise the fluid and contextual nature of this.

Is patients' rurality associated with in-hospital sepsis death in US hospitals?

Background

The focus of this study was to explore the association of patients' rurality and other patient and hospital-related factors with in-hospital sepsis mortality to identify possible health disparities across United States hospitals.

Methods

The National Inpatient Sample was used to identify nationwide sepsis patients (n = 1,977,537, weighted n = 9,887,682) from 2016 to 2019. We used multivariate survey logistic regression models to identify predictors for how patients' rurality is associated with in-hospital death.

Findings

During the study periods, in-hospital death rates among sepsis inpatients continuously decreased (11.3% in 2016 to 9.9% in 2019) for all rurality levels. Rao-Schott Chi-Square tests demonstrated that certain patient and hospital factors had varied in-hospital death rates. Multivariate survey logistic regressions suggested that rural areas, minorities, females, older adults, low-income, and uninsured patients have higher odds of in-hospital mortality. Further, specific census divisions like New England, Middle Atlantic, and East North Central had greater in-hospital sepsis death odds.

Conclusion

Rurality was associated with increased in-hospital sepsis death across multiple patient populations and locations. Further, rurality in New England, Middle Atlantic, and East North Central locations is exceptionally high odds. In addition, minority races in rural areas also have an increased odds of in-hospital death. Therefore, rural healthcare requires a more significant influx of resources and should also include assessing patient-related factors.

Testing conditionality with Bourdieu's capital theory: How economic, social, and embodied cultural capital are associated with diet and physical activity in the Netherlands

Although Bourdieu's capital theory emphasized that economic, social, and embodied cultural capital interact to shape health behavior, existing empirical research mainly considered separate associations of the three forms of capital. Our aim was to investigate if and how economic, social, and embodied cultural capital are conditional on each other in their associations with adults' diet and physical activity. Cross-sectional, self-reported data from the 2014 GLOBE survey of 2812 adults aged between 25 and 75 years residing in Eindhoven, the Netherlands were used. Step-wise multiple logistic regression models included economic, social, and embodied cultural capital and adjustment for potential confounders. The models estimated odds ratios of main effects and two-way interactions of the forms of capital with fruit consumption, vegetable consumption, sports participation, and leisure time walking or cycling. In the main effects models, embodied cultural capital was consistently positively associated with all outcomes. Social capital was positively associated with sports participation, fruit consumption, and vegetable consumption, and economic capital was positively associated with sports participation and vegetable consumption. In the two-way interaction models, having specific higher levels of both economic and social capital strengthened their positive association with sports participation. No other combinations of capital were conditional on each other. Economic and social capital were conditional on each other in their association with sports participation, so interventions that provide both economic and social support may be especially effective for increasing this type of physical activity. As its association was strong with all outcomes but not conditional on other forms of capital, embodied cultural capital may operate distinctly from economic and social resources. Policy that takes differences in embodied cultural capital into account or changes to the environment that dampen the importance of embodied cultural resources for health behavior may help improve both diet and physical activity.

Realising radical potential: building community power in primary health care through Participatory Action Research

BACKGROUND

While community participation is an established pro-equity approach in Primary Health Care (PHC), it can take many forms, and the central category of power is under-theorised. The objectives were to (a) conduct theory-informed analysis of community power-building in PHC in a setting of structural deprivation and (b) develop practical guidance to support participation as a sustainable PHC component.

METHODS

Stakeholders representing rural communities, government departments and non-governmental organisations engaged through a participatory action research (PAR) process in a rural sub-district in South Africa. Three reiterative cycles of evidence generation, analysis, action, and reflection were progressed. Local health concerns were raised and framed by community stakeholders, who generated new data and evidence with researchers. Dialogue was then initiated between communities and the authorities, with local action plans coproduced, implemented, and monitored. Throughout, efforts were made to shift and share power, and to adapt the process to improve practical, local relevance. We analysed participant and researcher reflections, project documents, and other project data using power-building and power-limiting frameworks.

RESULTS

Co-constructing evidence among community stakeholders in safe spaces for dialogue and cooperative action-learning built collective capabilities. The authorities embraced the platform as a space to safely engage with communities and the process was taken up in the district health system. Responding to COVID-19, the process was collectively re-designed to include a training package for community health workers (CHWs) in rapid PAR. New skills and competencies, new community and facility-based alliances and explicit recognition of CHW roles, value, and contribution at higher levels of the system were reported following the adaptations. The process was subsequently scaled across the sub-district.

