Why reduce health inequalities?

Impact of medical insurance integration on reducing urban-rural health disparity: Evidence from China

The urban-rural health disparity poses a significant challenge for countries worldwide. China encounters substantial disparities in healthcare services and health outcomes between urban and rural regions. In 2015, the Chinese government integrated the medical insurance schemes for urban and rural residents into a unified program, with the goal of mitigating the disparities and enhancing the sustainability and efficiency of the medical insurance system. Using data from the China Health and Retirement Longitudinal Study (CHARLS), we explored the impact of this integration on health outcomes and the health disparity between urban and rural residents, employing a triple difference approach with propensity score matching. We found that both urban and rural residents benefited from the medical insurance reform, experiencing improvements in their health outcomes to some extent. Urban residents reported better self-reported health, while rural residents exhibited improved health in terms of both self-reported health and number of diagnosed diseases. Notably, the disparity in activities of daily living (ADL) difficulties decreased. However, we also observed a worsening trend in ADL difficulties, especially among the elderly and the working population. This underscores the urgent need for further attention to health behaviors and healthcare resource allocation to these socio-demographic groups.

Progress towards health equity in Vietnam: evidence from nationwide official health statistics, 2010-2020

INTRODUCTION

One of the ultimate goals of strengthening the health system is to achieve health equity. Vietnam is considered one of the 'fast-track countries' to achieve the health-related Millennium Development Goals, but research on its equity strategies remains inadequate.

METHODS

Using Vietnamese official health statistics, we investigated inequity in four dimensions including health resources, service delivery, service utilisation and residents' health status from the perspectives of income levels, poverty rates and subnational regions. The Slope Index of Inequality, concentration curve/Concentration Index, absolute difference and Theil Index were used.

RESULTS

Four indicators showed 'pro-poor' inequality in health resources, including the per capita health budget, per capita health personnel, per capita health personnel at the community level and per capita hospital beds at the community level, while provincial hospital beds showed 'pro-rich' inequality. Two health service delivery indicators (delivery of antenatal care ≥3 times and proportion of community health service centres with medical doctors) show 'pro-rich' inequality, although two health status indicators, mortality and malnutrition rates for children under five, showed 'pro-poor' inequality. The Northern Midlands and Mountain Areas, and the Central Highlands were disadvantaged regarding service delivery and health status. Intraregional differences were the main factors contributing to the inequalities in delivery of antenatal care ≥3 times, provincial hospital beds and percentage of community health centres with medical doctors, with the Red River Delta and the South East region experiencing the greatest inequalities.

CONCLUSION

The overall level of health equity in Vietnam has increased over the past decade, although inequality in health service delivery has hindered progress towards health equity based on income, poverty and subnational regions. Targeted policies need to be introduced to reduce inequities relating to the health workforce and service delivery capacity.

Evolution in key indicators of maternal and child health across the wealth gradient in 41 sub-Saharan African countries, 1986-2019

BACKGROUND

Aggregate trends can be useful for summarizing large amounts of information, but this can obscure important distributional aspects. Some population subgroups can be worse off even as averages climb, for example. Distributional information can identify health inequalities, which is essential to understanding their drivers and possible remedies.

METHODS

Using publicly available Demographic and Health Survey (DHS) data from 41 sub-Saharan African countries from 1986 to 2019, we analyzed changes in coverage for eight key maternal and child health indicators: first dose of measles vaccine (MCV1); Diphtheria-Pertussis-Tetanus (DPT) first dose (DPT1); DPT third dose (DPT3); care-seeking for diarrhea, acute respiratory infections (ARI), or fever; skilled birth attendance (SBA); and having four antenatal care (ANC) visits. To evaluate whether coverage diverged or converged over time across the wealth gradient, we computed several dispersion metrics including the coefficient of variation across wealth quintiles. Slopes and 5-year moving averages were computed to identify overall long-term trends.

RESULTS

Average coverage increased for all quintiles and indicators, although the range and the speed at which they increased varied widely. There were small changes in the wealth-related gap for SBA, ANC, and fever. The wealth-related gap of vaccination-related indicators (DPT1, DPT3, MCV1) decreased over time. Compared to 2017, the wealth-gap between richest and poorest quintiles in 1995 was 7 percentage points larger for ANC and 17 percentage points larger for measles vaccination.

CONCLUSIONS

Maternal and child health indicators show progress, but the distributional effects show differential evolutions in inequalities. Several reasons may explain why countries had smaller wealth-related gap trends in vaccination-related indicators compared to others. In addition to service delivery differences, we hypothesize that the allocation of development assistance for health, the prioritization of vaccine-preventable diseases on the global agenda, and indirect effects of structural adjustment programs on health system-related indicators might have played a role.

Household income supplements in early childhood to reduce inequities in children's development

BACKGROUND

Early childhood interventions have the potential to reduce children's developmental inequities. We aimed to estimate the extent to which household income supplements for lower-income families in early childhood could close the gap in children's developmental outcomes and parental mental health.

METHODS

Data were drawn from a nationally representative birth cohort, the Longitudinal Study of Australian Children (N = 5107), which commenced in 2004 and conducted follow-ups every two years. Exposure was annual household income (0-1 year). Outcomes were children's developmental outcomes, specifically social-emotional, physical functioning, and learning (bottom 15% versus top 85%) at 4-5 years, and an intermediate outcome, parental mental health (poor versus good) at 2-3 years. We modelled hypothetical interventions that provided a fixed-income supplement to lower-income families with a child aged 0-1 year. Considering varying eligibility scenarios and amounts motivated by actual policies in the Australian context, we estimated the risk of poor outcomes for eligible families under no intervention and the hypothetical intervention using marginal structural models. The reduction in risk under intervention relative to no intervention was estimated.

RESULTS

A single hypothetical supplement of AU$26,000 (equivalent to ∼USD$17,350) provided to lower-income families (below AU$56,137 (∼USD$37,915) per annum) in a child's first year of life demonstrated an absolute reduction of 2.7%, 1.9% and 2.6% in the risk of poor social-emotional, physical functioning and learning outcomes in children, respectively (equivalent to relative reductions of 12%, 10% and 11%, respectively). The absolute reduction in risk of poor mental health in eligible parents was 1.0%, equivalent to a relative reduction of 7%. Benefits were similar across other income thresholds used to assess eligibility (range, AU$73,329-$99,864).

CONCLUSIONS

Household income supplements provided to lower-income families may benefit children's development and parental mental health. This intervention should be considered within a social-ecological approach by stacking complementary interventions to eliminate developmental inequities.

Inequity of maternal-child health services in ASEAN member states from 1993 to 2021

INTRODUCTION

Inequity in maternal-child health services is a challenge to global health as it hinders the achievement of Sustainable Development Goals (SDGs) and Universal Health Coverage. Though the Association of Southeast Asian Nations (ASEAN) has made remarkable achievements in maternal-child health, there remain gaps in reaching global goals. This study aimed to compare and investigate the inequity in maternal-child health (MCH) services in ASEAN member states to help guide policy decisions to improve equitable health services in the SDG era and beyond.

METHODS

Using the WHO Health Inequality Monitor, we identified inequity summary measures for five MCH services in ASEAN member states from 1993 to 2021: antenatal care, births attended by skilled health personnel, diphtheria, tetanus and pertussis (DTP3) immunization, measles immunization, and polio immunization. We divided the analysis dimension of inequity into urban-rural inequity, economic status inequity, and sub-regional inequity. Trends of absolute and relative inequity in every dimension of MCH services in ASEAN member states were examined with the principal component analysis (PCA).

RESULTS

The mean coverages of MCH services are 98.80% (Thailand), 86.72% (Cambodia), 84.54% (Viet Nam), 78.52 (Indonesia), 76.94% (Timor-Leste), 72.40% (Lao PDR), 68.10% (Philippines) and 48.52% (Myanmar) in 2021. Thailand have the lowest MCH services absolute inequity indexes of -1.945, followed by Vietnam (-1.449). Lao PDR and Myanmar have relatively higher MCH services absolute inequity indexes of 0.852 and 0.054 respectively. The service in Cambodia, Indonesia, and the Philippines is pro-specific regions (with subnational region absolute inequity indexes of -0.02, 0.01, and 1.01 respectively). The service in Myanmar is pro-rich (with economic status absolute inequity index of 0.43). The service in Lao PDR and Timor-Leste is pro-urban areas, pro-rich, and pro-specific regions.

