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Caldwell HA, Yusuf J, Carrea C, Conrad P, Embrett M, Fierlbeck K, Hajizadeh M, Kirk SF, Rothfus M, Sampalli T, Sim SM, Tomblin Murphy G, Williams L. Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review. JBI Evid Synth 2024; 22:949-1070. [PMID: 38632975 PMCID: PMC11163892 DOI: 10.11124/jbies-23-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity. INTRODUCTION To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system. INCLUSION CRITERIA This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies). METHODS This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format. RESULTS Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems. CONCLUSIONS Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally. REVIEW REGISTRATION DalSpace dalspace.library.dal.ca/handle/10222/80835.
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Affiliation(s)
- Hilary A.T. Caldwell
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Joshua Yusuf
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Cecilia Carrea
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Patricia Conrad
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | | | - Katherine Fierlbeck
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- MacEachen Institute for Public Policy and Governance, Dalhousie University, Halifax, NS, Canada
- Dalhousie Libraries, Dalhousie University, Halifax, NS, Canada
| | - Mohammad Hajizadeh
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Sara F.L. Kirk
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
| | - Melissa Rothfus
- Department of Political Science, Dalhousie University, Halifax, NS, Canada
| | | | - Sarah Meaghan Sim
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
- Nova Scotia Health, Halifax, NS, Canada
| | | | - Lane Williams
- Healthy Populations Institute, Dalhousie University, Halifax, NS, Canada
- Faculty of Health, Dalhousie University, Halifax, NS, Canada
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Gkiouleka A, Wong G, Sowden S, Kuhn I, Moseley A, Manji S, Harmston RR, Siersbaek R, Bambra C, Ford JA. Reducing health inequalities through general practice: a realist review and action framework. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-104. [PMID: 38551093 DOI: 10.3310/ytww7032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Background Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities. Objectives We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice. Design Realist review. Main outcome measures Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. Review methods Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. Results Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships. Limitations The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care. Conclusions Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred. Future work Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice. Study registration This trial is registered as PROSPERO CRD42020217871. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Anna Gkiouleka
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences and Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Isla Kuhn
- University of Cambridge Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annie Moseley
- Patient and Public Involvement Representative, Norwich, UK
| | - Sukaina Manji
- Department of Educational Research, Lancaster University, Lancaster, UK
| | | | - Rikke Siersbaek
- Health System Foundations for Sláintecare Implementation, Centre for Health Policy and Management, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John A Ford
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Bishop E, Allington D, Ringrose T, Martin C, Aldea A, García-Jaramillo M, León-Vargas F, Leal Y, Henao D, Gómez AM. Design and Usability of an Avatar-Based Learning Program to Support Diabetes Education: Quality Improvement Study in Colombia. J Diabetes Sci Technol 2023; 17:1142-1153. [PMID: 36377096 PMCID: PMC10563524 DOI: 10.1177/19322968221136141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND This quality improvement study, entitled Avatar-Based LEarning for Diabetes Optimal Control (ABLEDOC), explored the feasibility of delivering an educational program to people with diabetes in Colombia. The aim was to discover how this approach could be used to improve awareness and understanding of the condition, the effects of treatment, and strategies for effective management of blood-glucose control. METHODS Individuals with diabetes were recruited by Colombian endocrinologists to a human-centered study to codesign the educational program, using the Double Diamond model. Participants contributed to two phases. The first phase focused on gathering unmet educational needs and choice of curriculum. Three prototypes were developed as a result. During phase 2, a different group of participants engaged with the program for several weeks, before reporting back. RESULTS Thirty-six participants completed a Web survey during phase 1, and five were also interviewed by telephone. The majority (33 of 36; 91%) were receptive to the prospect of educational interventions and ranked the chosen topic of hypoglycemia highly. In phase 2, the three prototypes were tested by 17 participants, 10 of whom also gave feedback in focus groups. The response was overwhelmingly positive, with 16 of 17 (94%) stating they would use a program like this again. The 3D version was the most highly rated. CONCLUSIONS Immersive, avatar-based programs, delivered through smartphone, have the potential to deliver educational information that is trusted, engaging, and useful. Future work includes expansion of the curriculum, evaluation with a larger group, and exploration of the prospective role of artificial intelligence in personalizing this form of educational intervention.
