Towards health equity: a framework for the application of proportionate universalism

Australian and Canadian financial wellbeing policy landscape during COVID-19: An equity-informed policy scan

Background

This targeted and comprehensive policy scan examined how different levels of governments in Australia and Canada responded to the financial crisis brought on by the COVID-19 pandemic. We mapped the types of early policy responses addressing financial strain and promoting financial wellbeing. We also examined their equity considerations.

Methods

Through a systematic search, snowballing, and manual search, we identified Canadian and Australian policies at all government levels related to financial strain or financial wellbeing enacted or amended in 2019-2020. Using a deductive-inductive approach, policies were categorized by jurisdiction level, focal areas, and target population groups.

Results

In total, 213 and 97 policies in Canada and Australia, respectively, were included. Comparisons between Canadian and Australian policies indicated a more diversified and equity-targeted policy landscape in Canada. In both countries, most policies focused on individual and family finances, followed by housing and employment areas.

Conclusions

The policy scan identified gaps and missed opportunities in the early policies related to financial strain and financial wellbeing. While fast, temporary actions addressed individuals' immediate needs, we recommend governments develop a longer-term action plan to tackle the root causes of financial strain and poor financial wellbeing for better health and non-health crisis preparedness.

Statement on Ethics and Informed Consent

This research reported in this paper did not require ethical clearance or patient informed consent as the data sources were published policy documents. This study did not involve data collection with humans (or animals), nor any secondary datasets involving data provided by humans (or from animal studies).

External Factors Influencing the Implementation of Policy, System, and Environmental Change Strategies Within Cooperative Extension

Introduction. Multilevel approaches are important to promote the adoption of healthier practices at the individual and community levels. Cooperative Extension pairs policy, systems, and environmental (PSE) change approaches with direct education programs focused on individual and community health. This study sought to understand Family and Consumer Sciences (FCS) Extension agents' perceptions of PSE change supports, benefits for their communities, and resources and partnerships important for implementation. Method. The Consolidated Framework for Implementation Research was used to develop a survey to assess outer setting domains related to PSE work. In addition to close-ended questions, the survey included several open-ended, qualitative questions exploring the benefits, resources, and relationships required to implement PSE changes. The surveys were collected online from FCS agents in two states. Descriptive statistics were calculated, open responses were coded, and key themes were established. Results. FCS agents (n=116) indicated high levels of agreement about having necessary support from state-level specialists (71%) and the overall Extension organization (64%). The largest gaps in support were reported as grant or external funding sources, time, and county programming funds. Half of the sample agreed that PSE training was adequate, but only 38.5% reported previously participating in PSE-specific training. Open-ended question responses revealed diverse relationships and numerous benefits of PSE work, including more sustainable health behavior changes and greater local Extension visibility. Discussion. Our findings corroborate previous work and identify potential gaps that future interventions can address to better support Extension and public health professionals when implementing PSE work at the community level.

Cardiac rehabilitation and secondary prevention of CVD: time to think about cardiovascular health rather than rehabilitation

During the past century, there have been major developments in the medical and surgical treatment of cardiovascular disease (CVD). These advancements have resulted in more people surviving initial events and having reduced length of stay in hospital; consequently, there is an increasing number of people in need of ongoing and lifelong cardiovascular risk management. The physical and emotional effects of living with CVD are ongoing with broad challenges ranging from the individual to system level. However, post-discharge care of people with coronary disease continues to follow a 50-year-old cardiac rehabilitation model which focuses on the sub-acute phase and is of a finite in duration. The aim of this paper is to consider the concept of supporting survivors to live well with CVD rather than 'rehabilitating' them and propose factors for consideration in reframing secondary prevention towards optimizing cardiovascular health. We discuss deeply-held potential considerations and challenges associated with the concept of supporting survivors achieve optimal cardiovascular health and live well with CVD rather than 'rehabilitating' them. We propose the concept of 5 x P's for reframing traditional cardiac rehabilitation towards the concept of cardiovascular health for survivors beyond 'rehabilitation'. These include the need for personalization, processes, patient-centered care, parlance, and partnership. Taken together, consideration of challenges at the systems and population level will ultimately improve engagement with secondary prevention as well as outcomes for all people who need it.

Tobacco retail availability and smoking-A systematic review and meta-analysis

ISSUES

Health policy makers worldwide have adopted evidence-based legislation, largely directed at consumers, to reduce tobacco-related harm. It is suggested that limiting supply by decreasing retail availability can also reduce cigarette smoking. To inform policy makers this systematic literature review assesses whether reducing availability is associated with smoking behaviours.

APPROACH

Systematic literature searches of five databases were carried out up to January 2023. Included studies had at least one exposure (tobacco retail density, proximity or mixed measures thereof) and outcomes of smoking behaviour. Meta-analysis of effect estimates were undertaken if there were at least three studies with similar population, exposure and outcome measures.

KEY FINDINGS

Sixty-two studies were included, and positive associations were found between tobacco outlet density and cigarette smoking in pregnancy, youth, adults and cessation. Meta-analyses were undertaken for retail density and ever smoking (odds ratio [OR] 1.20; 95% confidence interval [CI] 1.04, 1.37; I2 = 87.3%), and current youth smoking (OR 1.23; 95% CI 1.08, 1.40; I2 = 0.0%), adult smoking (OR 1.11; 95% CI 1.01, 1.22; I2 = 74.8%); and mixed measures of retail availability near schools and current youth smoking (OR 1.03; 95% CI 1.01, 1.05; I2 = 0.0%).

IMPLICATIONS AND CONCLUSION

There is evidence higher tobacco retail density is consistently associated with cigarette smoking in pregnant women, young people and adults when ecological studies are included in meta-analysis. Meanwhile, evidence synthesis reveals restrictive tobacco retail laws based on proximity or mixed measures near home or very near school may not reduce smoking except in men who smoke heavily. Mechanisms to reduce retailer density should be thus considered part of tobacco control strategies.

Refining the Universal, School-Based OurFutures Mental Health Program to Be Trauma Informed, Gender and Sexuality Diversity Affirmative, and Adherent to Proportionate Universalism: Mixed Methods Participatory Design Process

BACKGROUND

Mental disorders are the leading cause of disease burden among youth. Effective prevention of mental disorders during adolescence is a critical public health strategy to reduce both individual and societal harms. Schools are an important setting for prevention; however, existing universal school-based mental health interventions have shown null, and occasionally iatrogenic, effects in preventing symptoms of common disorders, such as depression and anxiety.

OBJECTIVE

This study aims to report the adaptation process of an established, universal, school-based prevention program for depression and anxiety, OurFutures Mental Health. Using a 4-stage process; triangulating quantitative, qualitative, and evidence syntheses; and centering the voices of young people, the revised program is trauma-informed; lesbian, gay, bisexual, transgender, nonbinary, queer, questioning, and otherwise gender and sexuality diverse (LGBTQA+) affirmative; relevant to contemporary youth; and designed to tailor intervention dosage to those who need it most (proportionate universalism).

METHODS

Program adaptation occurred from April 2022 to July 2023 and involved 4 stages. Stage 1 comprised mixed methods analysis of student evaluation data (n=762; mean age 13.5, SD 0.62 y), collected immediately after delivering the OurFutures Mental Health program in a previous trial. Stage 2 consisted of 3 focus groups with high school students (n=39); regular meetings with a purpose-built, 8-member LGBTQA+ youth advisory committee; and 2 individual semistructured, in-depth interviews with LGBTQA+ young people via Zoom (Zoom Video Communications) or WhatsApp (Meta) text message. Stage 3 involved a clinical psychologist providing an in-depth review of all program materials with the view of enhancing readability, improving utility, and normalizing emotions while retaining key cognitive behavioral therapy elements. Finally, stage 4 involved fortnightly consultations among researchers and clinicians on the intervention adaptation, drawing on the latest evidence from existing literature in school-based prevention interventions, trauma-informed practice, and adolescent mental health.

RESULTS

Drawing on feedback from youth, clinical psychologists, and expert youth mental health researchers, sourced from stages 1 to 4, a series of adaptations were made to the storylines, characters, and delivery of therapeutic content contained in the weekly manualized program content, classroom activities, and weekly student and teacher lesson summaries.

