Income-related health inequalities in Canada and the United States: a decomposition analysis

Decomposition analysis on the equity of health examination utilization for the middle-aged and elderly people in China: based on longitudinal CHARLS data from 2011 to 2018

BACKGROUND

This study aimed to investigate the utilization rate and equity of health examination service among the middle-aged and elderly population in China from 2011 to 2018. The contribution of various determinants to the inequity in health examination service utilization was also examined.

METHODS

Data from the China Health and Retirement Longitudinal Survey (CHARLS) were analyzed to assess the health examination service utilization rate among the middle-aged and elderly population. A concentration curve and concentration index were employed to measure the equity of health examination service utilization and decomposed into its determining factors. Horizontal inequity index was applied to evaluate the trends in equity of health examination service.

RESULTS

The health examination service utilization rates among the middle-aged and elderly population were 29.45%, 20.69%, 25.40%, and 32.05% in 2011, 2013, 2015, and 2018, respectively. The concentration indexes for health examination service utilization were 0.0080 (95% CI: - 0.0084, 0.0244), 0.0155 (95% CI: - 0.0054, 0.0363), 0.0095 (95% CI: - 0.0088, 0.0277), and - 0.0100 (95% CI: - 0.0254, 0.0054) from 2011 to 2018, respectively. The horizontal inequity index was positive from 2011 to 2018, evidencing a pro-rich inequity trend. Age, residence, education, region, and economic status were the major identified contributors influencing the equity of health examination service utilization.

CONCLUSIONS

A pro-rich inequity existed in health examination service utilization among the middle-aged and elderly population in China. Reducing the wealth and regional gap, providing equal educational opportunities, and strengthening the capacity for chronic disease prevention and control are crucial for reducing the inequity in health examination service utilization.

The role of innovative technologies in reducing health system inequity

The scarcity of Health Human Resources (HHR), regional disparities, and decentralized healthcare systems have profoundly affected health equity in Canada. Adequate HHR allocation is essential for equitable healthcare delivery, and the COVID-19 pandemic has revealed the importance of resilient and culturally diverse organizational HHR. Geography and infrastructure shortcomings aggravate healthcare equity. This study examines the role of innovative technologies in reducing inequity and provides four practice-based examples in different therapeutic areas. Long-term solutions such as collaborative networks, infrastructure improvements, and effective HHR planning can mitigate current challenges. However, in the short and medium terms, advanced medical technologies, digital health, and artificial intelligence can reduce health inequities by improving access, reducing disparities, optimizing resource utilization, and providing skill development opportunities for healthcare professionals.

A happy home? Socio-economic inequalities in depressive symptoms and the role of housing quality in nine European countries

BACKGROUND

This study examines the prevalence of and socio-economic inequalities in depressive symptoms in nine high-income European countries, focusing in particular on the role of housing quality.

METHODS

Using the European Social Survey, a concentration index of depressive symptoms in each country is estimated. The role of housing quality is assessed by examining the risk factors associated with the concentration index, using the Recentred Influence Function method. To contextualise the housing quality results, other predictors of inequalities in depressive symptoms inequalities are also quantified and discussed.

RESULTS

Our results indicate that inequalities in depressive symptoms are concentrated among poorer respondents both in each country and in total. Austria and Belgium have the lowest inequalities and France has the highest. No geographic pattern is evident. Housing problems are associated with higher inequalities in six of the nine countries in the sample. While no association is evident for indicators of socio-economic status such as years of education and income, financial strain is significant.

CONCLUSIONS

This study is the first to estimate the degree of socio-economic inequality in depressive symptoms across European countries. The association between poor housing and poorer inequalities suggests that housing has a role to play lowering depressive symptoms inequalities.

Catastrophic health expenditure and its inequality in rural China: based on longitudinal data from 2013 to 2018

BACKGROUND

Catastrophic health expenditure (CHE) is an important indicator of measuring health inequality. Previous studies mainly focused on specific vulnerable populations rather than a wider range of vulnerable areas through panel data. Rural China is often associated with an underdeveloped economy and insufficient health resources. This study aims to update the information on the extent of and trends in the incidence and inequality of CHE among the households of rural China through longitudinal survey data.

METHODS

Data were obtained from three waves of the China Health and Retirement Longitudinal Study (CHARLS): 2013, 2015, and 2018. In total, 2,575 households were included in the analysis. CHE was defined as household health expenditures exceeding 40% of non-food expenditures. Inequality in CHE was measured using the concentration curve and concentration index. The contribution to CHE inequality was decomposed using the concentration index decomposition method.