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Affiliation(s)
| | | | | | - Clare Martin
- Faculty of Technology, Design and
Environment, Oxford Brookes University, Oxford, UK
| | - Arantza Aldea
- Faculty of Technology, Design and
Environment, Oxford Brookes University, Oxford, UK
| | | | - Fabian León-Vargas
- Faculty of Mechanical, Electronic and
Biomedical Engineering, Universidad Antonio Nariño, Bogotá, Colombia
| | - Yenny Leal
- Institut d’Investigació Biomèdica de
Girona Dr. Josep Trueta, Girona, Spain
| | - Diana Henao
- Endocrinology Unit, Hospital
Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Ana Maria Gómez
- Endocrinology Unit, Hospital
Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá, Colombia
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Gkiouleka A, Wong G, Sowden S, Bambra C, Siersbaek R, Manji S, Moseley A, Harmston R, Kuhn I, Ford J. Reducing health inequalities through general practice. Lancet Public Health 2023; 8:e463-e472. [PMID: 37244675 DOI: 10.1016/s2468-2667(23)00093-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 05/29/2023]
Abstract
Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice.
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Affiliation(s)
- Anna Gkiouleka
- Department of Public Health and Primary Care, Cambridge, UK
| | - Geoff Wong
- University of Cambridge, Cambridge, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Sukaina Manji
- Department of Educational Research, Lancaster University, Lancaster, UK
| | | | | | - Isla Kuhn
- University of Cambridge Medical Library, School of Clinical Medicine, Cambridge, UK
| | - John Ford
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
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Molló À, Vlacho B, Gratacòs M, Mata-Cases M, Rubinat E, Berenguera A, Real J, Puig-Treserra R, Cos X, Franch-Nadal J, Khunti K, Mauricio D. Impact of a multicomponent healthcare intervention on glycaemic control in subjects with poorly controlled type 2 diabetes: The INTEGRA study. Diabetes Obes Metab 2023; 25:1045-1055. [PMID: 36546592 DOI: 10.1111/dom.14951] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/06/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
AIM To evaluate whether a specially designed multicomponent healthcare intervention improves glycaemic control in subjects with poorly controlled type 2 diabetes. MATERIALS AND METHODS A cluster, non-randomized, controlled, pragmatic trial in subjects from 11 primary care centres with type 2 diabetes and HbA1c of more than 9% (> 75 mmol/mol) was conducted. The intervention (N = 225 subjects) was professional and patient-centred, including a dedicated monographic visit that encouraged therapeutic intensification by physicians. The sham control (N = 181) was identical to that of the intervention group except that the dedicated visit was omitted. The primary outcome was to compare the reductions in HbA1c values between the groups at 12 months of follow-up. RESULTS The mean age at baseline was 59.5 years, mean diabetes duration was 10.7 years and mean HbA1c was 10.3% (89.0 mmol/mol). Patients in the intervention arm achieved significantly greater HbA1c reduction than those in the sham control group at 12 months (mean difference -0.62%, 95% CI = -0.2%, -1.04%; P = .002). A larger percentage of intervention participants achieved an HbA1c of less than 8% (44.8% vs. 25.5%; P = .003) and were more frequently treated with more than three antidiabetic therapies (14.4% vs. 3.5%; P = .0008). Intervention was the only variable associated with higher odds of HbA1c less than 8% (odds ratio = 2.52; 95% CI = 1.54-4.12; P < .001). CONCLUSIONS A multicomponent intervention including a dedicated visit oriented at reducing therapeutic inertia by primary care physicians can improve glycaemic control in poorly controlled patients with type 2 diabetes.