CONCLUSIONS

The updated OurFutures Mental Health program is a trauma-informed, LBGTQA+ affirmative program aligned with the principles of proportionate universalism. The program adaptation responds to recent mixed findings on universal school-based mental health prevention programs, which include null, small beneficial, and small iatrogenic effects. The efficacy of the refined OurFutures Mental Health program is currently being tested through a cluster randomized controlled trial with up to 1400 students in 14 schools across Australia. It is hoped that the refined program will advance the current stalemate in universal school-based prevention of common mental disorders and ultimately improve the mental health and well-being of young people in schools.

Patients' experiences in the use of mobile health clinics in KwaMachi rural area of KwaZulu-Natal, South Africa

Background

A study was conducted to evaluate the role of mobile health clinics (MHCs) in providing healthcare services in rural areas, focusing on the population of KwaMachi in KwaZulu Natal, South Africa. The objective of the study was to explore the level of health promotion and health-seeking behaviour in KwaMachi, understand the services provided by the MHCs, and assess the experiences of individuals accessing healthcare through these clinics.

Methods

The study used qualitative research methods, including face-to-face interviews and focused group discussions. A sample of 20 patients, with equal representation of males and females across different age groups, was selected using purposive and convenience sampling methods. Two themes were developed: positive experiences and negative experiences. The collected data was analyzed using manual thematic analysis.

Findings

The findings of the study revealed that MHCs serve as the main entry point to the national healthcare system in rural areas, but they offer limited services, which contributes to the ongoing struggle of rural communities to access primary healthcare. While respondents generally had positive experiences with MHCs, some negative aspects need to be addressed. These included concerns about privacy during consultations, the unavailability of essential medications, limited services offered, lack of doctors, and inadequate management of clinical records leading to diagnostic inaccuracies.

Conclusion

The study highlights the challenges faced by rural communities in accessing healthcare services and the role of MHCs in addressing these challenges Based on these findings, the study concludes that there is a need for sustainable MHC programs that address the specific needs and preferences of the local population.

Recommendations

These insights are of value to policymakers seeking to enhance the impact of MHCs in improving healthcare access and outcomes in rural areas. By looking at areas of improvement in the services provided by MHCs, including addressing privacy concerns, ensuring the availability of essential medications, and improving the management of clinical records. The study provides valuable insights for policymakers to enhance the effectiveness of MHC programs in rural areas.

HbA1c changes in a deprived population who followed or not a diabetes self-management programme, organised in a multi-professional primary care practice: a historical cohort study on 207 patients between 2017 and 2019

BACKGROUND

Diabetes self-management (DSM) helps people with diabetes to become actors in their disease. Deprived populations are particularly affected by diabetes and are less likely to have access to these programmes. DSM implementation in primary care, particularly in a multi-professional primary care practice (MPCP), is a valuable strategy to promote care access for these populations. In Rennes (Western France), a DSM programme was designed by a MPCP in a socio-economically deprived area. The study objective was to compare diabetes control in people who followed or not this DSM programme.

METHOD

The historical cohort of patients who participated in the DSM programme at the MPCP between 2017 and 2019 (n = 69) was compared with patients who did not participate in the programme, matched on sex, age, diabetes type and place of the general practitioner's practice (n = 138). The primary outcome was glycated haemoglobin (HbA1c) change between 12 months before and 12 months after the DSM programme. Secondary outcomes included modifications in diabetes treatment, body mass index, blood pressure, dyslipidaemia, presence of microalbuminuria, and diabetes retinopathy screening participation.

RESULTS

HbA1c was significantly improved in the exposed group after the programme (p < 0.01). The analysis did not find any significant between-group difference in socio-demographic data, medical history, comorbidities, and treatment adaptation.

CONCLUSIONS

These results, consistent with the international literature, promote the development of DSM programmes in primary care settings in deprived areas. The results of this real-life study need to be confirmed on the long-term and in different contexts (rural area, healthcare organisation).

Improving access to general practice for and with people with severe and multiple disadvantage: a qualitative study

BACKGROUND

People with severe and multiple disadvantage (SMD) who experience combinations of homelessness, substance misuse, violence, abuse, and poor mental health have high health needs and poor access to primary care.

AIM

To improve access to general practice for people with SMD by facilitating collaborative service improvement meetings between healthcare staff, people with lived experience of SMD, and those who support them; participants were then interviewed about this work.

DESIGN AND SETTING

The Bridging Gaps group is a collaboration between healthcare staff, researchers, women with lived experience of SMD, and a charity that supports them in a UK city. A project was co-produced by the Bridging Gaps group to improve access to general practice for people with SMD, which was further developed with three inner-city general practices.

METHOD

Nine service improvement meetings were facilitated at three general practices, and six of these were formally observed. Nine practice staff and four women with lived experience of SMD were interviewed. Three women with lived experience of SMD and one staff member who supports them participated in a focus group. Data were analysed inductively and deductively using thematic analysis.

RESULTS

By providing time and funding opportunities to motivated general practice staff and involving participants with lived experience of SMD, service changes were made in an effort to improve access for people with SMD. These included prioritising patients on an inclusion patient list with more flexible access, providing continuity for patients via a care coordinator and micro-team of clinicians, and developing an information-sharing document. The process and outcomes improved connections within and between general practices, support organisations, and people with SMD.

CONCLUSION

The co-designed strategies described in this study could be adapted locally and evaluated in other areas. Investing in this focused way of working may improve accessibility to health care, health equity, and staff wellbeing.

Modeling chronic disease risk across equity factors using a population-based prediction model: the Chronic Disease Population Risk Tool (CDPoRT)

BACKGROUND

Predicting chronic disease incidence at a population level can help inform overall future chronic disease burden and opportunities for prevention. This study aimed to estimate the future burden of chronic disease in Ontario, Canada, using a population-level risk prediction algorithm and model interventions for equity-deserving groups who experience barriers to services and resources due to disadvantages and discrimination.

METHODS

The validated Chronic Disease Population Risk Tool (CDPoRT) estimates the 10-year risk and incidence of major chronic diseases. CDPoRT was applied to data from the 2017/2018 Canadian Community Health Survey to predict baseline 10-year chronic disease estimates to 2027/2028 in the adult population of Ontario, Canada, and among equity-deserving groups. CDPoRT was used to model prevention scenarios of 2% and 5% risk reductions over 10 years targeting high-risk equity-deserving groups.

RESULTS

Baseline chronic disease risk was highest among those with less than secondary school education (37.5%), severe food insecurity (19.5%), low income (21.2%) and extreme workplace stress (15.0%). CDPoRT predicted 1.42 million new chronic disease cases in Ontario from 2017/2018 to 2027/2028. Reducing chronic disease risk by 5% prevented 1500 cases among those with less than secondary school education, prevented 14 900 cases among those with low household income and prevented 2800 cases among food-insecure populations. Large reductions of 57 100 cases were found by applying a 5% risk reduction in individuals with quite a bit workplace stress.

CONCLUSION

Considerable reduction in chronic disease cases was predicted across equity-defined scenarios, suggesting the need for prevention strategies that consider upstream determinants affecting chronic disease risk.

Systematic review of social determinants of childhood immunisation in low- and middle-income countries and equity impact analysis of childhood vaccination coverage in Nigeria

BACKGROUND

Nigeria has a high proportion of the world's underimmunised children. We estimated the inequities in childhood immunisation coverage associated with socioeconomic, geographic, maternal, child, and healthcare characteristics among children aged 12-23 months in Nigeria using a social determinants of health perspective.

METHODS

We conducted a systematic review to identify the social determinants of childhood immunisation associated with inequities in vaccination coverage among low- and middle-income countries. Using the 2018 Nigeria Demographic and Health Survey (DHS), we conducted multiple logistic regression to estimate the association between basic childhood vaccination coverage (1-dose BCG, 3-dose DTP-HepB-Hib (diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenzae type B), 3-dose polio, and 1-dose measles) and socioeconomic, geographic, maternal, child, and healthcare characteristics in Nigeria.