CONCLUSION

The inequity of MCH services in ASEAN persists but is in a declining trend. Thailand and Vietnam have performed well in ensuring MCH services equity, while Laos and Myanmar are still facing serious inequity dilemmas. The progress of MCH service equity in Myanmar, Cambodia, the Philippines, and Indonesia is uneven. It is acceptable to learn from the successful experiences of Thailand and Vietnam to improve the equities in other ASEAN countries. Policies should be developed according to the specific types of MCH inequity in member states to improve equity levels.

Homelessness and health-related outcomes in the Republic of Ireland: a systematic review, meta-analysis and evidence map

Aim

To map existing research on homelessness and health in the Republic of Ireland, and to synthesize the evidence on housing-related disparities in health.

Methods

Peer-reviewed articles and conference abstracts published in English between 2012-2022 were retrieved from 11 bibliographic databases if they contained empirical data on homelessness and health in Ireland, and - in a subsequent screening stage - at least one measure of health disparity between the homeless and general populations. Reviewers extracted relative risks (RR), 95% confidence intervals (CI), and calculated pooled RR of comparable health disparities using pairwise random-effects meta-analyses.

Results

One hundred four articles contained empirical data on the health of homeless individuals residing in Ireland, addressing primarily substance use, addiction and mental health. Homelessness was associated with increased risk of illicit drug use (RR 7.33 [95% CI 4.2, 12.9]), reduced access to a general practitioner (GP) (RR 0.73 [CI 95% 0.71, 0.75]), frequent emergency department (ED) presentation (pooled RR 27.8 [95% CI 4.1, 189.8]), repeat presentation for self-harm (pooled RR 1.6 [95% CI 1.2, 2.0]) and premature departure from hospital (pooled RR 2.65 [95% CI 1.27, 5.53]).

Conclusions

Homelessness in Ireland is associated with reduced access to primary care and overreliance on acute care. Chronic conditions amongst homeless individuals are understudied.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01934-0.

Unmet healthcare needs and health inequalities in people with spinal cord injury: a direct regression inequality decomposition

BACKGROUND

Inequality in health is a prevalent and growing concern among countries where people with disabilities are disproportionately affected. Unmet healthcare needs explain a large part of the observed inequalities between and within countries; however, there are other causes, many non-modifiable, that also play a role.

AIM

This article explores the difference in health across income levels in populations with spinal cord injury (SCI). SCI is of special interest in the study of health systems, as it is an irreversible, long-term health condition that combines a high level of impairment with subsequent comorbidities.

METHODS

We estimated the importance of modifiable and non-modifiable factors that explain health inequalities through a direct regression approach. We used two health outcomes: years living with the injury and a comorbidity index. Data come from the International Spinal Cord Injury Survey (InSCI), which has individual data on people with SCI in 22 countries around the world. Due to the heterogeneity of the data, the results were estimated country by country.

RESULTS

On average, the results exhibit a prevalence of pro-rich inequalities, i.e., better health outcomes are more likely observed among high-income groups. For the years living with the injury, the inequality is mostly explained by non-modifiable factors, like the age at the time of the injury. In contrast, for the comorbidity index, inequality is mostly explained by unmet healthcare needs and the cause of the injury, which are modifiable factors.

CONCLUSIONS

A significant portion of health inequalities is explained by modifiable factors like unmet healthcare needs or the type of accident. This result is prevalent in low, middle, and high-income countries, with pervasive effects for vulnerable populations like people with SCI, who, at the same time are highly dependent on the health system. To reduce inequity, it is important not only to address problems from public health but from inequalities of opportunities, risks, and income in the population.

HIGHLIGHTS

• Better health status is evident among high-income groups, which is reflected in pro-rich inequalities. • Age at the time of the injury is the most important factor to explain inequalities in years living with the injury. • Unmet health care needs are the most important factor to explain inequalities in comorbidities. • The inequality in health varies by country dependent upon socioeconomic factors.

Measuring the inequalities in healthcare resource in facility and workforce: A longitudinal study in China

Objective

The study aimed to measure time trends of inequalities of the geographical distribution of health facilities and workforce in Shanghai from 2010 to 2016 and used a spatial autocorrelation analysis method to precisely detect the priority areas for optimizing health resource reallocation in metropolises like Shanghai in developing countries.

Methods

The study used secondary data from the Shanghai Health Statistical Yearbook and the Shanghai Statistical Yearbook from 2011 to 2017. Five indicators on health resources, namely, health institutions, beds, technicians, doctors, and nurses, were employed to quantitatively measure the healthcare resource in Shanghai. The Theil index and the Gini coefficient were applied to assess the global inequalities in the geographic distribution of these resources in Shanghai. Global and local spatial autocorrelation was performed using global Moran's index and local Moran's index to illustrate the spatial changing patterns and identify the priority areas for two types of healthcare resource allocation.

Results

Shanghai's healthcare resources showed decreasing trends of inequalities at large from 2010 to 2016. However, there still existed an unchanged over-concentration distribution in healthcare facilities and workforce density among districts in Shanghai, especially for doctors at the municipal level and facility allocation at the rural level. Through spatial autocorrelation analysis, it was found that there exhibited a significant spatial autocorrelation in the density distribution of all resources, and some identified priority areas were detected for resource re-allocation policy planning.

Conclusion

The study identified the existence of inequality in some healthcare resource allocations in Shanghai from 2010 to 2016. Hence, more detailed area-specific healthcare resource planning and distribution policies are required to balance the health workforce distribution at the municipal level and institution distribution at the rural level, and particular geographical areas (low–low and low–high cluster areas) should be focused on and fully considered across all the policies and regional cooperation to ensure health equality for municipal cities like Shanghai in developing countries.

Nutritional inequalities among under-five children: a geospatial analysis of hotspots and cold spots in 73 low- and middle-income countries

BACKGROUND

Child undernutrition is a severe health problem in the developing world, which affects children's development in the long term. This study analyses the extent and patterns of under-five child undernutrition using Demographic and Health Surveys (DHS) for 73 low- and middle-income countries (LMICs).

METHODS

First, we mapped the prevalence of undernutrition in the developing world. Second, using the LISA (a local indicator of spatial association) technique, we analyzed the geographical patterns in undernutrition to highlight the localized hotspots (regions with high undernutrition prevalence surrounded by similar other regions), cold spots (regions with low undernutrition prevalence surrounded by similar other regions), and outliers (regions with high undernutrition surrounded by low undernutrition and vice versa). Third, we used Moran's I to find global patterns in child undernutrition.

RESULTS

We find that South Asia has the highest under-five child undernutrition rates. The intra-country nutritional inequalities are highest in Burundi (stunting), Kenya (wasting), and Madagascar (underweight). The local indicator of spatial association (LISA) analysis suggests that South Asia, Middle East and North Africa (MENA) region, and Sub-Saharan Africa are undernutrition hotspots and Europe and Central Asia and Latin America, and the Caribbean are undernutrition cold spots (regions with low undernutrition surrounded by similar other regions). Getis Ord-Gi* estimates generally support LISA analysis. Moran's I and Geary's C gave similar results about the global patterns of undernutrition. Geographically weighted regressions suggest that several socioeconomic indicators significantly explain child undernutrition.

CONCLUSIONS

We found a significant within and across country variation in stunting, wasting and underweight rates among the under-five children's population. The geospatial analysis also suggested that stunting, wasting, and underweight patterns exhibit clear regional patterns, underscoring the need for coordinated interventions at the regional level.

Inequity in Access and Delivery of Virtual Care Interventions: A Scoping Review

The objectives of this review were to map and summarize the existing evidence from a global perspective about inequity in access and delivery of virtual care interventions and to identify strategies that may be adopted by virtual care services to address these inequities. We searched MEDLINE, EMBASE, and CINAHL using both medical subject headings (MeSH) and free-text keywords for empirical studies exploring inequity in ambulatory services offered virtually. Forty-one studies were included, most of them cross-sectional in design. Included studies were extracted using a customized extraction tool, and descriptive analysis was performed. The review identified widespread differences in accessing and using virtual care interventions among cultural and ethnic minorities, older people, socioeconomically disadvantaged groups, people with limited digital and/or health literacy, and those with limited access to digital devices and good connectivity. Potential solutions addressing these barriers identified in the review included having digitally literate caregivers present during virtual care appointments, conducting virtual care appointments in culturally sensitive manner, and having a focus on enhancing patients’ digital literacy. We identified evidence-based practices for virtual care interventions to ensure equity in access and delivery for their virtual care patients.