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Affiliation(s)
- Àngels Molló
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Bogdan Vlacho
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Pharmacology Department, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
| | - Mònica Gratacòs
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Manel Mata-Cases
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Esther Rubinat
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Health Care Research Group (GRECS), Lleida Institute for Biomedical Research Dr. Pifarré Foundation IRB Lleida, University of Lleida, Lleida, Spain
- Department of Nursing and Physiotherapy, Serra Hunter Lecturer, University of Lleida, Lleida, Spain
- Society, Health, Education and Culture Research Group (GESEC) of the University of Lleida, Lleida, Spain
| | - Anna Berenguera
- Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Departament d'Infermeria, Universitat de Girona, Girona, Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Jordi Real
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Ramon Puig-Treserra
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
| | - Xavier Cos
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- Innovation office at Institut Català de la Salut, Barcelona, Spain
| | - Josep Franch-Nadal
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Dídac Mauricio
- DAP-Cat group, Unitat de Suport a la Recerca Barcelona, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain
- CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital Universitari de la Santa Creu i Sant Pau, IIB Sant Pau, Barcelona, Spain
- Departament of Medicine, University of Vic-Central University of Catalonia, Vic, Spain
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Mentis AFA, Chrousos GP. BMC Endocrine Disorders' collection of articles on "Reducing inequalities in the Management of Endocrine Disorders". BMC Endocr Disord 2022; 22:96. [PMID: 35410156 PMCID: PMC8996643 DOI: 10.1186/s12902-022-00998-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Endocrine disorders represent a large component of the so-called "chronic non-communicable diseases", which are responsible for the lion share of morbidity and mortality in contemporary societies. As discussed in this retrospective collection of articles, solid evidence from diabetes mellitus, the exemplar of common chronic endocrine disorders, highlights profound inequity in all aspects of endocrine disorders' management and outcomes that should be considered and addressed at large.
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Affiliation(s)
- Alexios-Fotios A Mentis
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
- UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Athens, Greece
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece.
- UNESCO Chair on Adolescent Health Care, National and Kapodistrian University of Athens, Athens, Greece.
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Tapager I, Olsen KR, Vrangbæk K. Exploring equity in accessing diabetes management treatment: A healthcare gap analysis. Soc Sci Med 2021; 292:114550. [PMID: 34837828 DOI: 10.1016/j.socscimed.2021.114550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 12/21/2022]
Abstract
Healthcare inequities are often investigated empirically as associations between socio-economic characteristics and differences between observed healthcare utilisation and estimates of needs-based utilisation. However, the concept of 'need' is tricky to operationalise and utilisation may be contingent on inequities arising at an earlier stage. In this study, we apply a unique combination of register and survey data collected in 2019 to assess equity in opportunities to access treatment for patients with recently diagnosed type 2 diabetes. In the study of this population (N = 1864) we escape the challenge of estimating needs by arguing that need can be approximated from treatment guidelines within a nationwide framework of disease management programmes. Furthermore, instead of observed utilisation we use patient reports on whether they have been offered treatment as a measure of opportunities to access multiple components of care, that is, we focus on possible inequalities arising prior to possible utilisation inequalities. 'Healthcare gaps' are computed as the discrepancy between an index of guideline recommended treatments and patients' perceived offers of treatments, thus providing a novel take on the 'healthcare deprivation profiles' approach to the study of healthcare inequalities. Using this method, we explore and document inequalities along multiple dimensions of familiar socio-economic factors (income, education, occupation) as well as self-reported barriers to access. We also provide supporting evidence that healthcare gaps, as measured in our study, are associated with poorer quality of care, and that those who experience large gaps are more likely to be disadvantaged in terms of self-reported difficulties in relation to key self-care aspects. We conclude that even in a health system with comprehensive universal coverage, healthcare inequity can arise already at the stage of offering access to preventive treatment. The results warrant further research into the causes, consequences and remedies of such inequities.
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Affiliation(s)
- Ina Tapager
- Department of Public Health, University of Copenhagen Øster Farimagsgade 5, 1014, København K, Denmark.
| | - Kim Rose Olsen
- DaCHE, Department of Public Health, University of Southern Denmark JB Winsløws Vej 9, 5000, Odense, Denmark.
| | - Karsten Vrangbæk
- Department of Public Health, University of Copenhagen Øster Farimagsgade 5, 1014, København K, Denmark; Department of Political Science, University of Copenhagen, Øster Farimagsgade 5, 1014, København K, Denmark.
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Ginnard OZ, Alonso GT, Corathers SD, Demeterco-Berggren C, Golden LH, Miyazaki BT, Nelson G, Ospelt E, Ebekozien O, Lee JM, Obrynba KS, DeSalvo DJ. Quality Improvement in Diabetes Care: A Review of Initiatives and Outcomes in the T1D Exchange Quality Improvement Collaborative. Clin Diabetes 2021; 39:256-263. [PMID: 34421200 PMCID: PMC8329011 DOI: 10.2337/cd21-0029] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care.