RESULTS

From the systematic review, we identified the key determinants of immunisation to be household wealth, religion, and ethnicity for socioeconomic characteristics; region and place of residence for geographic characteristics; maternal age at birth, maternal education, and household head status for maternal characteristics; sex of child and birth order for child characteristics; and antenatal care and birth setting for healthcare characteristics. Based of the 2018 Nigeria DHS analysis of 6,059 children aged 12-23 months, we estimated that basic vaccination coverage was 31% (95% CI: 29-33) among children aged 12-23 months, whilst 19% (95% CI:18-21) of them were zero-dose children who had received none of the basic vaccines. After controlling for background characteristics, there was a significant increase in the odds of basic vaccination by household wealth (AOR: 3.21 (2.06, 5.00), p < 0.001) for the wealthiest quintile compared to the poorest quintile, antenatal care of four or more antenatal care visits compared to no antenatal care (AOR: 2.87 (2.21, 3.72), p < 0.001), delivery in a health facility compared to home births (AOR 1.32 (1.08, 1.61), p = 0.006), relatively older maternal age of 35-49 years compared to 15-19 years (AOR: 2.25 (1.46, 3.49), p < 0.001), and maternal education of secondary or higher education compared to no formal education (AOR: 1.79 (1.39, 2.31), p < 0.001). Children of Fulani ethnicity in comparison to children of Igbo ethnicity had lower odds of receiving basic vaccinations (AOR: 0.51 (0.26, 0.97), p = 0.039).

CONCLUSIONS

Basic vaccination coverage is below target levels for all groups. Children from the poorest households, of Fulani ethnicity, who were born in home settings, and with young mothers with no formal education nor antenatal care, were associated with lower odds of basic vaccination in Nigeria. We recommend a proportionate universalism approach for addressing the immunisation barriers in the National Programme on Immunization of Nigeria.

Aligning the planning, development, and implementation of complex interventions to local contexts with an equity focus: application of the PRISM/RE-AIM Framework

For the fields of implementation science and health equity, understanding and being responsive to local contexts is of utmost importance to better inform the development, implementation, and evaluation of healthcare and public health interventions to increase their uptake and sustainment. Contexts are multi-level and include political, historical, economic, and social factors that influence health, as well as organizational characteristics, reflecting the richness of members' views, resources, values, and needs. Poor alignment between solutions and those contextual characteristics could have an impact on inequities. The PRISM (Practical Robust Implementation and Sustainability Model) is a context-based implementation science framework that incorporates RE-AIM outcomes (Reach, Effectiveness, Adoption, Implementation, Maintenance) and offers guidance to researchers, practitioners, and their patient and community partners on how to conceptualize, assess, and address contextual domains with a focus on health equity. Drawing from systems thinking, participatory engagement, and health equity principles, this commentary expands on previous work to 1) offer a novel perspective on how to align an intervention's core functions and forms with the PRISM's contextual domains, and 2) foster an ongoing and iterative engagement process with diverse partners throughout the research and practice process using a co-creation approach. We recommend intervention-to-context alignment through iterative cycles. To that end, we present the RE-AIM Framework's 'outcomes cascade' to illustrate touch points of opportunity and gaps within and across each of the five RE-AIM outcomes to illustrate 'where things go wrong'. We present a case study to illustrate and offer recommendations for research and practice efforts to increase contextual responsiveness, and enhance alignment with context before, during, and after implementation efforts and to ensure equity is being addressed. We strive to make a conceptual contribution to advance the field of pragmatic research and implementation of evidence-based practices through the application of the contextually-based PRISM framework with a focus on health equity.

Ethical Frameworks and Global Health: A Narrative Review of the "Leave No One Behind" Principle

The "Leave No One Behind" (LNOB) principle, a fundamental commitment of the United Nations' Sustainable Development Goals, emphasizes the urgent need to address and reduce global health inequalities. As global health initiatives strive to uphold this principle, they face significant ethical challenges in balancing equity, resource allocation, and diverse health priorities. This narrative review critically examines these ethical dilemmas and their implications for translating LNOB into actionable global health strategies. A comprehensive literature search was conducted using PubMed, Scopus, Web of Science, and Semantic Scholar, covering publications from January 1990 to April 2024. The review included peer-reviewed articles, gray literature, and official reports that addressed the ethical dimensions of LNOB in global health contexts. A thematic analysis was employed to identify and synthesize recurring ethical issues, dilemmas, and proposed solutions. The thematic analysis identified 4 primary ethical tensions that complicate the operationalization of LNOB: (1) Universalism versus Targeting, where the challenge lies in balancing broad health improvements with targeted interventions for the most disadvantaged; (2) Resource Scarcity versus Equity; highlighting the ethical conflicts between maximizing efficiency and ensuring fairness; (3) Top-down versus Bottom-up Approaches, reflecting the tension between externally driven initiatives and local community needs; and (4) Short-term versus Long-term Sustainability, addressing the balance between immediate health interventions and sustainable systemic changes. To navigate these ethical challenges effectively, global health strategies must adopt a nuanced, context-sensitive approach incorporating structured decision-making processes and authentic community participation. The review advocates for systemic reforms that address the root causes of health disparities, promote equitable collaboration between health practitioners and marginalized communities, and align global health interventions with ethical imperatives. Such an approach is essential to truly operationalize the LNOB principle and foster sustainable health equity.

Settings, populations, and time: a conceptual framework for public health interventions

This paper presents a conceptual framework displaying how combinations of settings and populations seen in a long-term perspective may guide public health and health promotion planning and research. The notion of settings constitutes a key element of health promotion as stipulated by the Ottawa Charter from 1986. The setting approach highlights the individual, social and structural dimensions of health promotion. Likewise, the notion of populations and how they are selected forms a center pillar of public health. By joining the two perspectives, four combinations of intervention strategies appear by addressing: (1) a single population segment within a single setting, (2) multiple population segments within a single setting, (3) a single population segment within multiple settings or (4) multiple population segments within multiple settings. Furthermore, the addition of a time dimension inspired by the life-course perspective illustrates how trajectories of individuals and projects change settings and population segments as time goes by. The conceptual framework displays how systematic awareness of long-term, multi-setting, multi-population trajectories allow health promotion planners and researchers to systematically develop, plan and analyze their projects.

Local government's roles in community health and wellbeing in Australia: Insights from Tasmania

ISSUE ADDRESSED

Local governments are well-placed to respond to communities' health and wellbeing needs. However, in the Australian state of Tasmania, the sector's roles in that respect are unclear.

METHODS

We interviewed 10 municipal personnel in Tasmania to understand their views on local governments' community health and wellbeing functions.

RESULTS

Participants had an integrative understanding of community health and wellbeing and recognised that collective effort from all tiers of government, community members, and other place-based stakeholders would improve outcomes. They identified several roles local governments have to support and drive such improvements, including in relation to diverse place-specific determinants of health and wellbeing. Capacity and capability to fulfil what is needed varied, with rural and remote councils generally less able than urban counterparts to respond consistently or comprehensively to community members' complex needs. However, in the presence of clear expectations and parameters, and appropriate support from other tiers of government, participants were eager for their councils to do more to improve their communities' health and wellbeing, including via a mandate in legislation.

CONCLUSION

Local governments have the potential to do more to improve health and wellbeing outcomes in Tasmania, and the greatest gains could be made by addressing spatial inequalities faced by the sector. That insight is extensible to other comparable jurisdictions. SO WHAT?: We argue the need both for a shared societal goal of equitable wellbeing supported by all tiers of government and for actions proportionate to the needs of council areas.

Parental Report of Signs of Anxiety and Depression in Children and Adolescents with and Without Disability in Middle- and Low-Income Countries: Meta-analysis of 44 Nationally Representative Cross-Sectional Surveys

Population-based studies undertaken in high-income countries have indicated that children and adolescents with disabilities are more likely than their non-disabled peers to experience emotional difficulties such as anxiety and depression. Very little is known about the association between disability and emotional difficulties among children growing up in low and middle-income countries (LMICs). We aimed to estimate the strength of association between disability and two forms of emotional difficulties (anxiety, depression) in a range of LMICs and to determine whether the strength of this relationship was moderated by child age and gender. Secondary analysis of data collected in Round 6 of UNICEF's Multiple Indicator Cluster Surveys undertaken in 44 LMICs (combined n = 349,421). Data were aggregated across countries by both mixed effects multi-level modelling and restricted maximum likelihood meta-analysis. Young people with disabilities, when compared with their non-disabled peers, were approximately two and a half times more likely to be reported by parents to show daily signs of either anxiety or depression. The level of risk among young people with disabilities was highest in upper middle-income countries and lowest in low-income countries. We estimated that approximately 20% of young people with frequent anxiety or depression also had a disability. All approaches to mental health interventions (from primary prevention to clinical interventions) need to make reasonable accommodations to their services to ensure that the young people with emotional difficulties who also have a disability are not 'left behind'.