RESULTS

The incidence of CHE was 0.2341 (95% CI: 0.22, 0.25) in 2013, 0.2136 (95% CI: 0.20, 0.23) in 2015, and 0.2897 (95% CI: 0.27, 0.31) in 2018 in rural China. The concentration curve lay above the equality line, and the concentration index was negative: -0.1528 (95% CI: -0.1941, -0.1115) in 2013, -0.1010 (95% CI: -0.1442, -0. 0577) in 2015, and -0.0819 (95% CI: -0.1170, -0.0467) in 2018. Economic status, age, and chronic diseases were the main contributors to inequality in CHE.

CONCLUSIONS

The incidence of CHE in rural China displayed an upward trend from 2013 to 2018, although it was not continuous. Furthermore, a strong pro-low-economic inequality in CHE existed in rural China. Mainly economic status, age, and chronic diseases contributed to this pro-low-economic inequality. Health policies to allocate resources and services are needed to satisfy the needs of rural households and provide more accessible and affordable health services. More concern needs to be directed toward households with chronic diseases and older persons to reduce the incidence of CHE and promote health equality.

Factors Affecting the Good Governance in Teaching Hospitals: A Narrative Review

Background

One of the indicators of development in different countries is the efficiency of the health care system. Hospitals and health centers have a very important role in the sustainability of society as w well as its economic growth and development. Meanwhile, one of the important development indicators of hospitals is good governance. This study was aimed to determine the factors affecting good governance in teaching hospitals.

Methods

This study was a scoping review of Iranian databases, including IranDoc, ISD, Magiran and International databases such as Science Direct, ISI, PubMed and Scopus to meet the good governance factors in teaching hospitals. There were no time limitations to data collection. the keywords governance, good governance, hospital governance, and good governance in hospitals, teaching hospitals, hospital management, hospital leadership, and their synonyms were used in the search strategy. The content analysis method was used to analyze selected studies.

Results

The findings showed that the characteristics of effective governance in teaching hospitals can be considered as follow: efficiency, managing conflict of interests, facilitated operation, managed and under control activities, integration, and synergy, achieving the desired consequences, creating an atmosphere that is rewarding and for each member.

Conclusion

Based on the results regarding the good governance model in teaching hospitals, it is recommended that on the basis of the nature of service, the mission and value of teaching hospitals have to be clearly redefined. On the other hand, the methods based on which we treat patients should be seriously redefined and we should pay more attention to the patient's values because the patients feel that we are practicing and testing them.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIGHLIGHTS

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

Income-related inequalities in diagnosed diabetes prevalence among US adults, 2001-2018

AIMS

The overall prevalence of diabetes has increased over the past two decades in the United States, disproportionately affecting low-income populations. We aimed to examine the trends in income-related inequalities in diabetes prevalence and to identify the contributions of determining factors.

METHODS

We estimated income-related inequalities in diagnosed diabetes during 2001-2018 among US adults aged 18 years or older using data from the National Health Interview Survey (NHIS). The concentration index was used to measure income-related inequalities in diabetes and was decomposed into contributing factors. We then examined temporal changes in diabetes inequality and contributors to those changes over time.

RESULTS

Results showed that income-related inequalities in diabetes, unfavorable to low-income groups, persisted throughout the study period. The income-related inequalities in diabetes decreased during 2001-2011 and then increased during 2011-2018. Decomposition analysis revealed that income, obesity, physical activity levels, and race/ethnicity were important contributors to inequalities in diabetes at almost all time points. Moreover, changes regarding age and income were identified as the main factors explaining changes in diabetes inequalities over time.

CONCLUSIONS

Diabetes was more prevalent in low-income populations. Our study contributes to understanding income-related diabetes inequalities and could help facilitate program development to prevent type 2 diabetes and address modifiable factors to reduce diabetes inequalities.

Income-related health inequality among rural residents in western China

Objective

Health equality has drawn much public attention in both developed and developing countries. China, the largest developing country, has implemented a new round of health system reform to improve health equality since 2009. This study aims to examine the magnitude and sources of income-related health inequality in western rural regions of China.

Methods

Data were obtained from the Survey of Rural Economic and Social Development in Western China conducted in 2014, in which 14,555 individuals from 5,299 households in 12 provinces were included. Health outcome variables of interest were self-rated health status, prevalence of chronic disease and four-week illness. Concentration index was calculated to assess magnitude of income-related health inequality, and nonlinear decomposition analysis was performed to identify the sources of health inequality.