CONCLUSIONS

Community power-building in rural PHC was multidimensional, non-linear, and deeply relational. Collective mindsets and capabilities for joint action and learning were built through a pragmatic, cooperative, adaptive process, creating spaces where people could produce and use evidence to make decisions. Impacts were seen in demand for implementation outside the study setting. We offer a practice framework to expand community power in PHC: (1) prioritising community capability-building, (2) navigating social and institutional contexts, and (3) developing and sustaining authentic learning spaces.

Decolonizing Epidemiological Research: A Critical Perspective

Decolonizing epidemiological research is a crucial endeavor. Historically, colonial and imperialistic ideologies have pervaded epidemiology, leading to an emphasis on Western perspectives and the neglect of indigenous and other marginalized communities' needs and experiences. To effectively address health disparities and promote justice and equality, acknowledging and addressing these power imbalances are imperative. In this article, I highlight the need of decolonizing epidemiological research and make recommendations. These include increasing the representation of researchers from underrepresented communities, ensuring that epidemiological research is contextually relevant and responsive to the experiences of these communities, and collaborating with policymakers and advocacy groups to inform policies and practices that benefit all populations. Moreover, I underscore the importance of recognizing and valuing the knowledge and skills of marginalized populations, and integrating traditional knowledge-the distinct, culturally specific understanding unique to a particular group-into research efforts. I also emphasize the need of capacity building and equitable research collaborations and authorship as well as epidemiological journal editorship. Decolonizing epidemiology research is a continual process that requires continuing discourse, collaboration, and education.

An examination of relational dynamics of power in the context of supported (assisted) decision-making with older people and those with disabilities in an acute healthcare setting

INTRODUCTION

Supported (assisted) healthcare decision-making (ADM) focuses attention on how people with disabilities, including cognitive impairments, can be best supported to make decisions about their health and social care on an equitable basis with others. Meaningful implementation of legal frameworks for ADM challenges long-held presumptions about who has access to valued decision-making resources, influence and power within a particular socio-cultural setting. This study aims to explore the relational power dynamics around ADM with older people in acute care settings.

METHODS

This study adopts a critical hermeneutic approach to qualitatively explore the lived experience of ADM from the perspectives of Health and Social Care Professionals (N = 26). This is supported by an exploration of the experiences of older people (N = 4), older people with a diagnosis of dementia (N = 4) and family carers (N = 5).

RESULTS

We present three themes of data analysis that represent three spaces where the relational aspects of power in ADM are manifested. The first space, centralising decision-making power within multidisciplinary teams identified the privileging of physicians in traditional hierarchical leadership models that may lead to the implicit exclusion of family carers and some Health and Social Care Professionals in the ADM process. Privileging cognitive and communication competence identified a tendency to attribute decision-making autonomy to those with cognitive and communication competency. The final space, balancing the duty of care and individual autonomy, recognises acute care settings as typically risk-averse cultures that limit autonomy for decisions that carry risk, especially for those with cognitive impairment.

CONCLUSION

Findings indicate the need to address cultural sources of power operating through social norms premised on ageist and ableist ideologies. It is necessary to challenge institutional barriers to meaningful ADM including positional power that is associated with hierarchies of influence and protectionism. Finally, meaningful ADM requires resistance to the disempowerment created by structural, economic and social circumstances which limit choices for decision-making.

PATIENT OR PUBLIC CONTRIBUTION

A public and patient involvement panel of older people were consulted in the development of the grant application (HRB: APA-2016-1878). Representatives from Alzheimer's Society Ireland and Family Carers Ireland were steering committee members guiding design and strategy.

When a neglected tropical zoonotic disease emerges in non-endemic countries: need to proactively fill the unveiled knowledge gaps towards human monkeypox among the Lebanese population

INTRODUCTION

The ongoing multi-country outbreak of monkeypox (MPX) that emerges in non-endemic areas is a rare and unprecedented event that has sparked a widespread public health concern. Lebanon has reported four confirmed cases of MPX so far. Since good knowledge about the MPX virus and its associated disease is paramount for helping the Lebanese population prepare for a possible outbreak, therefore, it is important to assess their current level of knowledge regarding MPX and to identify its associated factors to highlight any knowledge gaps that need to be filled.