Health Inequalities in Older Norwegians and the Mediating Role of Social Networks

This study aims to contribute to understanding how social networks serve as an intervening pathway leading to socioeconomic health inequality among older adults in Norway. Longitudinal survey data from the second and the third waves of the Norwegian Life Course, Ageing, and Generation Study were used in this paper. Hayes PROCESS was used to estimate the mediating effect of the contact frequency and the support potential of friends on the impact of social-economic position (SEP) at wave 2 on health outcomes at wave 3. The total indirect effect of the income on physical health observed was 0.04. The total indirect effect of the highest level of education attained on physical health observed was 0.12. The result showed a social-economic gradient in health among older adults in Norway where the social network is a crucial pathway via which SEP influences peoples' health.

Māori Health Outcomes in Intensive Care Following Cardiac Surgery in Aotearoa New Zealand

BACKGROUND

Māori, the indigenous peoples of Aotearoa New Zealand (NZ) experience disproportionately worse outcomes in cardiovascular health compared to non-Māori. Waikato Hospital provides tertiary cardiothoracic services to the Midland region of NZ, and has instituted an official policy to eliminate ethnic inequity in health. We aimed to audit the outcomes of our cardiothoracic intensive care unit (ICU) against this standard.

METHOD

We analysed data from the prospectively-entered Australia and NZ Intensive Care Society database for all planned cardiothoracic ICU admissions from 2014 to 2018 at Waikato Hospital for patients aged 15-years and older (n=2,736). Outcomes measured were in-ICU, in-hospital, and 1-year mortality.

RESULTS

Māori were under-represented in this cohort (17.9%) compared to the general Midland population. Māori patients were younger (median 60 vs 68-years old, p<0.001), were more commonly female (34.8% vs 23.6%, p<0.001), domiciled in more deprived areas (2018 NZ Index of Deprivation of 9 vs 6, p<0.001), and more likely to have rheumatic heart disease (35.6% vs 16.6%, p<0.001). More non-Māori required coronary vessel only surgery (57.4% vs 45.2%), whilst more Māori required valvular only surgery (41.1% vs 31.2%) (p<0.001 overall). Baseline Acute Physiology and Chronic Health Evaluation (APACHE) III risk of death score was higher for Māori (1.53% vs 0.89%, p<0.001), as was the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (2.04% vs 1.55%, p<0.001). Unadjusted mortality was higher for Māori in-ICU (3.1% vs 1.3%, p=0.005) and at 1-year (7.1% vs 3.8%, p=0.002). Adjusted in-ICU mortality, however, was predicted by combined coronary-valvular surgery (adjusted odds ratio, AOR 25.5 [95% confidence interval (CI) 3.30-348.46], p=0.005), Australia and New Zealand Risk of Death (ANZROD) score (AOR 1.11 [CI 1.05-1.19] p<0.001), and renal replacement therapy requirement (AOR 154.56 [CI 30.86-1,107.17] p<0.001), but not by Māori ethnicity (AOR 0.27 [CI 0.03-1.43] p=0.156).

CONCLUSION

Our audit has identified significant inequity for Māori at our cardiothoracic ICU. Māori are sicker on presentation for planned cardiac surgery, as evidenced by higher admission severity scores, and experience higher unadjusted mortality up to 1-year compared to non-Māori. Māori also appear under-represented despite a greater burden of cardiovascular disease in the community. Further study is required to identify if upstream risk factors, including failure of early detection and referral for disease, contribute to these findings.

Linking health education, civic engagement, and research at a large Federally Qualified Health Center to address health disparities

OBJECTIVE

To develop a framework for patient-centered research in a community health center.

STUDY SETTING

Primary organizational case-study data were collected at a large Federally Qualified Health Center (FQHC) in Southern California from 2019 to 2021.

STUDY DESIGN

Thirty stakeholders, including patients, community leaders, students, medical providers, and academic partners, participated in community-engagement capacity-building exercises and planning. These activities were guided by Community Based Participatory Principles and were part of an initiative to address health disparities by supporting patient and community-engaged research.

DATA COLLECTION

The study included an iterative development process. Stakeholders participated in a total of 44 workgroup meetings and 7 full-group quarterly convenings. The minutes of the meetings from both workgroups and quarterly convenings were used to document the evolution of the initiative.

PRINCIPLE FINDINGS

Stakeholders concluded that health equity research needs to be part of a larger engagement ecosystem and that, in some ways, engagement on research projects may be a later-stage form of engagement following patient/community and staff/researcher coeducation and cocapacity building efforts.

CONCLUSIONS

Community health center stakeholders viewed successful engagement of community members in patient-centered health equity research as involving a web of longitudinal, evolving internal and external relationships rather than discrete, time-limited, and single-project-based dyadic connections.

Visualizing the Knowledge Domain in Health Education: A Scientometric Analysis Based on CiteSpace

OBJECTIVES

This study aimed to visualize the evidence in the global research on health education to better improve the nation's health literacy and to guide future research.

METHOD

We searched the Web of Science (Core Collection) electronic databases. The search strategies: topic: ("Health Education" OR "Education, Health" OR "Community Health Education" OR "Education, Community Health" OR "Health Education, Community") AND document: (Article) AND language:(English). Articles of evidence from January 2011 to December 2021 with those words in the title or abstract or keywords will be included in this review. We used the Citespace 5.6.R5 (64-bit) to investigate and determine the thematic patterns, and emerging trends of the knowledge domain, and presented a narrative account of the findings.

RESULT

We analyzed 10,273 eligible articles. It showed that BMC Public Health displays the most prolific journals. Author MARCO PAHOR is highlighted in health education. The University of Sydney has published the most studies about health education. The USA plays an important role in these studies. Specifically, the visualization shows several hotspots: disease prevalence surveys and a specific population of knowledge, attitude and practice surveys, health intervention, chronic and non-communicable management, youth-health action, sexual and reproductive health, and physical activity promotion. Furthermore, document co-citation analysis indicated that there are 10 main clusters, which means the research front in health education. Meanwhile, by the citation detected, COVID-19, has achieved universal health coverage in related studies, however, public health education and the health workforce might be more popular in the coming years.

CONCLUSION

Health education is an effective measure to shift the concept of public health and improve healthy living standards. The present study facilitates an extensive understanding of the basic knowledge and research frontiers that are pivotal for the developmental process of health education and allows scholars to visualize the identification modes and tendencies.

COVID-19 double jeopardy: the overwhelming impact of the social determinants of health

Background

The COVID-19 pandemic has strained healthcare systems by creating a tragic imbalance between needs and resources. Governments and healthcare organizations have adapted to this pronounced scarcity by applying allocation guidelines to facilitate life-or-death decision-making, reduce bias, and save as many lives as possible. However, we argue that in societies beset by longstanding inequities, these approaches fall short as mortality patterns for historically discriminated against communities have been disturbingly higher than in the general population.

Methods

We review attack and fatality rates; survey allocation protocols designed to deal with the extreme scarcity characteristic of the earliest phases of the pandemic; and highlight the larger ethical perspectives (Utilitarianism, non-Utilitarian Rawlsian justice) that might justify such allocation practices.

Results

The COVID-19 pandemic has dramatically amplified the dire effects of disparities with respect to the social determinants of health. Patients in historically marginalized groups not only have significantly poorer health prospects but also lower prospects of accessing high quality medical care and benefitting from it even when available. Thus, mortality among minority groups has ranged from 1.9 to 2.4 times greater than the rest of the population. Standard allocation schemas, that prioritize those most likely to benefit, perpetuate and may even exacerbate preexisting systemic injustices.

Conclusions

To be better prepared for the inevitable next pandemic, we must urgently begin the monumental project of addressing and reforming the structural inequities in US society that account for the strikingly disparate mortality rates we have witnessed over the course of the current pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01629-0.