Modelling population-level and targeted interventions of weight loss on chronic disease prevention in the Canadian population

Obesity is a known risk factor for major chronic diseases. Prevention of chronic disease is a top global priority. The study aimed to model scenarios of population-level and targeted weight loss interventions on 10-year projected risk of chronic disease in Canada using a population-level risk prediction algorithm. The validated Chronic Disease Population Risk Tool (CDPoRT) forecasts 10-year risk of chronic disease in the adult population. We applied CDPoRT to the 2013/14 Canadian Community Health Survey to generate prospective chronic disease estimates for adults 20 years and older in Canada (n = 83,220). CDPoRT was used to model the following scenarios: British Columbia's (BC) and Quebec's (QC) provincial population-level weight reduction targets, a population-level intervention that could achieve weight loss, targeted weight loss interventions for overweight and obese groups, and the combination of a population-level and targeted weight loss intervention. We estimated chronic disease risk reductions and number of cases prevented in each scenario compared with the baseline. At baseline, we predicted an 18.4% risk and 4,151,929 new cases of chronic disease in Canada over the 10-year period. Provincial weight loss targets applied to the Canadian population estimated chronic disease reductions of 0.6% (BC) and 0.1% (QC). The population-level intervention estimated a greater reduction in risk (0.2%), compared to the targeted interventions (0.1%). The combined approach estimated a 0.3% reduction in chronic disease risk. Our modelling predicted that population-level approaches that achieve weight loss in combination with targeted weight loss interventions can substantially decrease the chronic disease burden in Canada.

Geographical and sociodemographic differences in statin dispensation after acute myocardial infarction in Sweden: a register-based prospective cohort study applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) for basic comparisons of healthcare quality

BACKGROUND

In Sweden, as in many other countries, official monitoring of healthcare quality is mostly focused on geographical disparities in relation to a desirable benchmark. However, current evaluations could be improved by considering: (1) The intersection of other relevant axes of inequity like age, sex, income and migration status; and (2) The existence of individual heterogeneity around averages. Therefore, using an established quality indicator (ie, dispensation of statins after acute myocardial infarction, AMI), we valuate both geographical and sociodemographic inequalities and illustrate how the analysis of individual heterogeneity and discriminatory accuracy (AIHDA) enhances such evaluations.

POPULATION AND METHODS

We applied AIHDA and calculated the area under the receiver operating characteristics curve (AUC) of regional and sociodemographic differences in the statin dispensations of 35 044 patients from 21 Swedish regions and 24 sociodemographic strata who were discharged from the hospital with an AMI diagnosis between January 2011 and December 2013. Following the Swedish National Board of Health and Welfare, we used a benchmark value of 90%.

RESULTS

Dispensation of stains after AMI in Sweden did not reach the desired target of 90%. Regional differences were absent/very small (AUC=0.537) while sociodemographic differences were small (AUC=0.618). Women, especially those with immigrant background and older than 65 years, have the lowest proportions of statin dispensations after AMI.

CONCLUSIONS

As the AUC statistics are small, interventions trying to achieve the benchmark value should be universal. However, special emphasis should nevertheless be directed towards women, especially older women with immigrant backgrounds.

Bringing down barriers to children's healthy eating: a critical review of opportunities, within a complex food system

This narrative review revises the scientific evidence of recent years on healthy eating in children and adolescents, making sense of promising avenues of action, from a food system perspective. A conceptual framework is provided to better understand how eating habits of children and adolescents are shaped to identify key multisectoral approaches that should be implemented to promote healthier diets. The following influencing factors are discussed: individual factors (physiological and psychological factors, food preferences and food literacy competencies), factors within the personal and socio-cultural food environments, external food environments, and the supply chain. In each section, the main barriers to healthy eating are briefly discussed focussing on how to overcome them. Finally, a discussion with recommendations of actions is provided, anchored in scientific knowledge, and transferable to the general public, industry, and policymakers. We highlight that multidisciplinary approaches are not enough, a systems approach, with a truly holistic view, is needed. Apart from introducing systemic changes, a variety of interventions can be implemented at different levels to foster healthier diets in children through fostering healthier and more sustainable food environments, facilitating pleasurable sensory experiences, increasing their food literacy, and enhancing their agency by empowering them to make better food related decisions. Acknowledging children as unique individuals is required, through interpersonal interactions, as well as their role in their environments. Actions should aim to enable children and adolescents as active participants within sustainable food systems, to support healthier dietary behaviours that can be sustained throughout life, impacting health at a societal level.

"Those Who Need It the Most": Equity Framing in 2021 U.S. Print News About Food Assistance

Objective

To understand how equity appeared in news about food assistance from 2021.

Methods

We assessed a national sample of news articles (N=298) for equity arguments and language about racial and health equity.

Results

Only 28% of coverage argued that food assistance programs promote equity. Just 6% mentioned people of color or named racial disparities in food access.

Discussion

Narratives that explain how food assistance programs reduce inequities could deepen their policy appeal and broaden public perceptions around recipients.

Health Equity Implications

There are opportunities for news coverage to expand the discussion of how food assistance programs improve racial and health equity outcomes.

Targeted Approaches, Universalism, and Targeted Universalism: Opportunities for the U.S. Correctional Health Care System

Social policy has traditionally been implemented in two ways: using targeted or universal approaches. Each of these mechanisms has advantages and disadvantages to the populations to whom the policies are applied and to the system applying the policies. A third approach to social policy implementation has emerged: targeted universalism. Targeted universalism is not simply a combination of targeted and universal approaches. It stands apart as a unique way of conceptualizing and implementing social policy. This viewpoint provides an overview of targeted approaches, universalism, and targeted universalism to social policy development and implementation. It examines the ways targeted universalism could be applied to the U.S. correctional health care system to ensure that people who are incarcerated receive the health care to which they are constitutionally entitled.

Proportionate universalism intervention is effective for tackling nutritional social gradient in adolescents: the PRALIMAP-INÈS mixed randomised trial

OBJECTIVE

This study aimed to investigate the effectiveness of proportionate universalism intervention to reduce the slope of the nutritional social gradient in adolescents.

STUDY DESIGN

A mixed (experimental and quasi-experimental) multicentre trial.

METHODS

Data from 985 adolescents of the PRALIMAP-INÈS trial (North-eastern France, 2012-2015) were analysed. For this, adolescents were split into five social classes according to the Family Affluence Scale: Highly Less Advantaged (H.L.Ad; n = 33), Less Advantaged (L.Ad; n = 155), Intermediate (Int; n = 404), Advantaged (Ad; n = 324) and Highly Advantaged (H.Ad; n = 69). The overweight care management was a standard care for all and a strengthened one adapted to the social class of adolescents. The main outcome was the 1-year change of the body mass index z-score (BMIz) slope. Other nutritional outcomes were BMI, ΔBMI_p95 (BMI minus 95th percentile of the WHO reference), %BMI_p95 (percent of 95th percentile of the WHO reference), leisure-time sport, consumption of fruits and vegetables and consumption of sugary foods and drinks.

RESULTS

The inclusion data confirmed a weight social gradient expressed by a significant BMIz linear regression coefficient (β = -0.09 [-0.14 to -0.04], P < 0.0001). The higher the social class, the lower the BMIz. The 1-year BMIz linear regression coefficient was -0.07 [-0.12 to -0.02], corresponding to a significant weight social gradient reduction of 23.3% (β = 0.021 [0.001 to 0.041]; P = 0.04). Consistent results were found for other nutritional outcomes.

CONCLUSIONS

PRALIMAP-INÈS shows that proportionate universalism intervention is effective to reduce the adolescents' nutritional social gradient and suggests that equitable health programmes and policies are a realistic goal.