METHODS

An online cross-sectional study was conducted over the first 2 weeks of August 2022 among adults aged 18 years and above recruited from all Lebanese provinces using a convenience sampling technique. An anonymous, Arabic, self-reported questionnaire covering all main aspects of knowledge regarding MPX was developed and adapted based on the available literature. The Chi-square test was used to determine the associations between knowledge levels and independent variables including baseline characteristics. Multivariable logistic regression was also carried out on the significant variables in the bivariate analyses to identify the factors associated with the good knowledge level.

RESULTS

A total of 793 Lebanese adults participated in the study. The overall level of knowledge level regarding human MPX was poor among the Lebanese population; with only 33.04% of them having a good knowledge level ≥ 60%. Knowledge gaps and a substantial poor knowledge level were found in the majority of MPX knowledge domains especially those related to the routes of transmission (76.67%), clinical presentation and symptoms (71.63%), treatment (86.25%), and severity of the disease (91.3%). Interestingly, participants have a good knowledge level of the precautionary measures (80.45%), and the response to a suspected infection (65.20%). Female gender [(aOR = 0.870, CI 95% (0.613-0.941)], increased age 49 [aOR = 0.743, CI 95% (0.381-0.908)], and living in rural areas [aOR = 0.412, CI 95% (0.227-0.861)] were found negatively associated with a good level of knowledge. However, participants with higher educational levels [aOR = 1.243, CI 95% (1.032-3.801)], those working in the medical field [aOR = 1.932, CI 95% (1.331-3.419)], those suffering from chronic disease/immunodeficiency [aOR = 1.231, CI 95% (1.128-2.002)], and participants with moderate/high economic situations [aOR = 2.131, CI 95% (1.431-4.221)] were more likely to have a good knowledge score compared to their counterparts.

CONCLUSIONS

The current study pointed out to poor knowledge level regarding MPX among the Lebanese population with substantial knowledge gaps in most aspects of MPX knowledge. The findings stress the urgent need to raise awareness and proactively fill the unveiled gaps, especially among less informed groups.

How well does the Scottish Index of Multiple Deprivation identify income and employment deprived individuals across the urban-rural spectrum and between local authorities?

BACKGROUND

Area-based indices of deprivation are used to identify populations at need, to inform service planning and policy, to rank populations for monitoring trends in inequalities, and to evaluate the impacts of interventions. There is scepticism of the utility of area deprivation indices in rural areas because of the spatial heterogeneity of their populations.

OBJECTIVE

To compare the sensitivity of the Scottish Index of Multiple Deprivation (SIMD) for detecting income and employment deprived individuals by urban-rural classification and across local authorities.

STUDY DESIGN

Descriptive analysis of cross-sectional data.

METHODS

Data from the 2020 Scottish Index of Multiple Deprivation (SIMD) were used to calculate the number and percentage of income and employment deprived people missed within each of the six-fold urban-rural classification strata and each local authority using areas ranked by the national SIMD, within local authority rankings, and within urban-rural strata rankings, for deprivation thresholds between the 5% most deprived areas and the 30% most deprived areas. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) were calculated within local authorities and urban-rural classification strata to estimate the concentration of deprivation within ranked data zones.

RESULTS

The number and percentage of income and employment deprived people is higher in urban than rural areas. However, using the national, local authority, and within urban-rural classification strata rankings of SIMD, and under all deprivation thresholds (from the 5%-30% most deprived areas), the percentage of income and employment deprived people missed by targeting the most deprived areas within urban-rural strata is higher in more remote and rural areas, and in island local authorities. The absolute number of income and employment deprived individuals is greater in urban areas across rankings and thresholds.

CONCLUSION

The SIMD misses a higher percentage of income and employment deprived people in remote, rural and island areas across deprivation thresholds and irrespective of whether national, local or within urban-rural classification strata are used. However, the absolute number of people missed is higher in urban areas.

Theory in Action: Public Health and Community Power Building for Health Equity

CONTEXT

Within the field of public health, there is growing awareness of how complex social conditions shape health outcomes and the role that power plays in driving health inequities. Despite public health frameworks lifting up the need to tackle power imbalances to advance equity, there is little guidance on how to accomplish this as an integral part of health promotion.

OBJECTIVE

This article addresses the need for public health professionals to better understand power and identifies opportunities for shifting power to achieve more equitable outcomes. First, it defines power and community power building. Next, it reviews a pragmatic theoretical framework that organizes power into 3 faces: (1) exercising influence in formal decision-making processes; (2) organizing the decision-making environment; and (3) shaping worldviews about social issues. Finally, it connects each face of power to community power-building practices using concrete examples.