Local Characteristics Related to SARS-CoV-2 Transmissions in the Seoul Metropolitan Area, South Korea

The Seoul metropolitan area is one of the most populated metropolitan areas in the world; hence, Seoul's COVID-19 cases are highly concentrated. This study identified local demographic and socio-economic characteristics that affected SARS-CoV-2 transmission to provide locally targeted intervention policies. For the effective control of outbreaks, locally targeted intervention policies are required since the SARS-CoV-2 transmission process is heterogeneous over space. To identify the local COVID-19 characteristics, this study applied the geographically weighted lasso (GWL). GWL provides local regression coefficients, which were used to account for the spatial heterogeneity of SARS-CoV-2 outbreaks. In particular, the GWL pinpoints statistically significant regions with specific local characteristics. The applied explanatory variables involving demographic and socio-economic characteristics that were associated with higher SARS-CoV-2 transmission in the Seoul metropolitan area were as follows: young adults (19~34 years), older population, Christian population, foreign-born population, low-income households, and subway commuters. The COVID-19 case data were classified into three periods: the first period (from January 2020 to July 2021), the second period (from August to November 2020), and the third period (from December 2020 to February 2021), and the GWL was fitted for the entire period (from January 2020 to February 2021). The result showed that young adults, the Christian population, and subway commuters were the most significant local characteristics that influenced SARS-CoV-2 transmissions in the Seoul metropolitan area.

Health Inequality Analysis in Europe: Exploring the Potential of the EQ-5D as Outcome

Objective: This study explored the additive value of the multi-item EuroQol 5-Dimension 5-Level (EQ-5D-5L) as an outcome measure in health inequality analyses, relative to the single-item EuroQol visual analog scale (EQ VAS). Methods: A sample comprising the general population from Italy, the Netherlands, and United Kingdom (UK) completed the EQ-5D-5L and the EQ VAS. The level of education was selected as a proxy for socio-economic status (SES). EQ-5D-5L level sum scores (LSS) were compared against EQ VAS scores. Stratified and multivariable analyses were used to study the associations between SES and the LSS/EQ VAS relative to the presence of chronic health conditions. Results: A total of 10,172 people participated in this study. In the UK and Netherlands, the LSS was worst for respondents with a low educational level and better for respondents with middle and high educational levels. For Italy, the LSS was best for respondents with a middle educational level compared to respondents with low and high educational levels. The same patterns were observed for the EQ VAS, but differences were slightly smaller. Multivariable analyses showed generally stronger predictive relations in the UK, and with the LSS. The presence of chronic health conditions and being unable to work were independent strong predictors, canceling out the effects of education. Conclusions: In three different European countries, the EQ-5D measures show the presence of education-dependent health inequalities, which are universally explained in regression analysis by independently the presence of chronic health conditions and the inability to work. In stratified analysis, the EQ-5D-5L LSS discriminates slightly better between participants with different levels of SES compared to the EQ VAS.

The impact of disinvestment on alcohol and drug treatment delivery and outcomes: a systematic review

BACKGROUND

In the context of substantial financial disinvestment from alcohol and drug treatment services in England, our aim was to review the existing evidence of how such disinvestments have impacted service delivery, uptake, outcomes and broader health and social implications.

METHODS

We conducted a systematic review of quantitative and qualitative evidence (PROSPERO CRD42020187295), searching bibliographic databases and grey literature. Given that an initial scoping search highlighted a scarcity of evidence specific to substance use treatment, evidence of disinvestment from publicly funded sexual health and smoking cessation services was also included. Data on disinvestment, political contexts and impacts were extracted, analysed, and synthesized thematically.

RESULTS

We found 20 eligible papers varying in design and quality including 10 related to alcohol and drugs services, and 10 to broader public health services. The literature provides evidence of sustained disinvestment from alcohol and drug treatment in several countries and a concurrent decline in the quantity and quality of treatment provision, but there was a lack of methodologically rigorous studies investigating the impact of disinvestment.

CONCLUSIONS

This review identified a paucity of scientific evidence quantifying the impacts of disinvestment on alcohol and drug treatment service delivery and outcomes. As the global economy faces new challenges, a stronger evidence base would enable informed policy decisions that consider the likely public health impacts of continued disinvestment.

Socioeconomic Inequalities and Obesity in South Africa-A Decomposition Analysis

Background: Prior evidence shows that inequalities are related to overweight and obesity in South Africa. Using data from a recent national study, we examine the socioeconomic inequalities associated with obesity in South Africa and the factors associated with it. Methods: We use quantitative data from the South African National Health and Nutrition Examination Survey (SANHANES-1) carried out in 2012. We estimate the concentration index (CI) to identify inequalities and decompose the CI to explore the determinants of these inequalities. Results: We confirm the existence of pro-rich inequalities associated with obesity in South Africa. The inequalities among males are larger (CI of 0.16) than among women (CI of 0.09), though more women are obese than men. Marriage increases the risk of obesity for women and men, while smoking decreases the risk of obesity among men significantly. Higher education is associated with lower inequalities among females. Conclusions: We recommend policies to focus on promoting a healthy lifestyle, including the individual’s perception of a healthy body size and image, especially among women.

Inequities in Children's Reading Skills: The Role of Home Reading and Preschool Attendance

OBJECTIVE

Children from socioeconomically disadvantaged backgrounds have poorer learning outcomes. These inequities are a significant public health issue, tracking forward to adverse health outcomes in adulthood. We examined the potential to reduce socioeconomic gaps in children's reading skills through increasing home reading and preschool attendance among disadvantaged children.

METHODS

We drew on data from the nationally representative birth cohort of the Longitudinal Study of Australian Children (N = 5107) to examine the impact of socioeconomic disadvantage (0-1 year) on children's reading skills (8-9 years). An interventional effects approach was applied to estimate the extent to which improving the levels of home reading (2-5 years) and preschool attendance (4-5 years) of socioeconomically disadvantaged children to be commensurate with their advantaged peers, could potentially reduce socioeconomic gaps in children's reading skills.

RESULTS

Socioeconomically disadvantaged children had a higher risk of poor reading outcomes compared to more advantaged peers: absolute risk difference = 20.1% (95% confidence interval [CI]: 16.0%-24.2%). Results suggest that improving disadvantaged children's home reading and preschool attendance to the level of their advantaged peers could eliminate 6.5% and 2.1% of socioeconomic gaps in reading skills, respectively. However, large socioeconomic gaps would remain, with disadvantaged children maintaining an 18.3% (95% CI: 14.0%-22.7%) higher risk of poor reading outcomes in absolute terms.

CONCLUSION

There are clear socioeconomic disparities in children's reading skills by late childhood. Findings suggest that interventions that improve home reading and preschool attendance may contribute to reducing these inequities, but alone are unlikely to be sufficient to close the equity gap.

An exploratory study to investigate alcohol consumption among breast-feeding mothers

OBJECTIVE

We examined the likelihood of breast-feeding mothers consuming alcohol according to several socio-demographic factors.

DESIGN

We carried out secondary data analyses using participant information obtained from a cross-sectional survey designed to capture the dietary habits of UK infants aged 4-18 months.

SETTING

Data concerning breast-feeding mothers' social and domestic circumstances and alcohol consumption were drawn from the 2011 Diet and Nutrition Survey of Infants and Young Children.

PARTICIPANTS

Complete data from 2683 breast-feeding mothers were included, and further analyses were carried out on those who continued to drink alcohol (n 227).

RESULTS

Logistic regression enabled the identification of social factors associated with breast-feeding and continued alcohol consumption among mothers. Several social factors were found to influence the likelihood of breast-feeding mothers drinking alcohol. For example, older mothers, mothers with partners who drank alcohol, those with higher educational attainment and household income and those who consumed alcohol whilst pregnant were more likely to continue to drink alcohol. Mothers' breast-feeding infants older than 12 months were less likely to drink alcohol than those feeding infants aged 4-6 months.

CONCLUSIONS

Evidence suggests that social circumstances influence the likelihood of alcohol use among mothers who are breast-feeding. Greater understanding of mothers' decision making with respect to the continuation or discontinuation of alcohol use whilst breast-feeding, according to the social context in which they live, is warranted.

Māori health outcomes in an intensive care unit in Aotearoa New Zealand

Māori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Māori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Māori. Our study aimed to describe Māori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Māori were over-represented relative to the general population. Compared to non-Māori, Māori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Māori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Māori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Māori risk for critical illness. There was no difference in mortality outcomes.