Exposure of Women With and Without Disabilities to Violence and Discrimination: Evidence from Cross-sectional National Surveys in 29 Middle- and Low-Income Countries

There is a paucity of robust nationally representative data from low- and middle-income countries (LMICs) on the prevalence and risk factors associated with exposure of women with/without disability to either discrimination or violence. We undertook secondary analysis of data collected in Round 6 of UNICEF's Multiple Indicator Cluster Surveys (MICS) involving nationally representative data from 29 countries with a total sample size of 320,426 women aged 18 to 49 years. We estimated: (1) prevalence rates for exposure to discrimination and violence among women with/without disabilities in the previous year in a range of LMICs; (2) the relative risk of exposure when adjusted for demographic and contextual characteristics; (3) the relative risk of exposure associated with specific functional difficulties associated with disabilities; and (4) the association between country-level estimates and national wealth and human development potential. Our results indicated that women with disabilities were approximately twice as likely as women without disabilities to be exposed to violence and discrimination in the past year, and approximately one-third more likely to feel unsafe in either their home or local neighbourhood and to be at greater risk of domestic violence. Risk of exposure was associated with national characteristics (national wealth, human development potential) and within country factors, especially relative household wealth and level of education. These results must be of concern on two counts. First, they attest to the ongoing violation of the human rights of women with disabilities. Second, they point to increased exposure among women with disabilities to several well-documented social determinants of poorer health.

Integrated Early Childhood Development in Cambodia: Protocol of a Cluster Stepped-Wedge Trial

OBJECTIVES

Limited evidence is available on mechanisms linking integrated, multisector interventions with early childhood development. The Integrated Early Childhood Development program aims to improve children's development by promoting targeted caregiving behaviors beginning prenatally through age 5 years, in partnership with the Royal Government of Cambodia.

METHODS

This cluster stepped-wedge trial is being conducted in Cambodia among 3 cohorts, encompassing 339 villages and 1790 caregivers who are pregnant or caring for a child aged <5 years. The 12- to 15-month intervention is delivered to each cohort using a staggered stepped-wedge design. Among all cohorts, enrollment evaluations will be followed by 3 data collection waves. Targeted caregiving interventions are provided through community, group, and home-visiting platforms. Child development is measured using the Caregiver Reported Early Development Instrument and the Early Childhood Development Index 2030. The evaluation assesses mediation through targeted caregiving behaviors: responsive caregiving, nutrition, health and hygiene, and household stability and support; moderation by household wealth, caregiver education, and child birth weight; and sustainability after the intervention concludes.

CONCLUSIONS

This protocol article describes the plans for a cluster randomized controlled trial to measure the impact of an integrated, multisector intervention on children's development. By partnering with the Royal Government of Cambodia and addressing intervention pathways and moderators, this trial will provide guidance for policies and programs to promote early childhood development using principles of implementation science and equity, including increased investment for vulnerable families.

Impact of ¡Míranos! on parent-reported home-based healthy energy balance-related behaviors in low-income Latino preschool children: a clustered randomized controlled trial

BACKGROUND

Widespread establishment of home-based healthy energy balance-related behaviors (EBRBs), like diet, physical activity, sedentary behavior, screen time, and sleep, among low-income preschool-aged children could curb the childhood obesity epidemic. We examined the effect of an 8-month multicomponent intervention on changes in EBRBs among preschool children enrolled in 12 Head Start centers.

METHODS

The Head Start (HS) centers were randomly assigned to one of three treatment arms: center-based intervention group (CBI), center-based plus home-based intervention group (CBI + HBI), or control. Before and following the intervention, parents of 3-year-olds enrolled in participating HS centers completed questionnaires about their child's at-home EBRBs. Adult-facilitated physical activity (PA) was measured by an index based on questions assessing the child's level of PA participation at home, with or facilitated by an adult. Fruit, vegetable, and added sugar intake were measured via a short food frequency questionnaire, and sleep time and screen time were measured using 7-day logs. A linear mixed effects model examined the intervention's effect on post-intervention changes in PA, intake of fruit, vegetable, and added sugar, sleep time, and screen time from baseline to post-intervention.

RESULTS

A total of 325 parents participated in the study (CBI n = 101; CBI + HBI n = 101; and control n = 123). Compared to control children, CBI and CBI + HBI parents reported decreases in children's intake of added sugar from sugar-sweetened beverages. Both CBI and CBI + HBI parents also reported smaller increases in children's average weekday screen time relative to controls. In addition, CBI + HBI parents reported CBI + HBI parents reported increases in children's adult-facilitated PA, fruit and vegetable intake, and daily sleep time during weekdays (excluding weekends) and the total week from baseline to post-intervention, while children in the CBI increased sleep time over the total week compared to the children in the control group.

CONCLUSIONS

Parent engagement strengthened the improvement in parent-reported EBRBs at home in young children participating in an evidence-based obesity prevention program in a childcare setting. Future studies should investigate equity-related contextual factors that influence the impact of obesity prevention in health-disparity populations.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03590834. Registered July 18, 2018, https://clinicaltrials.gov/ct2/show/NCT03590834.

Grayken lessons: between a rock and a hard place? A 37-year-old man with acute liver injury while enrolled in a managed alcohol program for severe alcohol use disorder

Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.

A Health Equity Lens Contributes to an Effective Pandemic Response: A Canadian Regional Perspective

As cases of COVID-19 began to increase in Ontario, Canada, throughout 2020, early evidence from surveillance and media highlighted disproportionately higher rates of COVID-19 infection, hospitalization and mortality among racialized and low-income populations. This disproportionate impact on underserved populations calls for a shift in approach away from what has traditionally occurred in health protection, that is the use of a universal approach which assumes everyone is affected and benefits equally from the same type and intensity of interventions. In this article, public health agencies are, therefore, being called to consider moving away from using a purely universal approach, often used in the control of communicable diseases, and apply a more tailored approach and use principles of health equity and proportionate universalism to reduce COVID-19 cases and their impacts among underserved groups and address health inequities exacerbated by the pandemic. We highlight examples from York Region Public Health, one of the largest health units in Ontario, to demonstrate areas of possible impact of this paradigm shift. It is clear that with a health equity lens applied to the pandemic response, the impact of COVID-19 can be further reduced and health inequities that predated the global pandemic can improve.

Promoting the health of vulnerable populations: Three steps towards a systems-based re-orientation of public health intervention research

This paper proposes a novel framework for the development of interventions in vulnerable populations. The framework combines a complex systems lens with syndemic theory. Whereas funding bodies, research organizations and reporting guidelines tend to encourage intervention research that (i) focuses on singular and predefined health outcomes, (ii) searches for generalizable cause-effect relationships, and (iii) aims to identify universally effective interventions, the paper suggests that a different direction is needed for addressing health inequities: We need to (i) start with exploratory analysis of population-level data, and (ii) invest in contextualized in-depth knowledge of the complex dynamics that produce health inequities in specific populations and settings, while we (iii) work with stakeholders at multiple levels to create change within systems.

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

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

Constituent-driven health policy informed by policy advocacy literature

In this position paper, a theoretical framework is proposed to formulate engaged, evidence-based health policy based on the priorities of constituents. An initial literature review was conducted to gain insight on the gaps in knowledge. Three emergent domains were identified: advocacy, research, and policymaking. The inputs and intermediates to the final output (equitable, evidence-based health policy outcomes) were identified and further elaborated upon in each corresponding section of the paper. Additionally, the main objective of each domain based on the literature review and the implications of each step were noted. Researchers have been identified as crucial to the education of policymakers to ultimately produce informed, evidence-based policy. Community advocates and researchers must attempt to advocate for policy issues as the ultimate role of policymakers in this process necessitates effective engagement to promote political will in the policymaking process. To do so, community advocates must scale-up from the individual to coalitions with strong leadership. In conjunction with a policy champion, these efforts by constituents (community advocates and researchers) would result in the most effective modes of policy development and implementation. The Constituent-driven Policy Advocacy Model (CPAM) introduced in this paper creates the potential for a new precedent in policymaking, in which advocacy, community engagement, evidence synthesis and evaluation, as well as science communication are common practices, leading to more sensitive, targeted, and equitable policy outcomes.