IMPLEMENTATION

This article highlights real-world case examples to demonstrate how theory translates to action by describing how public health practitioners in government, academic, and nonprofit settings incorporate the 3 faces of power into their work. The case examples illustrate how public health organizations and practitioners can partner with those most impacted by inequities to help shape decision making, agenda setting, and worldviews to influence policy and practice toward more equitable outcomes.

DISCUSSION

The public health field can learn from and build on these innovative examples to establish new practices, scale up promising approaches, and evaluate what works to shift power for the greater good.

Health professional's implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review protocol

INTRODUCTION

Despite efforts to improve population health and reduce health inequalities, higher morbidity and mortality rates for people with lower socioeconomic status (SES) persist. People with lower SES are said to receive worse care and have worse outcomes compared with those with higher SES, in part due to bias and prejudice. Implicit biases adversely affect professional patient relationships and influence healthcare-related decision-making. A better understanding of the relationship between SES and healthcare-related decision-making is therefore essential to address socioeconomic inequalities in health.

AIM

To scope the reported impact of health professionals bias about SES on clinical decision-making and its effect on the care of adults with lower SES in wider literature.

METHODS

This scoping review will use Joanna Briggs Institute methods and will report its findings in line with Preferred Items for Systematic Reviews and Meta-Analyses for Protocols and Scoping Reviews guidelines. Data analysis, interpretation and reporting will be underpinned by the PAGER (Patterns, Advances, Gaps, Evidence for Practice and Research recommendations) framework and input from a patient and public interest representative. A systematic search for literature will be conducted on various, pertinent databases to identify relevant literature such as peer-reviewed articles, editorials, discussion papers and empirical research papers. Additionally, other sources of relevant literature such as policies, guidelines, reports and conference abstracts, identified through key website searches will be considered for inclusion.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The results will be disseminated through an open access peer-reviewed international journal, conference presentations and a plain language summary that will be shared with the public and other relevant stakeholders.

Educational level differences in the primary and secondary prevention of stroke

The aim of this study is to estimate the educational level differences in the primary and secondary prevention of stroke among the Chinese population. Data were obtained from the China Kadoorie Biobank (CKB) survey of 512,891 people aged 30-79 years in 10 geographic regions of China, which was conducted from 2002 to 2008. The Prediction for Atherosclerotic Cardiovascular Disease Risk in China model was used to identify individuals with a high estimated 10-year stroke risk. A total of 8884 participants (1.7%) had established stroke and 218,972 (42.7%) had a high stroke risk. In both primary and secondary prevention, the participants' educational level was positively associated with the control of smoking, blood pressure, consuming a healthy diet, and the use of antiplatelet, BP-lowering medications but negatively associated with higher physical activity levels (all P_trend < 0.001). In addition, the positive associations were observed with the control of drinking and use of anti-hyperglycaemia medication for primary prevention (all P_trend < 0.001) and with the use of lipid-lowering medication for secondary prevention (P_trend = 0.019). The results of the interaction between education level and prevention level showed that, compared with participants in primary prevention, educational level disparities in those with secondary prevention had significantly higher use of antiplatelets and lipid-lowering drugs, achieving the physical activity goal and non-current drinker (all P_{for interaction} < 0.05). A higher education level was associated with an increased acceptance of primary and secondary prevention strategies (not smoking or drinking, consuming a healthier diet) except for engaging in a suitable level of physical activity.

Examining the impact of different social class mechanisms on health inequalities: A cross-sectional analysis of an all-age UK household panel study

BACKGROUND

Socioeconomic inequalities are well established across health, morbidity and mortality measures. Social class theory describes how social groups relate, interact and accrue advantages/disadvantages relative to one another, with different theorists emphasising different dimensions. In the context of health inequalities, different social class measures are used interchangeably to rank population groups in terms of health rather than directly exploring the role of social class in creating inequalities. We aim to better understand how four distinct social class mechanisms explain differences in a range of self-reported and biological health outcomes.

METHODS

We use data from the UK Household Longitudinal Study, a representative population survey of UK adults, to identify measures pertaining to Early years, Bourdieusian, Marxist, and Weberian social class mechanisms. Using logistic and least-squares regression we consider the relative extent to which these mechanisms explain differences in health (Self-reported health, SF12 Physical (PCS) and Mental (MCS) Component Scores, General Health Questionnaire; N = 21,446) and allostatic load, a biomarker-based measure of cumulative stress (N = 5003).