Putting the "Love of Humanity" Back in Corporate Philanthropy: The Case of Health Grants by Corporate Foundations

With the growing call for private sector actors to address global challenges, it is necessary to first assess whether regions with the greatest needs are accessing corporate philanthropy. In this paper, we ask whether corporate philanthropy is reaching those with the greatest health-care needs. Drawing on economic geography and corporate homophily, we argue that corporate philanthropy tends to exacerbate health inequality as grants are destined for counties with fewer health problems. We test and find support for this hypothesis using data on health grants made by US corporate foundations and county-level health data. Our results that corporate health grants are less likely to go to counties which have a lower proportion of medical service providers and insured citizens suggest that corporate foundations are unwittingly complicit in worsening the resource gap between small, poor, rural counties and large, wealthy, urban counties. From an ethical perspective, we provide some guidance as to how this may be corrected.

Hierarchical Models for International Comparisons: Smoking, Disability, and Social Inequality in 21 European Countries

BACKGROUND

International comparisons of social inequalities in health outcomes and behaviors are challenging. Due to the level of disaggregation often required, data can be sparse and methods to make adequately powered comparisons are lacking. We aimed to illustrate the value of a hierarchical Bayesian approach that partially pools country-level estimates, reducing the influence of sampling variation and increasing the stability of estimates. We also illustrate a new way of simultaneously displaying the uncertainty of both relative and absolute inequality estimates.

METHODS

We used the 2014 European Social Survey to estimate smoking prevalence, absolute, and relative inequalities for men and women with and without disabilities in 21 European countries. We simultaneously display smoking prevalence for people without disabilities (x-axis), absolute (y-axis), and relative inequalities (contour lines), capturing the uncertainty of these estimates by plotting a 2-D normal approximation of the posterior distribution from the full probability (Bayesian) analysis.

RESULTS

Our study confirms that across Europe smoking prevalence is generally higher for people with disabilities than for those without. Our model shifts more extreme prevalence estimates that are based on fewer observations, toward the European mean.

CONCLUSIONS

We demonstrate the utility of partial pooling to make adequately powered estimates of inequality, allowing estimates from countries with smaller sample sizes to benefit from the increased precision of the European average. Including uncertainty on our inequality plot provides a useful tool for evaluating both the geographical patterns of variation in, and strength of evidence for, differences in social inequalities in health.

Evolution of inequalities in the coronavirus pandemics in Portugal: an ecological study

Background

Previous literature shows systematic differences in health according to socioeconomic status (SES). However, there is no clear evidence that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection might be different across SES in Portugal. This work identifies the coronavirus disease 2019 (COVID-19) worst-affected municipalities at four different time points in Portugal measured by prevalence of cases, and seeks to determine if these worst-affected areas are associated with SES.

Methods

The worst-affected areas were defined using the spatial scan statistic for the cumulative number of cases per municipality. The likelihood of being in a worst-affected area was then modelled using logistic regressions, as a function of area-based SES and health services supply. The analyses were repeated at four different time points of the COVID-19 pandemic: 1 April, 1 May, 1 June, and 1 July, corresponding to two moments before and during the confinement period and two moments thereafter.

Results

Twenty municipalities were identified as worst-affected areas in all four time points, most in the coastal area in the Northern part of the country. The areas of lower unemployment were less likely to be a worst-affected area on the 1 April [adjusted odds ratio (AOR) = 0.36 (0.14–0.91)], 1 May [AOR = 0.03 (0.00–0.41)] and 1 July [AOR = 0.40 (0.16–1.05)].

Conclusion

This study shows a relationship between being in a worst-affected area and unemployment. Governments and public health authorities should formulate measures and be prepared to protect the most vulnerable groups.

Regional health disparities in Burkina Faso during the period of health care decentralization. Results of a macro-level analysis

BACKGROUND

Burkina Faso has undertaken decentralization reforms in the health care sector to improve the performance of the health system. This study aimed to analyze the differences in health outcomes by health district's demographic and economic status, and the distribution of health resources during the period of health care decentralization.

METHODS

A bivariate correlation analysis was conducted using data at the health districts and regions level. Data from the health management information system (HMIS) and national households' surveys were used.

RESULTS

The results indicate a strong correlation between district's population size and the availability of health resources (P ≤ .05). The health visits per capita and skilled birth attendance are correlated with the economic status of the health district (P ≤ .05). Malnutrition among under-five and maternal mortality was associated with the availability of health personnel and health infrastructures (P ≤ .05). No correlation was found between financial resources and health outcomes.

CONCLUSION

The results indicated disparities in health among the health districts in Burkina Faso. The ways to address this inequality include more transparent resource allocation, as well as policies to address the socio-economic disparities and financial barriers to health services. Further research is needed to collect relevant data and investigate the effects of decentralization, which was not possible in our study.

Impact of Gender Inequalities in the Causes of Mortality on the Competitiveness of OECD Countries

The aim of the present study is to quantify the relations between gender inequalities in mortality by selected causes of mortality and between competitiveness of Organisation for Economic Co-operation and Development (OECD) countries. Data for the analyses were obtained from OECD databases and the World Economic Forum (Global Competitiveness Index), for the years 2011–2016, for all 36 countries. The methods of descriptive analysis, analysis of differences in causes of mortality by gender characteristics, regression analysis, relationship analysis of gender inequalities in causes of mortality and competitiveness, and cluster analysis were used for the statistical data processing. Based on the research findings, it can be concluded that gender inequality occurs in most of the examined mortality groups of diagnoses, while it was most significant in the case of mortality due to neoplasms. The impacts of mortality on competitiveness are significant. In assessing gender inequalities in causes of mortality, significant impacts were seen in most mortality causes, but the most significant impact was identified within mortality due to neoplasms. Emphasis should be placed on men when reducing inequalities. Health and health equity should be supported by national governments, and health equity should be one of the key performance indicators of the country.

The Effects of Performance of Public Sector Health System on Quality of Life in China: Evidence from the CGSS2015

The determinants of quality of life can be social, economic, cultural, and governmental, to name a few. Prior research has shown that demographic factors and social support can have a significant impact on an individual’s quality of life. This research attempts to examine the effects of public sector health system performance on individuals’ quality of life in China, measured by (1) self-reported health, (2) depressed mood, and (3) happiness. The targeted population was individuals aged 18 and above. The primary data was collected from the CGSS2015 (Chinese General Social Survey 2015), and the National Statistical Yearbook was also used. Using various statistical models, this study finds that the correlation coefficients of government performance in providing healthcare for patients on quality of life are 0.144, 0.167, and 0.328, respectively. The more satisfied with medical care and public health delivered by the government, the higher the level of quality of life. In addition, the relationship between government expenditure on public health service and quality of life is positively significant. These findings are robust after weighting methods are used. The performance of the Public Sector Health System has a significantly positive association with quality of life in China.

Smart City and High-Tech Urban Interventions Targeting Human Health: An Equity-Focused Systematic Review

Urban infrastructure systems responsible for the provision of energy, transportation, shelter, and communication to populations are important determinants of health and health equity. The term “smart city” has been used synonymously with other terms, such as “digital city”, “sustainable city”, and “information city”, even though definitional distinctions exist between terms. In this review, we use “smart cities” as a catch-all term to refer to an emerging concept in urban governance practice and scholarship that has been increasingly applied to achieve public health aims. The objective of this systematic review was to document and analyze the inclusion of equity considerations and dimensions (i.e., a measurement, analytical, or dialectical focus on systematic disparities in health between groups) in smart city interventions aimed to improve human health and well-being. Systematic searches were carried out in the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psychological Information Database (PsycINFO), the PubMed database from the National Center for Biotechnology Information, Elsevier’s database Scopus, and Web of Science, returning 3219 titles. Ultimately, 28 articles were retained, assessed, and coded for their inclusion of equity characteristics using the Cochrane PROGRESS-Plus tool (referring to (P) place of residence, (R) race, (O) occupation, (G) gender, (R) religion, (E) education, (S) socio-economic status (SES), and (S) social capital). The most frequently included equity considerations in smart city health interventions were place of residence, SES, social capital, and personal characteristics; conversely, occupation, gender or sex, religion, race, ethnicity, culture, language, and education characteristics were comparatively less featured in such interventions. Overall, it appears that most of intervention evaluations assessed in this review are still in the early testing phases, and thus did not include or feature robust evaluative designs or commercially available technologies

A Systematic Review Protocol to Identify the Key Benefits and Associated Program Characteristics of Community Gardening for Vulnerable Populations

Gardening has long been a popular pastime. There is a growing evidence base for the health and well-being benefits of gardening. Community gardening brings a social aspect to gardening, thereby increasing the potential benefits to include addressing social inclusion and poor community health through sharing of values, support of others, and building networks. This systematic review protocol aims to determine the characteristics of community gardening that could lead to beneficial outcomes such as connection with the community and development of new skills. Thirteen academic databases will be searched for studies looking at the benefits of community gardening, with a focus on vulnerable populations. Data will be extracted from all studies meeting the inclusion criteria and summarized to provide an overview of the current literature. This systematic review aims to provide a comprehensive investigation into community gardening, its benefits, and how they are achieved for the target population. By gathering and synthesizing this information, the review should allow policy makers and practitioners to work more effectively to address health and social inequities, by highlighting areas of need and enabling optimization of future interventions.