Sixteen-year trends in multiple lifestyle risk behaviours by socioeconomic status from 2004 to 2019 in New South Wales, Australia

Few studies have examined trends in inequalities related to lifestyle risk behaviours. This study examined 1) 16-year (2004-2019) trends of individual lifestyle risk factors and a combined lifestyle risk index and 2) trends in socioeconomic inequalities in these risk factors, in New South Wales (NSW; Australia) adults. Data was sourced from the NSW Adult Population Health Survey, an annual telephone survey of NSW residents aged ≥16 years, totalling 191,905 completed surveys. Excessive alcohol consumption, current smoking, insufficient physical activity, insufficient fruit and/or vegetable consumption, sugar-sweetened beverage [SSB] consumption, and a combined lifestyle risk index (overall high-risk lifestyle defined as total number of lifestyle risk behaviours ≥2) were examined. Socioeconomic status was assessed using education attainment, postal area-level disadvantage measured by Index of Relative Socioeconomic Disadvantage (IRSD), and remoteness based on Accessibility-Remoteness Index of Australia Plus (ARIA+). Socioeconomic inequalities were examined as prevalence difference for absolute inequalities and prevalence ratio for relative inequalities. The prevalence of lifestyle behaviours by levels of each socioeconomic status variable were estimated using predicted probabilities from logistic regression models. After adjusting for covariates, there was a decrease in prevalence over time for most lifestyle risk behaviours. Between 2004 and 2019, the prevalence decreased for current smoking from 21.8% to 17.1%, insufficient physical activity from 39.1% to 30.9%, excessive alcohol consumption from 15.4% to 13.7%, daily SSB consumption from 29.9% to 21.2%, and overall high-risk lifestyle from 50.4% to 43.7%. Socioeconomic inequalities, based on one or more of the socioeconomic variables, increased over time for current smoking, insufficient physical activity, daily SSB consumption, and an overall high-risk lifestyle. Overall, the health behaviours of the NSW population improved between 2004 and 2019. However, some socioeconomic inequalities increased during this time, highlighting the need for effective public health strategies that seek to improve health behaviours among the most socioeconomically disadvantaged.

Parent-infant observation for prediction of later childhood psychopathology in community-based samples: A systematic review

BACKGROUND

Difficulties in parent-child interaction are easily observed and are a potential target for early intervention. This review aimed to assess the utility of current observational methods used to assess parent-child interactions-within the first year of life-and their ability to screen and identify children from low-risk samples most at risk of developing childhood psychopathology.

METHODS

Six bibliographic databases were searched, and reference lists screened. All peer reviewed papers studying the association between an independent observation of parent-child interaction and later childhood psychopathology in community-based samples were included. Included studies were those recruiting from population or community-based birth cohort data, which we define as 'low-risk'. Studies based on populations known to have a diagnosis of psychiatric illness or developmental disorder, or at high genetic or environmental risk of being diagnosed with such disorder, were excluded. Results were synthesised qualitatively due to high heterogeneity.

RESULTS

20,051 papers were identified, nine were included in this study. Childhood psychopathology was associated with fewer positive parent-infant interactions, lower parent vocalisation frequency and lower levels of adult speech and activity. Maternal sensitivity was inversely related to separation anxiety and oppositional defiant/conduct disorders were associated with lower shared look rates. Disruptive behaviour disorders were associated with higher frequency of child vocalisation.

CONCLUSION

Assessment of parent-child interactions, particularly the level of maternal activity, may be an early indicator of later childhood psychopathology in low-risk samples. Further longitudinal, population-based studies are required.

TRIAL REGISTRATION

PROSPERO review registration: CRD42020162917 https://www.google.com/search?client=firefox-b-d&q=CRD42020162917.

Everywhere and for everyone: proportionate universalism as a framework for equitable access to community drug checking

BACKGROUND

Illicit drug overdoses have reached unprecedented levels, exacerbated by the COVID-19 pandemic. Responses are needed that address the increasingly potent and unpredictable drug supply with better reach to a wide population at risk for overdose. Drug checking is a potential response offered mainly within existing harm reduction services, but strategies are needed to increase reach and improve equitable delivery of drug checking services.

METHODS

The purpose of this qualitative study was to explore how to extend the reach of drug checking services to a wide population at risk of overdose. We conducted 26 in-depth interviews with potential service users to identify barriers to service use and strategies to increase equitable delivery of drug checking services. Our analysis was informed by theoretical perspectives on equity, and themes were developed relevant to equitable delivery through attention to quality dimensions of service use: accessibility, appropriateness, effectiveness, safety, and respect.

RESULTS

Barriers to equitable service delivery included criminalization and stigma, geographic and access issues, and lack of cultural appropriateness that deter service use for a broad population with diverse needs. Strategies to enhance equitable access include 1ocating services widely throughout communities, integrating drug checking within existing health care services, reframing away from risk messaging, engaging peers from a broad range of backgrounds, and using discrete methods of delivery to help create safer spaces and better reach diverse populations at risk for overdose.

CONCLUSIONS

We propose proportionate universalism in drug checking as a guiding framework for the implementation of community drug checking as an equity-oriented harm reduction intervention and as a population health response. Both a universal equity-oriented approach and multiple tailored approaches are required to facilitate drug checking services that maximize reach and appropriateness to respond to diverse needs.

Addressing Financial Barriers to Health Care Among People Who are Low-Income and Insured in New York City, 2014–2017

While health care-associated financial burdens among uninsured individuals are well described, few studies have systematically characterized the array of financial and logistical complications faced by insured individuals with low household incomes. In this mixed methods paper, we conducted 6 focus groups with a total of 55 residents and analyzed programmatic administrative records to characterize the specific financial and logistic barriers faced by residents living in public housing in East and Central Harlem, New York City (NYC). Participants included individuals who enrolled in a municipal community health worker (CHW) program designed to close equity gaps in health and social outcomes. Dedicated health advocates (HAs) were explicitly paired with CHWs to provide health insurance and health care navigational assistance. We describe the needs of 150 residents with reported financial barriers to care, as well as the navigational and advocacy strategies taken by HAs to address them. Finally, we outline state-level policy recommendations to help ameliorate the problems experienced by participants. The model of paired CHW–HAs may be helpful in addressing financial barriers for insured populations with low household income and reducing health disparities in other communities.

Equity of referrals to type 2 diabetes rehabilitation in a universal welfare state

Objective

Despite aims of equal access to treatment and care in the Nordic countries, marked socioeconomic inequality in the development of type 2 diabetes (T2D) complications persists. The study purpose was to estimate the associations of individual socioeconomic position and deprivation at the general practitioner (GP) level with referrals to T2D rehabilitation.Research Design and Methods: In 2015-2018, 3390 people affiliated with 432 primary GPs living in the municipality of Copenhagen were identified through registry data as newly diagnosed with T2D. Of these, 656 (19%) individuals were referred to municipal rehabilitation services in 2015-2021. Individual socioeconomic position was measured by education, income, and employment. The Danish Deprivation Index (DADI) was used as a measure of GP-level deprivation.

Results

Patients were more likely to be referred to municipal rehabilitation if they had low vs. high income (hazard ratio (HR) 2.87 [women], 1.64 [men]), were not employed vs. employed (HR 1.95 [women], 1.23 [men]) and were affiliated with GPs with a low vs. very high level of deprivation (HR 7.63 [women], 4.30 [men]). The results suggest that GPs practice proportionate universalism by allocating treatment to lower socioeconomic individuals in likely higher need of care. However, the overall HR for referrals was lower among GPs with more deprived patient populations, indicating unequal treatment of all citizens, which conflicts with the aims of general universal health care. Inequality in rehabilitation healthcare services must be further addressed and investigated to prevent exacerbating health disparities.