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Affiliation(s)
| | - G. Todd Alonso
- Barbara Davis Center, University of Colorado, Aurora, CO
| | - Sarah D. Corathers
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | | | | | | | | | - Joyce M. Lee
- Pediatric Endocrinology, University of Michigan, Ann Arbor, MI
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Ford JA, Gkiouleka A, Kuhn I, Sowden S, Head F, Siersbaek R, Bambra C, Harmston RR, Manji S, Moseley A, Wong G. Reducing health inequalities through general practice: protocol for a realist review (EQUALISE). BMJ Open 2021; 11:e052746. [PMID: 34130967 PMCID: PMC8208022 DOI: 10.1136/bmjopen-2021-052746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/13/2021] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Healthcare organisations recognise the moral imperative to address inequalities in health outcomes but often lack an understanding of which types of interventions are likely to reduce them. This realist review will examine the existing evidence on the types of interventions or aspects of routine care in general practice that are likely to decrease or increase health inequalities (ie, inequality-generating interventions) across cardiovascular disease, cancer, diabetes and chronic obstructive pulmonary disease. METHODS AND ANALYSIS Our realist review will follow Pawson's five iterative stages. We will start by developing an initial programme theory based on existing theories and discussions with stakeholders. To navigate the large volume of literature, we will access the primary studies through the identification of published systematic reviews of interventions delivered in general practice across the four key conditions. We will examine the primary studies included within each systematic review to identify those reporting on inequalities across PROGRESS-Plus categories. We will collect data on a range of clinical outcomes including prevention, diagnosis, follow-up and treatment. The data will be synthesised using a realist logic of analysis. The findings will be a description and explanation of the general practice interventions which are likely to increase or decrease inequalities across the major conditions. ETHICS AND DISSEMINATION Ethics approval is not required because this study does not include any primary research. The findings will be integrated into a series of guiding principles and a toolkit for healthcare organisations to reduce health inequalities. Findings will be disseminated through peer-reviewed publications, conference presentations and user-friendly summaries. PROSPERO REGISTRATION NUMBER CRD42020217871.
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Affiliation(s)
- John Alexander Ford
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Anna Gkiouleka
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Sarah Sowden
- Institute Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Head
- NHS Cambridgeshire and Peterborough Clinical Commissioning Group, Cambridge, UK
| | | | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Sukaina Manji
- Patient and Public Involvement Representative, Peterborough, UK
| | - Annie Moseley
- Patient and Public Involvement Representative, Norwich, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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10
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Campbell RAS, Colhoun HM, Kennon B, McCrimmon RJ, Sattar N, McKnight J, Wild SH. Socio-economic status and mortality in people with type 1 diabetes in Scotland 2006-2015: a retrospective cohort study. Diabet Med 2020; 37:2081-2088. [PMID: 31967666 DOI: 10.1111/dme.14239] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 01/05/2023]
Abstract
AIMS To describe the association between socio-economic status and mortality in a nation-wide cohort of people with type 1 diabetes in Scotland and to compare patterns over time and with the general population. METHODS A retrospective cohort study was performed using data for people with type 1 diabetes from a population-based register linked to mortality records. Socio-economic status was derived from quintiles of an area-based measure: the Scottish Index of Multiple Deprivation. Sex-specific directly age-standardized mortality rates for each Scottish Index of Multiple Deprivation quintile and rate ratios comparing the most vs least deprived quintile were calculated for two time periods: 2006-2010 and 2011-2015. Data for the population without type 1 diabetes between 2011 and 2015 were available for comparison. RESULTS Data for 3802 deaths among 33 547 people with type 1 diabetes were available. The age-standardized mortality rate per 1000 person-years decreased over time (from 2006-2010 to 2011-2015) for men and women with type 1 diabetes: 24.8 to 20.2 and 22.5 to 17.6, respectively. Mortality in populations with and without type 1 diabetes was generally higher for men than women and was inversely associated with socio-economic status. Rate ratios for the most vs least deprived groups increased over time among people with type 1 diabetes (men: 2.49 to 2.81; women: 1.92 to 2.86) and were higher than among populations without type 1 diabetes in 2011-2015 (men: 2.06; women: 1.66). CONCLUSIONS Socio-economic deprivation was associated with a steeper mortality gradient in people with type 1 diabetes than in the population without type 1 diabetes in Scotland. Age-standardized mortality has decreased over time but socio-economic inequalities may be increasing.