NHS commissioning in probation in England - Still on a wing and a prayer

Policy reforms in England and Wales mean that all individuals released from prison will have some contact with probation services, either serving a community sentence, or being on licence post-release. Despite often having complex health needs, including a higher prevalence of mental health problems, substance misuse problems and physical health problems than the general population, this socially excluded group of people often do not access healthcare until crisis point. This is partly due to service-level barriers such as a lack of appropriate and accessible healthcare provision. We conducted a national survey of all Clinical Commissioning Groups (CCGs, n = 210) and Mental Health Trusts (MHTs, n = 56) in England to systematically map healthcare provision for this group. We compared findings with similar surveys conducted in 2013 and 2014. We had excellent response rates, with the data analysed here representing responses from 75% of CCGs and 52% of MHTs in England. We found that just 4.5% (n = 7) of CCG responses described commissioning a service specifically for probation service clients, and 7.6% (n = 12) described probation-specific elements within their mainstream service provision. Responses from 19.7% of CCGs providing data (n = 31) incorrectly suggested that NHS England are responsible for commissioning healthcare for probation clients rather than CCGs. Responses from 69% (n = 20) of MHTs described providing services specifically for probation service clients, and 17.2% (n = 5) described probation-specific elements within their mainstream service provision. This points to a need for an overarching health and justice strategy that emphasises organisational responsibilities in relation to commissioning healthcare for people in contact with probation services to ensure that there is appropriate healthcare provision for this group.

Is socioeconomic inequality in postnatal depression an early-life root of disadvantage for children?

This paper investigates the role that socioeconomic inequality in postnatal depression might play in intergenerational transmission of inequality. Infants' development is thought to be particularly sensitive to mothers' mental health at this time, suggesting that greater early-life exposure to maternal depression among disadvantaged groups might be a root of later socioeconomic inequalities. Heightened contact with health services during this period presents opportunities for intervention, but higher unmet need for treatment of postnatal depression among the disadvantaged might be widening inequalities. The aim of this study is to quantify the potential contribution of postnatal depression to socioeconomic inequalities in adverse childhood health and development outcomes. Regression-based decomposition of the concentration index is used to explore the association between income inequality in postnatal depressive symptoms and income inequality in children's outcomes. Four problems of early adolescence are explored: emotional and conduct problems, special educational needs, and low self-assessed health. Data are taken from the UK Millennium Cohort Study, with a sample of 4359 mothers and children with complete data on outcomes and covariates, and a second sample of 5441 when missing covariates are filled using multiple imputation. The key finding is that socioeconomic inequality in maternal postnatal depression is a significant contributor to inequalities in special educational needs, emotional problems, and low self-assessed health for children at age 11 years, even after accounting for a range of other factors that might explain such associations. These findings highlight the importance of understanding the impact of postnatal depression interventions on inequalities, and the downstream influence on children's outcomes. Addressing inequalities in mothers' postnatal depression might be an avenue for reducing early-life disadvantage for children.

Inequalities in healthcare resources and outcomes threatening sustainable health development in Ethiopia: panel data analysis

OBJECTIVE

To measure inequalities in the distributions of selected healthcare resources and outcomes in Ethiopia from 2000 to 2015.

DESIGN

A panel data analysis was performed to measure inequalities in distribution of healthcare workforce, infrastructure, outcomes and finance, using secondary data.

SETTING

The study was conducted across 11 regions in Ethiopia.

PARTICIPANTS

Regional population and selected healthcare workforce.

OUTCOMES MEASURED

Aggregate Theil and Gini indices, changes in inequalities and elasticity of healthcare resources.

RESULTS

Despite marked inequality reductions over a 16 year period, the Theil and Gini indices for the healthcare resources distributions remained high. Among the healthcare workforce distributions, the Gini index (GI) was lowest for nurses plus midwives (GI=0.428, 95% CI 0.393 to 0.463) and highest for specialist doctors (SPDs) (GI=0.704, 95% CI 0.652 to 0.756). Inter-region inequality was the highest for SPDs (95.0%) and the lowest for health officers (53.8%). The GIs for hospital beds, hospitals and health centres (HCs) were 0.592(95% CI 0.563 to 0.621), 0.460(95% CI 0.404 to 0.517) and 0.409(95% CI 0.380 to 0.439), respectively. The interaction term was highest for HC distributions (47.7%). Outpatient department visit per capita (GI=0.349, 95% CI 0.321 to 0.377) and fully immunised children (GI=0.307, 95% CI 0.269 to 0.345) showed inequalities; inequality in the under 5 years of age mortality rate increased overtime (P=0.048). Overall, GI for government health expenditure (GHE) was 0.596(95% CI 0.544 to 0.648), and the estimated relative GHE share of the healthcare workforce and infrastructure distributions were 46.5% and 53.5%, respectively. The marginal changes in the healthcare resources distributions were towards the advantaged populations.

CONCLUSION

This study revealed high inequalities in healthcare resources in favour of the advantaged populations which can hinder equal access to healthcare and the achievements of healthcare outcomes. The government should strengthen monitoring mechanisms to address inequalities based on the national healthcare standards.

Tuberculosis incidence inequalities and its social determinants in Manaus from 2007 to 2016

Background

Brazil is among the 30 countries with high-burden of tuberculosis worldwide, and Manaus is the capital with the highest tuberculosis incidence. The accelerated economic and population growth in Manaus in the last 30 years has strengthened the process of social stratification that may result in population groups that are less favored in terms of healthcare and are vulnerable to infection and illness due to tuberculosis. This study aimed to characterize inequalities associated with tuberculosis incidence in relation to the socioeconomic and demographic characteristics of the resident population of Manaus and to identify their determinants from 2007 to 2016.

Methods

An ecological study was conducted using the data from the Diseases Notification Information System. Tuberculosis incidence rates by population characteristics (gender, ethnicity, and socioeconomic level) were calculated for each year, studied, and represented in equiplot charts. To measure the disparity of tuberculosis incidence in the resident population in Manaus, the Gini index of tuberculosis in each neighborhood was calculated based on the incidence rates of the census sectors. A thematic map was constructed to represent the spatial distribution of tuberculosis incidence inequality. Linear regression models were used to identify the relationship between the tuberculosis incidence inequality and its social determinants.

Results

From 2007 to 2016, there was an increase in the tuberculosis incidence in Manaus, together with an increase in incident inequality among genders, ethnic groups, and socioeconomic level. The incidence of tuberculosis inequality was associated with the inequalities of its possible determinants (Gini of the proportion of male population, Gini of the proportion of indigenous population, Gini of the proportion of illiteracy, Gini of income, Gini of the proportion of households connected to the water network, and Gini of the mean number of bathrooms per inhabitant), the per capita income, and the proportion of cases with laboratory confirmation.

Conclusions

Disparities in tuberculosis incidence in the resident population in neighborhoods can be explained by the sociodemographic and economic heterogeneity. Our findings recommend that public policies and tuberculosis control strategies consider differences in the determinants of tuberculosis inequality for the development of specific actions for each population group.

Neo-Marxian social class inequalities in oral health among the South Korean population

AIM

The aims of this study were to examine inequalities in periodontitis and tooth loss among South Korean adults using the Wright's Neo-Marxian social class (NMSC) indicator and to assess the impact of material, psychosocial, health behavioural and workplace environmental factors in the association of social class with oral health.

