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

Characteristics associated with SARS-CoV-2 testing, infection and vaccine uptake among essential non-healthcare workers in Montréal, 2021

Background

Essential non-healthcare workers experienced higher rates of SARS-CoV-2 infection compared to non-essential workers.

Objective

Identify characteristics associated with SARS-CoV-2 testing, infection and vaccine uptake among essential non-healthcare workers in Montréal, Québec.

Methods

Secondary, cross-sectional analysis of data collected from participants prospectively recruited in two observational studies (first study, Onsite Testing Study, January-March 2021; second study, Self-Testing Study, July-October 2021) of essential non-healthcare workers in 2021. Logistic regression with generalized linear mixed models was used to explore characteristics associated with our outcomes (previous SARS-CoV-2 testing, exposure and vaccination).

Results

Overall, 2,755 participants were included (first study, Onsite Testing Study, n=2,128; and second study, Self-Testing Study, n=627). A higher proportion of participants identified as male (n=1,601; 58%), non-White (n=1,527; 55%) and worked in the manufacturing/supplier sector (n=1,706; 62%). Relative to the first study, Onsite Testing Study, participants in the second study, Self-Testing Study, had higher odds (78% vs. 46%; aOR 4.1, 95% CI: 3.2-5.2) of previous SARS-CoV-2 testing and of testing positive prior to study enrolment (6.2% vs. 4.3%; aOR 1.7, 95% CI: 1.1-2.6). Individuals reporting recent SARS-CoV-2 exposure had higher odds of previous SARS-CoV-2 testing (aOR 4.0, 95% CI: 3.0-5.4), while older age (aOR 0.98, 95% CI: 0.98-0.99 per one-year increase) and being male (aOR 0.6, 95% CI: 0.5-0.7) were associated with lower odds of previous testing. Results were similar in stratified analyses. Participants from businesses with more than 50 employees had higher odds of having received a SARS-CoV-2 vaccine (91% vs. 80%; aOR 2.6, 95% CI: 1.4-4.8).

Conclusion

Consideration of individual and business characteristics associated with testing and vaccination programs for SARS-CoV-2 could improve equity, uptake and impact.

Practice- and System-Based Interventions to Reduce COVID-19 Transmission in Primary Care Settings: A Qualitative Study

Using qualitative interviews with 68 family physicians (FPs) in Canada, we describe practice- and system-based approaches that were used to mitigate COVID-19 exposure in primary care settings across Canada to ensure the continuation of primary care delivery. Participants described how they applied infection prevention and control procedures (risk assessment, hand hygiene, control of environment, administrative control, personal protective equipment) and relied on centralized services that directed patients with COVID-19 to settings outside of primary care, such as testing centres. The multi-layered approach mitigated the risk of COVID-19 exposure while also conserving resources, preserving capacity and supporting supply chains.

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

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

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

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

"It felt like building a plane while in flight": the consideration of social inequalities in the design and planning of a contact-tracing intervention for COVID-19 in Montreal, Quebec

OBJECTIVE

In Canada and globally, the COVID-19 pandemic has increased social inequalities in health (SIH), furthering the vulnerability of certain groups and communities. Contact-tracing is a cornerstone intervention with COVID-19 prevention and control programs. The aim of this study was to describe whether and how SIH were considered during the design of the COVID-19 contact-tracing intervention in Montreal.

METHODS

This study is part of the multi-country research program HoSPiCOVID, looking at the resilience of public health systems during the COVID-19 pandemic. A descriptive qualitative study was carried out in Montreal, based on a "bricolage" conceptual framework describing the consideration for SIH in intervention and policy design. Qualitative data were collected using semi-structured interviews with 16 public health practitioners, recruited using both purposive and snowball sampling. Data were analyzed thematically, both inductively and deductively.

RESULTS

According to participants, SIH were not initially considered during the design of the contract-tracing intervention in Montreal. The participants were frustrated by the Minister of Health's initial resistance to integrating SIH into their public health response. However, adaptations were gradually made to better meet the needs of underserved populations.

CONCLUSION

There is a need for a clear and common vision of SIH within the public health system. Decision-makers need to consider SIH prior to designing public health interventions in order for these not to further increase SIH in the future, especially in the face of a health crisis.

Challenges and Limitations in Distributional Cost-Effectiveness Analysis: A Systematic Literature Review

BACKGROUND

Cost-effectiveness is a tool to maximize health benefits and to improve efficiency in healthcare. However, efficient outcomes are not always the most equitable ones. Distributional cost-effectiveness analysis (DCEA) offers a framework for incorporating equity concerns into cost-effectiveness analysis.

OBJECTIVE

This systematic review aims to outline the challenges and limitations in applying DCEA in healthcare settings.

METHODS

We searched Medline, Scopus, BASE, APA Psych, and JSTOR databases. We also included Google Scholar. We searched for English-language peer-reviewed academic publications, while books, editorials and commentary papers were excluded. Titles and abstract screening, full-text screening, reference list reviews, and data extraction were performed by the main researcher. Another researcher checked every paper for eligibility. Details, such as study population, disease area, intervention and comparators, costs and health effects, cost-effectiveness findings, equity analysis and effects, and modelling technique, were extracted. Thematic analysis was applied, focusing on challenges, obstacles, and gaps in DCEA.

RESULTS

In total, 615 references were identified, of which 18 studies met the inclusion criteria. Most of these studies were published after 2017. DCEA studies were mainly conducted in Europe and Africa and used quality health-adjusted measurements. In the included studies, absolute inequality indices were used more frequently than relative inequality indices. Every stage of the DCEA presented challenges and/or limitations.

CONCLUSION

This review provides an overview of the literature on the DCEA in healthcare as well as the challenges and limitations related to the different steps needed to conduct the analysis. In particular, we found problems with data availability, the relative unfamiliarity of this analysis among policymakers, and challenges in estimating differences among socioeconomic groups.