The Impact of the COVID-19 Pandemic and Associated Societal Restrictions on People Experiencing Homelessness (PEH): A Qualitative Interview Study with PEH and Service Providers in the UK

People experiencing homelessness (PEH) faced unique challenges during the COVID-19 pandemic, including changes to accommodation availability, societal restrictions impacting access to essentials like food, and services moving to online and remote access. This in-depth qualitative research aims to add to the existing, but limited research exploring how the pandemic affected PEH. 33 semi-structured qualitative interviews (22 with PEH during the pandemic and 11 with homelessness sector service providers) were undertaken in the United Kingdom between April 2021 and January 2022. Interviews were audio-recorded, transcribed and analysed using reflexive thematic analysis. To ensure consistency of coding, 10% of interviews were coded by two researchers. The PEH sample was 50% female, aged 24-59 years, 59% white British, and included people who had lived in hostels/hotels, with friends/family, and on the streets during the COVID-19 pandemic. Providers came from varied services, including support charities, housing, and addiction services. Five key themes were identified: (i) the understanding of and adherence to public health guidance and restrictions; (ii) the experience of people accommodated by the 'Everyone In' initiative; (iii) the impact of social distancing guidelines on PEH experiences in public spaces; (iv) the importance of social support and connections to others; and (v) how homelessness services adapted their provision. Policy makers and public health communicators must learn from PEH to maximize the effectiveness of future public health strategies. Housing providers and support services should recognize the implications of imposing a lack of choice on people who need accommodation during a public health emergency. The loss of usual support for PEH triggered a loss of ability to rely on usual 'survival strategies', which negatively influenced their health. This research highlights successes and difficulties in supporting PEH during the COVID-19 pandemic and informs planning for similar public health events.

Trends, barriers and enablers to measles immunisation coverage in Saskatchewan, Canada: A mixed methods study

Many social, cultural, and systemic challenges affect the uptake of measles immunisation services. Prior studies have looked at the caregivers' perspectives, but little is known about the perspectives of the health care providers on the barriers of measles immunisation services in Canada. This study examined measles immunisation coverage trends across the regional health authorities in Saskatchewan and explored the barriers and enablers to measles immunisation coverage from providers' perspectives. The study adopted an explanatory sequential mixed method. We utilized the entire population of 16,582 children under two years of age available in the Saskatchewan Immunisation Management System (SIMS) registry for 2002 and 2013 in aggregate format and interviewed 18 key informants in pre-determined two-stages in 2016 and 2017. The quantitative analysis was done with Joinpoint regression modelling, while the qualitative interview data was analyzed using hybrid inductive and deductive thematic approaches. There was a 16.89%-point increase in measles immunisation coverage in the province from 56.32% to 73.21% between 2002 and 2013. There was also a persistently higher coverage among the affluent (66.95% - 82.37%) than the most deprived individuals (45.79% - 62.60%) in the study period. The annual rate of coverage change was marginally higher among the most deprived (16.81%; and average annual percentage change (AAPC) 2.0, 95% CI 1.7-2.2) than among the affluent group (15.42% and AAPC 3.0; 95% CI 2.0-4.0). While access-related issues, caregivers' fears, hesitancy, anti-vaccination challenges, and resource limitations were barriers to immunisation, improving community engagement, service delivery flexibility, targeted social responses and increasing media role were found useful to address the uptake of measles and other vaccine-preventable diseases immunisation. There is low coverage and inequity in measles immunisation uptake in Saskatchewan from social and institutional barriers. Even though there is evidence of disparity reduction among the different groups, the barriers to increasing measles immunisation coverage have implications for the health of the socio-economically deprived groups, the healthcare system and other vaccination programs. There is a need to improve policy framework for community engagement, targeted programs, and public health discourse.

The philosophical foundations of 'health for all' and Universal Health Coverage

The WHO constitution calls for 'health for all' and Universal Health Coverage has been called "the ultimate expression of fairness", however it is not always clear how health systems can move towards equity. Should we prioritise the needs of the worst off? And if so, should we direct resources to these marginalised groups or marginalised individuals? This article provides an overview of the philosophical underpinnings of health equity and proportionate universalism, highlighting the trade-offs involved in operationalising a core tenant of global health practice.

Morele dilemma’s rond gelijke kansen op gezondheid

In het kader van kansengelijkheid is het verbeteren van de gezondheid van achtergestelde groepen voor gemeenten een belangrijke maar lastige opdracht. Naast gebrek aan kennis over wat effectieve interventies zijn, kan er ook onzekerheid zijn over de vraag wat moreel gezien eigenlijk het beste is om te doen. Om een beeld te krijgen van deze ‘morele obstakels’ inventariseerden we bij de afdeling Volksgezondheid van de gemeente Utrecht welke ethische dilemma’s medewerkers tegenkomen in hun streven naar gelijke kansen op gezondheid. Op basis van vier dilemmabesprekingen met gemeentemedewerkers en filosofische literatuur over rechtvaardigheid, formuleren we hier vijf inzichten over wat het concreet betekent om in de gemeentelijke volksgezondheidspraktijk gelijke kansen op gezondheid te bevorderen. Te weten 1) kansengelijkheid bevorderen vereist dat medewerkers in de beleidspraktijk morele afwegingen maken; 2) kansengelijkheid vraagt om balanceren tussen idealisme en realisme; 3) feitelijke kansengelijkheid vereist meer dan formele kansengelijkheid; 4) kansengelijkheid kunnen we het beste bevorderen door prioriteit te geven aan degenen die het slechtst af zijn; 5) kansengelijkheid bevorderen vraagt om paternalisme. Deze inzichten, samen met de gebruikte gespreksstructuur, kunnen gemeentemedewerkers ondersteunen bij het maken van keuzen die bijdragen aan gelijke kansen op gezondheid.

Implementing Universal and Targeted Policies for Health Equity: Lessons From Australia

BACKGROUND

Debate continues in public health on the roles of universal or targeted policies in providing equity of access to health-related goods or services, and thereby contributing to health equity. Research examining policy implementation can provide fresh insights on these issues.

METHODS

We synthesised findings across case studies of policy implementation in four policy areas of primary healthcare (PHC), telecommunications, Indigenous health and land use policy, which incorporated a variety of universal and targeted policy structures. We analysed findings according to three criteria of equity in access - availability, affordability and acceptability - and definitions of universal, proportionate-universal, targeted and residual policies, and devolved governance structures.

RESULTS

Our analysis showed that existing universal, proportionate-universal and targeted policies in an Australian context displayed strengths and weaknesses in addressing availability, affordability and acceptability dimensions of equity in access.

CONCLUSION

While residualist policies are unfavourable to equity of access, other forms of targeting as well as universal and proportionate-universal structure have the potential to be combined in context-specific ways favourable to equity of access to health-related goods and services. To optimise benefits, policies should address equity of access in the three dimensions of availability, affordability and acceptability. Devolved governance structures have the potential to augment equity benefits of either universal or targeted policies.

A scoping review of community-based mental health intervention for children and adolescents in South Asia

Children and adolescents in South Asia are exposed to significant mental health risks. Yet, policy to prevent or treat youth mental health problems in this context is underdeveloped, and services are difficult to access. Community-based mental health treatment may offer a potential solution, by increasing resource capacity in deprived settings. However, little is known about the current community-based mental health provision for South Asian youth. A scoping review was conducted across six scientific databases and hand searching of reference lists to identify relevant studies. Study selection and data extraction were performed by three independent reviewers using predefined criteria, an adapted version of the template for intervention description and replication checklist and the Cochrane Risk of Bias Tool. The search identified 19 relevant studies published from January 2000 to March 2020. Studies most frequently addressed PTSD and autism, were conducted in India and Sri Lanka, used education-based intervention and were based in urban school settings. Community-based mental health provision for the South Asian youth is in its infancy, but holds promise for providing essential resources to treat or prevent mental health disorder. New insights on approaches are discussed, which are valuable for South Asian settings, primarily task-shifting and stigma reduction, with implications for policy, practice and research.

Advancing Health Equity Efforts to Reduce Obesity: Changing the Course

Population-based solutions are needed to stabilize and then reverse the continued upward trends in obesity prevalence in the US population and worldwide. This review focuses on the related, urgent issue of disparities in obesity prevalence affecting US racial/ethnic minority and other socially marginalized populations. The review provides background on these disparities from a health equity perspective and highlights evidence of progress in equity-focused obesity efforts. Five recommendations for advancing equity efforts are offered as potential approaches to build on progress to date: (a) give equity issues higher priority, (b) adopt a health equity lens, (c) strengthen approaches by using health equity frameworks, (d) broaden the types of policies considered, and (e) emphasize implementation science concepts and tools. Potential challenges and opportunities are identified, including the prospect of longer-term, transformative solutions that integrate global and national initiatives to address obesity, undernutrition, and climate change.