METHODS

This study used the data from the 4th Korea National Health and Nutrition Examination Survey with 6710 participants aged 19-54 years old. Participants were classified into 12 social class positions based on the Wright's social class map. Healthy gum and absence of tooth loss were the health outcomes. Mediating factors were material (M), psychosocial (PS), health behavioural (HB) and workplace environmental (WPE) factors. A series of logistic regressions were performed to analyse the data. Odds ratio (OR) and 95% confidence interval (CI) were used to report the results.

RESULTS

For the absence of periodontal pockets status, expert supervisors were the healthiest periodontal group among the social classes (OR = 2.15 95% CI 1.59-2.90) in the age and gender adjusted model. For the absence of tooth loss, skilled workers had the highest OR for absence of tooth loss (OR = 1.64 95% CI 1.31-2.05) in the age- and gender-adjusted model. For absence of periodontal pockets, the explanatory power of the M factor was the highest in all social class positions except for nonskilled supervisors followed by the HB factor. Additionally, the absence of tooth loss had a fairly similar pattern. The explanatory power of the M factor was the highest in all social class positions except for the petty bourgeoisie (highest: HB) and nonskilled supervisors (highest: WPE) followed by the HB and WPE factors.

CONCLUSION

There were nongradient oral health inequalities among the South Korean population according to the NMSC. Oral health promotion programmes that focus on changing the socioeconomic environment and health behaviours should be implemented.

A Typology for Charting Socioeconomic Mortality Gradients: "Go Southwest"

BACKGROUND

Holistic depiction of time-trends in average mortality rates, and absolute and relative inequalities, is challenging.

METHODS

We outline a typology for situations with falling average mortality rates (m↓; e.g., cardiovascular disease), rates stable over time (m-; e.g., some cancers), and increasing average mortality rates (m↑; e.g., suicide in some contexts). If we consider inequality trends on both the absolute (a) and relative (r) scales, there are 13 possible combination of m, a, and r trends over time. They can be mapped to graphs with relative inequality (log relative index of inequality [RII]; r) on the y axis, log average mortality rate on the x axis (m), and absolute inequality (slope index of inequality; SII; a) as contour lines. We illustrate this by plotting adult mortality trends: (1) by household income from 1981 to 2011 for New Zealand, and (2) by education for European countries.

RESULTS

Types range from the "best" m↓a↓r↓ (average, absolute, and relative inequalities all decreasing; southwest movement in graphs) to the "worst" m↑a↑r↑ (northeast). Mortality typologies in New Zealand (all-cause, cardiovascular disease, nonlung cancer, and unintentional injury) were all m↓r↑ (northwest), but variable with respect to absolute inequality. Most European typologies were m↓r↑ types (northwest; e.g., Finland), but with notable exceptions of m-a↑r↑ (north; e.g., Hungary) and "best" or southwest m↓a↓r↓ for Spain (Barcelona) females.

CONCLUSIONS

Our typology and corresponding graphs provide a convenient way to summarize and understand past trends in inequalities in mortality, and hold potential for projecting future trends and target setting.

Interventions to enhance the adoption of asthma self-management behaviour in the South Asian and African American population: a systematic review

South Asian and other minority communities suffer poorer asthma outcomes, have a higher rate of unscheduled care and benefit less from most existing self-management interventions when compared to the majority population. Possible reasons for these differences include failure to implement asthma self-management strategies, or that strategies implemented were inappropriate for their needs; alternatively, they may relate to the minority and/or lower socioeconomic status of these populations. We aimed to synthesise evidence from randomised controlled trials for asthma self-management in South Asian and Black populations from different sociocultural contexts, and identify barriers and facilitators to implementing self-management. We systematically searched eight electronic databases, and research registers, and manually searched relevant journals and reference lists of reviews. Seventeen trials met the inclusion criteria and were analysed narratively. We found two culturally targeted interventions compared to fifteen culturally modified interventions. Interventions used diverse self-management strategies; education formed a central component. Interventions in South Asian and African-American minority communities were less effective than interventions delivered in indigenous populations in South Asia, though the latter trials were at higher risk of bias. Education, with continuous professional support, was common to most interventions. Facilitators to asthma self-management included: ensuring culturally/linguistically appropriate education, adapting to learning styles, addressing daily stressors/social support and generic self-management strategies. In conclusion, when developing and evaluating self-management interventions aimed at different cultures, the influence of sociocultural contexts (including whether patients are from a minority or indigenous population) can be important for the conceptualisation of culture and customisation of self-management strategies.

Health in All Policies in South Australia-Did It Promote and Enact an Equity Perspective?

Mobilising cross-sectoral action is helpful in addressing the range of social determinants that contribute to health inequities. The South Australian Health in All Policies (SA HiAP) approach was implemented from 2007 to stimulate cross-sector policy activity to address the social determinants of health to improve population wellbeing and reduce health inequities. This paper presents selected findings from a five year multi-methods research study of the SA HiAP approach and draws on data collected during interviews, observation, case studies, and document analysis. The analysis shows that SA HiAP had dual goals of facilitating joined-up government for co-benefits (process focus); and addressing social determinants of health and inequities through cross-sectoral policy activity (outcomes focus). Government agencies readily understood HiAP as providing tools for improving the process of intersectoral policy development, while the more distal outcome-focused intent of improving equity was not well understood and gained less traction. While some early rhetorical support existed for progressing an equity agenda through SA HiAP, subsequent economic pressures resulted in the government narrowing its priorities to economic goals. The paper concludes that SA HiAP’s initial intentions to address equity were only partially enacted and little was done to reduce inequities. Emerging opportunities in SA, and internationally, including the UN Sustainable Development Goals, may revive interest in addressing equity.

How do trends in mortality inequalities by deprivation and education in Scotland and England & Wales compare? A repeat cross-sectional study

OBJECTIVE

To compare the trends in mortality inequalities by educational attainment with trends using area deprivation.

SETTING

Scotland and England & Wales (E&W).

PARTICIPANTS

All people resident in Scotland and E&W between 1981 and 2011 aged 35-79 years.

PRIMARY OUTCOME MEASURES

Absolute inequalities (measured using the Slope Index of Inequality (SII)) and relative inequalities (measured using the Relative Index of Inequality (RII)) in all-cause mortality.

RESULTS

Relative inequalities in mortality by area deprivation have consistently increased for men and women in Scotland and E&W between 1981-1983 and 2010-2012. Absolute inequalities increased for men and women in Scotland, and for women in E&W, between 1981-1983 and 2000-2002 before subsequently falling. For men in E&W, absolute inequalities were more stable until 2000-2002 before a subsequent decline. Both absolute and relative inequalities were consistently higher in men and in Scotland. These trends contrast markedly with the reported declines in mortality inequalities by educational attainment and apparent improvement of Scotland's inequalities with those in E&W.

CONCLUSIONS

Trends in health inequalities differ when assessed using different measures of socioeconomic status, reflecting either genuinely variable trends in relation to different aspects of social stratification or varying error or bias. There are particular issues with the educational attainment data in Great Britain prior to 2001 that make these education-based estimates less certain.

Explaining changes in child health inequality in the run up to the 2015 Millennium Development Goals (MDGs): The case of Zambia

Background

Child health interventions were drastically scaled up in the period leading up to 2015 as countries aimed at meeting the 2015 target of the Millennium Development Goals (MDGs). MDGs were defined in terms of achieving improvements in average health. Significant improvements in average child health are documented, but evidence also points to rising inequality. It is important to investigate factors that drive the increasing disparities in order to inform the post-2015 development agenda of reducing inequality, as captured in the Sustainable Development Goals (SDGs). We investigated changes in socioeconomic inequality in stunting and fever in Zambia in 2007 and 2014. Unlike the huge literature that seeks to quantify the contribution of different determinants on the observed inequality at any given time, we quantify determinants of changes in inequality.

Methods

Data from the 2007 and 2014 waves of the Zambia Demographic and Health Survey (DHS) were utilized. Our sample consisted of children aged 0–5 years (n = 5,616 in 2007 and n = 12,714 in 2014). We employed multilevel models to assess the determinants of stunting and fever, which are two important child health indicators. The concentration index (CI) was used to measure the magnitude of inequality. Changes in inequality of stunting and fever were investigated using Oaxaca-type decomposition of the CI. In this approach, the change in the CI for stunting/fever is decomposed into changes in CI for each determinant and changes in the effect—measured as an elasticity—of each determinant on stunting/fever.