RESULTS

Respondents with higher social position according to all social class measures had better self-rated, physical and mental health, and lower allostatic load. Associations with Marxist social class were among the strongest (e.g. Relative Index of Inequality for very good/excellent self-rated health comparing highest versus lowest Marxist social class: 4.96 (4.45, 5.52), with the Weberian measure also strongly associated with self-rated (4.35 (3.90, 4.85)) and physical health (Slope Index of Inequality for SF12-PCS: 7.94 (7.39, 8.48)). Health outcome associations with Bourdieusian and Marxist measures were generally stronger for women and older respondents, and physical health associations with all measures were stronger among those aged 50+ years.

CONCLUSIONS

The impact of social class on health is multi-faceted. Policies to reduce health inequalities should focus more on unequal capital ownership, economic democracy and educational inequalities, reflecting Marxist and Weberian mechanisms.

See Change: Overcoming Anti-Black Racism in Health Systems

Anti-Black racism embedded in contemporary health systems harms Black and Indigenous People of Color (BIPoC) in concert with various diseases. Seemingly unrelated at first, the COVID-19 pandemic is a recent example that reveals how the combined manifestations of anti-Black racism in disease governance, course, and burden exacerbate the historic and still present subjugation of Black people. Thus, such conditions highlight a biosocial network that intricately propagates and consolidates systems of oppression since the birth of the United States of America. In this article, we show how anti-Black racism in conjunction with past and ongoing epidemics exemplify intertwined conditions embodying and perpetuating racial inequities in the North American country. Through schematic visualizations and techniques of progressive disclosure, we situate disease governance, course, and burden as action spaces within a design model that alternates views of organizational strategies, operations, offerings, and people's experiences, supporting an action-oriented discussion in each of these spaces. We utilize insights from this analysis to recommend that public health moves forward, considering more holistic, solution-oriented questions that embrace systemic complexity and people-centered perspectives when seeking to improve health outcomes for all.

A wake-up call for social epidemiologists studying health inequalities: Response to Dijkstra & Horstman

In their paper, published in this journal, Dijkstra & Horstman critically reflect on a selection of social epidemiological articles and examine how low socioeconomic status populations are constructed in these articles. They identify four components which they argue represent the "dominant thought style" of this literature: 1) proliferation, 2) generalization, 3) problematization and 4) individualization. We largely agree with their first two points, but strongly disagree with the other two, and explain why in our reply. All in all, we believe that their analysis is a wake-up call for social epidemiologists, rightly pointing to the risk that the relevance and moral origins of the use and study of categories, like 'low socioeconomic status', can easily become less visible, and therefore should be articulated and explained every time.

Relationship between subjective socioeconomic status and sense of gain of health-care reform and the mediating role of self-rated health: a cross-sectional study in China

BACKGROUND

The sense of gain has gradually become the main evaluation index for the effectiveness of China's deepening reform and is affected by many factors. However, there is no relevant research on the sense of gain of health-care reform (SGHR) and its influencing factors. The purpose of this study was to explore the influence of subjective socioeconomic status (SSS) on SGHR and the mediating role of self-rated health (SRH) between them.

METHODS

Data (25,149 samples total) from China Family Panel Studies (CFPS) in 2018 were included in the analysis. A nonparametric test was used to explore the differences in demographic characteristics of SGHR, and a correlation analysis and mediating effect model were used to explore the influence of SSS on SGHR and the mediating effect of SRH.

RESULTS

Demographic characteristics such as age, urban and rural areas, educational background, marriage and choice of medical treatment had significant differences in the distribution of perceived acquisition of medical reform. SSS, SRH and SGHR are statistically positively correlated with each other. SSS has a positive statistical correlation with SGHR, and may have an indirect effect through SRH.

CONCLUSIONS

SSS is an important predictor of SGHR, and SRH may play a partially mediating role in SGHR.

What does the literature mean by social prescribing? A critical review using discourse analysis

Social prescribing (SP) seeks to enhance the role of the voluntary and community sector in addressing patients' complex needs in primary care. Using discourse analysis, this review investigates how SP is framed in the scientific literature and explores its consequences for service delivery. Theory driven searches identified 89 academic articles and grey literature that included both qualitative and quantitative evidence. Across the literature three main discourses were identified. The first one emphasised increasing social inequalities behind escalating health problems and presented SP as a response to the social determinants of health. The second one problematised people's increasing use of health services and depicted SP as a means of enhancing self-care. The third one stressed the dearth of human and relational dimensions in general practice and claimed that SP could restore personalised care. Discourses circulated unevenly in the scientific literature, conditioned by a wider political rationality which emphasised individual responsibility and framed SP as 'solution' to complex and contentious problems. Critically, this contributed to an oversimplification of the realities of the problems being addressed and the delivery of SP. We propose an alternative 'care-based' framing of SP which prioritises (and evaluates) holistic, sustained and accessible practices within strengthened primary care systems.