Watch me grow integrated (WMG-I): protocol for a cluster randomised controlled trial of a web-based surveillance approach for developmental screening in primary care settings

INTRODUCTION

The increasing prevalence of developmental disorders in early childhood poses a significant global health burden. Early detection of developmental problems is vital to ensure timely access to early intervention, and universal developmental surveillance is recommended best practice for identifying issues. Despite this, there is currently considerable variation in developmental surveillance and screening between Australian states and territories and low rates of developmental screening uptake by parents. This study aims to evaluate an innovative web-based developmental surveillance programme and a sustainable approach to referral and care pathways, linking primary care general practice (GP) services that fall under federal policy responsibility and state government-funded child health services.

METHODS AND ANALYSIS

The proposed study describes a longitudinal cluster randomised controlled trial (c-RCT) comparing a 'Watch Me Grow Integrated' (WMG-I) approach for developmental screening, to Surveillance as Usual (SaU) in GPs. Forty practices will be recruited across New South Wales and Queensland, and randomly allocated into either the (1) WMG-I or (2) SaU group. A cohort of 2000 children will be recruited during their 18-month vaccination visit or opportunistic visit to GP. At the end of the c-RCT, a qualitative study using focus groups/interviews will evaluate parent and practitioner views of the WMG-I programme and inform national and state policy recommendations.

ETHICS AND DISSEMINATION

The South Western Sydney Local Health District (2020/ETH01625), UNSW Sydney (2020/ETH01625) and University of Queensland (2021/HE000667) Human Research Ethics Committees independently reviewed and approved this study. Findings will be reported to the funding bodies, study institutes and partners; families and peer-reviewed conferences/publications.

TRIAL REGISTRATION NUMBER

ANZCTR12621000680864.

Organizing the health interview survey at the local level: design of a pilot study

Background

The local Health Interview Study (LHIS) was developed to gain health information at the level of the municipality in Flanders, the northern part of Belgium. It enables municipalities to make evidence-based decisions in their public health policy. To test the feasibility of implementing the LHIS, a pilot study was conducted in Melle, a small Flemish municipality with 11.736 inhabitants.

Methods

The target sample size was 1000 (≥ 15 years). A systematic sampling technique was applied with substitutes for non-respondents who were matched in terms of statistical sector, age and sex. Selected persons were contacted by post to complete the questionnaire and in case of non-response, a reminder was sent. Questionnaires were collected using a concurrent mixed-mode design: a paper and pencil, and web option. All questions were selected from the Belgian Health Interview Survey relating to health status and determinants of health.

Results

One thousand twenty-two questionnaires were obtained after inviting 3137 individuals (response rate = 32.6%). Older adults were more likely to participate than younger adults, and women more than men. The final sample resembled the initial sample in terms of sex and statistical sector, but not in terms of age. Younger adults were underrepresented whereas older adults were overrepresented. Lastly, older adults were more likely to fill in the questionnaire on paper than younger adults, and women more than men.

Conclusion

The LHIS can be successfully implemented in Flemish municipalities. The method, however, does not guarantee that the composition of the final sample reflects the initial sample. Therefore, weights should be added in the analyses to correct for potential deviations in sample composition. Furthermore, implementing a sequential mixed-mode design with a web option preceding a paper and pencil option in future studies could reduce costs and improve data quality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00909-z.

Towards health equity: core components of an extended home visiting intervention in disadvantaged areas of Sweden

BACKGROUND

Understanding the mechanisms of implementation of public health interventions in community settings is a key aspect of programme assessments. To determine core components and establish a programme theory are important tools to improve functioning and support dissemination of programme models to new locations. An extended early childhood home visiting intervention has been developed on-site in a socioeconomically disadvantaged area of Sweden since 2013 with the aim of reducing persisting health inequities in the population. This study aimed at investigating the core programme components and how the intervention was perceived to contribute towards health equity from early childhood.

METHODS

Qualitative framework method was applied in a document analysis and subsequent semi-structured interviews with 15 key actors involved in the programme.

RESULTS

The intervention was found to be constituted of five core components centred around the situation-based, parental strengthening work method delivered by a qualified team of child health care nurse and social worker. The programme theory foresaw positive effects on child and parental health, responsive parenting practices, families' use of welfare services according to need and increased integration and participation in society. The principles of Proportionate Universalism were recognised in the programme theory and the intervention was perceived as an important contribution to creating conditions for improved health equity for the families. Still, barriers to health equity were identified on the structural level which limit the potential impact of the programme.

CONCLUSIONS

The core components of the Extended home visiting programme in Rinkeby correspond well to those of similar evidence-based home visiting interventions. Combining focus on early childhood development and responsive parenting with promoting access to the universal welfare services and integration into society are considered important steppingstones towards health equity. However, a favourable macro-political environment is required in the endeavour to balance the structural determinants' influence on health inequities. Improved availability and accessibility to welfare services that respond to the needs of the families regarding housing, education and employment are priorities.

TRIAL REGISTRATION

The study was retrospectively registered on 11/08/2016 in the ISRCTN registry ( ISRCTN11832097 ).

How to support equal standing in local health equity?

Attempts to decrease socioeconomic health disparities face various challenges, which include ethical questions about prioritization and value-conflicts. To deal with these questions in a way that takes equal standing as a central value, this paper explores the potential of a relational egalitarian capability approach to local health equity policies. Especially for local health equity policies, a relational egalitarian capability approach seems promising as it offers more perspectives for action and evaluation additional to considerations of distributive justice. To scrutinize if this approach can offer an adequate normative basis for health equity policies and be a helpful ethical guide in practice, five desiderata are identified that a relational egalitarian capability approach to local health equity should fulfil. These desiderata stem from a consideration of political-ethical pluralism and scarcity of time and resources as non-ideal conditions characterizing public policy practice, as well as of three questions that any capability approach should answer to be applicable in practice. For each of the five desiderata, a brief outline is given of what relational egalitarian theories and the capability approach offer in response to the questions implied by these desiderata. Ultimately, these questions need to be answered in relation to specific policies in particular contexts.

Performance and resource requirements of in-person versus voice call versus automated telephone-based socioeconomic data collection modalities for community-based health programmes: a systematic review protocol

INTRODUCTION

Gathering data on socioeconomic status (SES) is a prerequisite for any health programme that aims to assess and improve the equitable distribution of its outcomes. Many different modalities can be used to collect SES data, ranging from (1) face-to-face elicitation, to (2) telephone-administered questionnaires, to (3) automated text message-based systems. The relative costs and perceived benefits to patients and providers of these different data collection approaches is unknown. This protocol is for a systematic review that aims to compare the resource requirements, performance characteristics, and acceptability to participants and service providers of these three approaches to collect SES data from those enrolled in health programmes.

METHODS AND ANALYSIS

An information specialist will conduct searches on the Cochrane Library, MEDLINE, Embase, Global Health, ClinicalTrials.gov, the WHO ICTRP and OpenGrey. All databases will be searched from 1999 to present with no language limits used. We will also search Google Scholar and check the reference lists of relevant articles for further potentially eligible studies. Any empirical study design will be eligible if it compares two or more modalities to elicit SES data from the following three; in-person, voice call, or automated phone-based systems. Two reviewers will independently screen titles, abstracts and full-text articles; and complete data extraction. For each study, we will extract data on the modality characteristics, primary outcomes (response rate and equivalence) and secondary outcomes (time, costs and acceptability to patients and providers). We will synthesise findings thematically without meta-analysis.

ETHICS AND DISSEMINATION

Ethical approval is not required, as our review will include published and publicly accessible data. This review is part of a project to improve equitable access to eye care services in low-ioncome and middle-income countries. However, the findings will be useful to policy-makers and programme managers in a range of health settings and non-health settings. We will publish our findings in a peer-reviewed journal and develop an accessible summary of results for website posting and stakeholder meetings.

PROSPERO REGISTRATION NUMBER

CRD42021251959.