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Affiliation(s)
| | - H M Colhoun
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
- Department of Public Health, NHS Fife, Kirkcaldy, UK
| | - B Kennon
- Department of Diabetes, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - R J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - N Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - J McKnight
- Metabolic Unit, Western General Hospital, Edinburgh, UK
| | - S H Wild
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
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11
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Silva-Tinoco R, Cuatecontzi-Xochitiotzi T, De la Torre-Saldaña V, León-García E, Serna-Alvarado J, Guzmán-Olvera E, Cabrera D, Gay JG, Prada D. Role of social and other determinants of health in the effect of a multicomponent integrated care strategy on type 2 diabetes mellitus. Int J Equity Health 2020; 19:75. [PMID: 32448267 PMCID: PMC7245830 DOI: 10.1186/s12939-020-01188-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 05/11/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although important advances in treatment strategies have been developed in type 2 diabetes mellitus (T2DM), large gaps exist in achieving glycemic control and preventing complications, particularly in low-and middle-income countries, which suggests a potential effect of social determinants of health (SDH, i.e., education level and socioeconomic status). However, few studies have determined the role of SDH and other determinants of health (ODH, i.e., diabetes knowledge and self-care scores) in achieving T2DM goals during effective multidisciplinary interventions. We aimed to examine a multicomponent integrated care (MIC) program on diabetes care goals and determine the effect of SDH and ODH on T2DM patients. METHODS A before-and-after design (a pretest, a 5-month intervention, and a follow-up) was used in a T2DM population from Mexico City. The SDH included education level and socioeconomic status; the ODH included diabetes knowledge, self-care scores, and deltas (i.e., differences between baseline and follow-up scores). The triple-target goal (glycated hemoglobin, blood pressure, and LDL-cholesterol) was established as a measurement of T2DM goals. RESULTS The DIABEMPIC (DIABetes EMPowerment and Improvement of Care) intervention (n = 498) reduced the glycated hemoglobin levels (mean reduction 2.65%, standard deviation [SD]: 2.02%) and cardiometabolic parameters; it also improved health-related quality of life. From 1.81% at baseline, 25.9% of participants (p-value< 0.001) achieved the triple-target goal. We found a significant association between education level (p-value = 0.010), diabetes knowledge at baseline (p-value = 0.004), and self-care scores at baseline (p-value = 0.033) in the delta (change between baseline and follow-up assessments) of HbA1c levels. Improvements (increase) in diabetes knowledge (p-value = 0.006) and self-care scores (p-value = 0.002) were also associated with greater reductions in HbA1c. CONCLUSIONS MIC strategies in urban primary care settings contribute to control of T2DM. SDH, such as education level, and ODH (diabetes knowledge and self-care scores at baseline) play a key role in improving glycemic control in these settings.
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Affiliation(s)
- Rubén Silva-Tinoco
- Clínica Especializada en el Manejo de la Diabetes de la Ciudad de México-Iztapalapa, Servicios de Salud Pública de la Ciudad de México, Iztapalapa, 09060, Mexico City, Mexico.
| | - Teresa Cuatecontzi-Xochitiotzi
- Clínica Especializada en el Manejo de la Diabetes de la Ciudad de México-Iztapalapa, Servicios de Salud Pública de la Ciudad de México, Iztapalapa, 09060, Mexico City, Mexico
| | - Viridiana De la Torre-Saldaña
- Clínica Especializada en el Manejo de la Diabetes de la Ciudad de México-Iztapalapa, Servicios de Salud Pública de la Ciudad de México, Iztapalapa, 09060, Mexico City, Mexico
| | - Enrique León-García
- Servicios de Salud Pública del Gobierno de la Ciudad de México, Mexico City, Mexico
| | | | - Eileen Guzmán-Olvera
- Servicios de Salud Pública del Gobierno de la Ciudad de México, Mexico City, Mexico
| | - Dolores Cabrera
- Servicios de Salud Pública del Gobierno de la Ciudad de México, Mexico City, Mexico
| | - Juan G Gay
- Tecnología e Información para la Salud, TIS, Mexico City, Mexico
| | - Diddier Prada
- Unidad de Investigación Biomédica en Cáncer, Instituto Nacional de Cancerología - Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, San Fernando 22, Colonia Sección XVI, Tlalpan, 14080, Mexico City, Mexico. .,Department of Biomedical Informatics, Faculty of Medicine, Universidad Nacional Autónoma de México, Av. Universidad 3000, Circuito Exterior S/N Delegación Coyoacán, 04510, Mexico City, Mexico. .,Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York City, 10032, USA.
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