Results

While average rates of stunting reduced in 2014 socioeconomic inequality in stunting increased significantly. Inequality in fever incidence also increased significantly, but average rates of fever did not reduce.

The increase in the inequality (CI) of determinants accounted for the largest part (42.5%) of the increase in inequality of stunting, while the increase in the effect of determinants explained 35% of the increase. The determinants with the greatest total contribution (change in CI plus change in effect) to the increase in inequality of stunting were mother’s height and weight, wealth, birth order, facility delivery, duration of breastfeeding, and maternal education.

For fever, almost all (86%) the increase in inequality was accounted for by the increase in the effect of determinants of fever, while the distribution of determinants mattered less. The determinants with the greatest total contribution to the increase in inequality of fever were wealth, maternal education, birth order and breastfeeding duration.

In the multilevel model, we found that the likelihood of a child being stunted or experiencing fever depends on the community in which they live.

Conclusions

To curb the increase in inequality of stunting and fever, policy may focus on improving levels of, and reducing inequality in, access to facility deliveries, maternal nutrition (which may be related to maternal weight and height), complementary feeding (for breastfed children), wealth, maternal education, and child care (related to birth order effects). Improving overall levels of these determinants contribute to the persistence of inequality if these determinants are unequally concentrated on the well off to begin with.

Equity in healthcare resource allocation decision making: A systematic review

OBJECTIVE

To identify elements of endorsed definitions of equity in healthcare and classify domains of these definitions so that policy makers, managers, clinicians, and politicians can form an operational definition of equity that reflects the values and preferences of the society they serve.

DESIGN

Systematic review where verbatim text describing explicit and implicit definitions of equity were extracted and subjected to a thematic analysis.

DATA SOURCES

The full holdings of the AMED, CINAHL plus, OVID Medline, Scopus, PsychInfo and ProQuest (ProQuest Health & Medical Complete, ProQuest Nursing and Allied Health Source, ProQuest Social Science Journals) were individually searched in April 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they provided an original, explicit or implicit definition of equity in regards to healthcare resource allocation decision making. Papers that only cited earlier definitions of equity and provided no new information or extensions to this definition were excluded.

RESULTS

The search strategy yielded 74 papers appropriate for this review; 60 of these provided an explicit definition of equity, with a further 14 papers discussing implicit elements of equity that the authors endorsed in regards to healthcare resource allocation decision making. FIVE KEY THEMES EMERGED: i) Equalisation across the health service supply/access/outcome chain, ii) Need or potential to benefit, iii) Groupings of equalisation, iv) Caveats to equalisation, and v) Close enough is good enough.

CONCLUSIONS

There is great inconsistency in definitions of equity endorsed by different authors. Operational definitions of equity need to be more explicit in addressing these five thematic areas before they can be directly applied to healthcare resource allocation decisions.

Disparities in precarious workers' health care access in South Korea

BACKGROUND

This study explored whether precarious workers have difficulties in health care access as compared with non-precarious workers.

METHODS

The 2008 Korean Community Health Survey data were used for this study. Information was obtained on 51,322 participants (40,514 non-precarious workers and 10,808 precarious workers). Precarious workers were defined as part-time or contingent workers.

RESULTS

Precarious workers had significantly higher risk of limited access to hospitals (OR = 1.14; 95% CI: 1.06-1.22) and dentists (OR = 1.28; 95% CI: 1.21-1.36) than non-precarious workers; disparities in doctor contacts among precarious workers were mostly linked to not having enough money. The risk of not receiving preventive care-medical checkups (OR = 0.52; 95% CI: 0.49-0.55) or cancer screenings (OR = 0.82; 95% CI: 0.77-0.86)-was also significantly elevated among precarious workers.

CONCLUSION

We found that precarious workers had more difficulty accessing health care or receiving health checkups or cancer screenings than their non-precarious counterparts. Am. J. Ind. Med. 59:1136-1144, 2016. © 2016 Wiley Periodicals, Inc.

Revitalising the evidence base for public health: an assets model

Historically, approaches to the promotion of population health have been based on a deficit model. That is, they tend to focus on identifying the problems and needs of populations that require professional resources and high levels of dependence on hospital and welfare services. These deficit models are important and necessary to identify levels of needs and priorities. But they need to be complemented by some other perspectives as they have some drawbacks. Deficit models tend to define communities and individuals in negative terms, disregarding what is positive and works well in particular populations. In contrast `assets' models tend to accentuate positive capability to identify problems and activate solutions. They focus on promoting salutogenic resources that promote the self esteem and coping abilities of individuals and communities, eventually leading to less dependency on professional services.

Much of the evidence available to policy makers to inform decisions about the most effective approaches to promoting health and to tackling health inequities is based on a deficit model and this may disproportionately lead to policies and practices which disempower the populations and communities who are supposed to benefit from them. An assets approach to health and development embraces a `salutogenic' notion of health creation and in doing so encourages the full participation of local communities in the health development process.

The asset model presented here aims to revitalise how policy makers, researchers and practitioners think and act to promote a more resourceful approach to tackling health inequities. The model outlines a systematic approach to asset based public health which can provide scientific evidence and best practice on how to maximise the stock of key assets necessary for promoting health. Redressing the balance between the assets and deficit models for evidence based public health could help us to unlock some of the existing barriers to effective action on health inequities. This re-balancing would help in better understanding the factors that influence health and what can be done about them. It would promote a positive and inclusive approach to action. (Promotion & Education, 2007, Supplement (2): pp 17-22).

The impact of increasing income inequalities on educational inequalities in mortality - An analysis of six European countries

Background

Over the past decades, both health inequalities and income inequalities have been increasing in many European countries, but it is unknown whether and how these trends are related. We test the hypothesis that trends in health inequalities and trends in income inequalities are related, i.e. that countries with a stronger increase in income inequalities have also experienced a stronger increase in health inequalities.

Methods

We collected trend data on all-cause and cause-specific mortality, as well as on the household income of people aged 35–79, for Belgium, Denmark, England & Wales, France, Slovenia, and Switzerland. We calculated absolute and relative differences in mortality and income between low- and high-educated people for several time points in the 1990s and 2000s. We used fixed-effects panel regression models to see if changes in income inequality predicted changes in mortality inequality.

Results

The general trend in income inequality between high- and low-educated people in the six countries is increasing, while the mortality differences between educational groups show diverse trends, with absolute differences mostly decreasing and relative differences increasing in some countries but not in others. We found no association between trends in income inequalities and trends in inequalities in all-cause mortality, and trends in mortality inequalities did not improve when adjusted for rising income inequalities. This result held for absolute as well as for relative inequalities. A cause-specific analysis revealed some association between income inequality and mortality inequality for deaths from external causes, and to some extent also from cardiovascular diseases, but without statistical significance.

Conclusions

We find no support for the hypothesis that increasing income inequality explains increasing health inequalities. Possible explanations are that other factors are more important mediators of the effect of education on health, or more simply that income is not an important determinant of mortality in this European context of high-income countries. This study contributes to the discussion on income inequality as entry point to tackle health inequalities. More research is needed to test the common and plausible assumption that increasing income inequality leads to more health inequality, and that one needs to act against the former to avoid the latter.

Electronic supplementary material

The online version of this article (doi:10.1186/s12939-016-0390-0) contains supplementary material, which is available to authorized users.

Nutritional Status of Adults among Munda and Pod Populations in a Peri Urban Area of Kolkata City, India

A cross sectional study on 387 Munda and 317 Pod adult males and females was conducted in the peri urban region of Kolkata city, India, to assess their health status. Chronic Energy Deficiency (CED) was calculated from the Body Mass Index (BMI) and seven anthropometric measurements were considered for this study. Significantly higher CED was observed among the Munda males and females. Higher percentage of CED was noticed among the females than the male Munda. Linear regression coefficient (b +/- standard error) of BMI on age and anthropometric measurements revealed significant decrease in BMI with increase in age among Munda males and females as well as Pod females. All other measurements more or less increased with increase in BMI. Thus, both intra- and inter-ethnic health differences were observed between and among the two socioeconomically backward populations. Higher gender differentials were found among the Munda and this needs an immediate attention of the government to overcome the health inequality at regional level.