Glossary: economics and health

As we emerge from the COVID-19 pandemic, there is an increasing focus on how the economy is rebuilt and the impact this will have on population health. Many of the economic policy proposals being discussed have their own vocabulary, which is not always understood in the same way within or between disciplines. This glossary seeks to provide a common language and concise summary of the key economic terminology relevant for policymakers and public health at this time.

An incongruous intervention: Exploring the role of anti-institutionalism in less-educated individual's limited uptake of nutrition information

Despite many efforts, nutritional health interventions have been largely unable to reduce health inequalities between less- and more-educated individuals, since their effectiveness among the former is often limited. Conventionally, adverse financial circumstances and poorer health literacy are argued to explain this. Drawing on recent sociological insights, we propose a complementing and novel sociocultural explanation based on how contemporary power relations in society breed anti-institutionalism among less-educated individuals. Using a survey of a representative sample of the Dutch population (n = 2398), we focus on the strategic case of the lower uptake of nutrition information among less-educated individuals. We find that two aspects of anti-institutionalism, i.e. institutional distrust and antipaternalism, substantially account for the educational gap in the uptake of nutrition information. This indicates that current nutrition information inspires opposition among less-educated individuals. More generally, it suggests that the development of nutritional health interventions should avoid invoking institutional connotations, to increase their acceptance by those who commonly need these most.

Addressing Inequalities Toward Inclusive Governance for Achieving One Health: A Rapid Review

Sustainable development goals (SDGs) adopted in 2015 are geared toward sustainable development through various pathways, one being reducing inequality as covered in SDG 10. Inequalities are a threat to health and wellbeing of populations and a planet Earth in which we live. This rapid review aims to identify key issues that are likely to exacerbate inequalities around the six SDGs directly related to One Health, which are SDG 3, 6, 11, 13, 14 and 15, and suggest some actions that may help to address them using inclusive governance taking into account the coronavirus disease of 2019 (COVID-19) pandemic. Informed by the literature on SDGs and using the “inclusive development concept” by Gupta and Vegelin, literature search was done in Google Scholar, PubMed Central, as well as, searching of references in the relevant articles identified using search terms from the six SDGs that are directly related to One Health. In the context of the SDGs, in order to achieve One Health through inclusive governance, and tackle inequalities, the following needs to be considered and addressed: increasing number of armed conflicts; ongoing COVID-19 pandemic; ensuring availability of water and sanitation facilities; improving city and urban areas planning to cope with climate change; improving governance arrangements for addressing climate change factoring gender and human rights; multisectoral planning for conservation of oceans, seas, and marine resources; balancing trade regulation of wildlife trade with conservation efforts; need for a research collaborative involving experts from environmental sciences, wildlife, agriculture and human health to study and develop scientific evidence on contribution of changes in land use practices to occurrence of zoonotic diseases; and need of a legislation for promoting animal welfare to protect public health. Also, inclusion of people with disabilities in the use of digital technologies is critical.

'Known to be unhealthy': Exploring how social epidemiological research constructs the category of low socioeconomic status

We examine how the category of low socioeconomic status (LSES) was constructed in European social epidemiological research and policy advice from 1977 to 2019. We analysed 22 empirical social epidemiological research publications on LSES and health, as well as six scientific advisory reports that offered government officials an overview of scientific evidence on health inequalities. We show the construction and reification of LSES as a problematic group in dominant thought, which consists of the following components: 1) the proliferation of SES concepts, indicators and groups labelled LSES; 2) generalisation through which LSES is constructed as a single population; 3) problematisation through which LSES is constructed as an inherently unhealthy population; and 4) individualisation by which a LSES personality is presented as an explanation of health differences. We also show how this knowledge is extrapolated into the policy domain in the form of scientific advisory reports. These findings provide evidence of the construction of LSES as an inherently unhealthy population through hyperproliferation and references to the objectivity of scientific research. With respect to the LSES category, the dynamics of research and policy resemble those regarding categories of ethnicity and gender. We conclude that if the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations 'known to be unhealthy'.