Results

The Concentration indexes for poor self-rated health status, prevalence of chronic disease and four-week illness were -0.0898 (P<0.001),-0.0860 (P<0.001) and -0.1284 (P<0.001), respectively. Income and education were two main sources of health inequality, accounting for about 25-50% and 15% contribution to the inequality. Ethnicity made <10% contribution to income-related health inequality, and enrollment in New Rural Cooperative Medical Scheme contributed to <1%.

Conclusion

This study found slight income-related health inequality among rural residents in western China, implying that although China has made substantial progress in economic development and poverty alleviation, health inequality in western rural region should still be concerned by the government. To achieve health equality further, the Chinese government should not only strengthen its reimbursement mechanism of the current health insurance scheme to improve affordability of primary healthcare for residents in western rural regions, but also implement health poverty alleviation policies targeting socioeconomically vulnerable population and ethnic minorities in future.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada

BACKGROUND

Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking.

QUESTIONS/PURPOSES

(1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario?

METHODS

We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups.

RESULTS

TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05).

CONCLUSION

These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A comparison of health and socioeconomic gradients in health between the United States and Canada

Data from the early 2000s indicated worse overall health and larger socioeconomic (SES) health inequalities in the U.S. than in Canada. Yet, sociopolitical contexts, health levels, and SES-health inequalities have changed in both countries during the intervening two decades. Drawing on new data, we update the comparison of health levels and SES-health gradients between the two countries. Analyses, focused on self-rated health, are based on two complementary sets of data sources: Resilience and Recovery (RR) data, a harmonized U.S.-Canada survey of social conditions collected in 2020 (N = 3743); and a pair of leading nationally representative health data sources from each country: the National Health Interview Surveys (NHIS, N = 104,027) and the Canadian Community Health Survey (CCHS, N = 97,605), both collected in 2017-2018. Health levels and disparities, net of demographic and socioeconomic covariates, were estimated using modified Poisson models for relative comparisons; descriptives and predicted levels of fair/poor health show the comparisons from absolute perspective. Both data sources show that U.S. adults continue to have significantly worse health than Canadians; the disadvantage may be due to SES differences between the two populations. However, the two data sources yield conflicting findings on SES-health inequalities: the RR data indicate no difference between the two countries in socioeconomic health gradients, while the NHIS/CCHS data show a significantly steeper gradient in the U.S. than in Canada for both education and income. Canadian adults continue to report better health than their U.S. peers, but it is unclear whether health inequalities remain smaller as well. We discuss potential reasons for the conflicting findings and call for a large new cross-national data collection, which will enable scholars and policymakers to better understand health and wellbeing in the U.S. and Canadian contexts.

Comparison of mortality hazard ratios associated with health behaviours in Canada and the United States: a population-based linked health survey study

BACKGROUND

Modern health surveillance and planning requires an understanding of how preventable risk factors impact population health, and how these effects vary between populations. In this study, we compare how smoking, alcohol consumption, diet and physical activity are associated with all-cause mortality in Canada and the United States using comparable individual-level, linked population health survey data and identical model specifications.

METHODS

The Canadian Community Health Survey (CCHS) (2003-2007) and the United States National Health Interview Survey (NHIS) (2000, 2005) linked to individual-level mortality outcomes with follow up to December 31, 2011 were used. Consistent variable definitions were used to estimate country-specific mortality hazard ratios with sex-specific Cox proportional hazard models, including smoking, alcohol, diet and physical activity, sociodemographic indicators and proximal factors including disease history.

RESULTS

A total of 296,407 respondents and 1,813,884 million person-years of follow-up from the CCHS and 58,232 respondents and 497,909 person-years from the NHIS were included. Absolute mortality risk among those with a 'healthy profile' was higher in the United States compared to Canada, especially among women. Adjusted mortality hazard ratios associated with health behaviours were generally of similar magnitude and direction but often stronger in Canada.

CONCLUSION

Even when methodological and population differences are minimal, the association of health behaviours and mortality can vary across populations. It is therefore important to be cautious of between-study variation when aggregating relative effect estimates from differing populations, and when using external effect estimates for population health research and policy development.

Regional and socioeconomic disparities in cardiovascular disease in Canada during 2005-2016: evidence from repeated nationwide cross-sectional surveys

Introduction

The objective of this study is to examine the temporal trends and patterns of regional and socioeconomic disparities in cardiovascular disease (CVD) in Canada during 2005–2016.

Methods

A total of 670 000 adults aged ≥20 years who participated in the Canadian Community Health Surveys between 2005 and 2016 were enrolled for this study. CVD referred to heart disease and stroke in this study. Equivalised household income was used as a proxy of socioeconomic status. Absolute and relative socioeconomic inequalities were measured by slope index of inequality (SII) and relative index of inequality (RII), respectively.

Results

In 2015/2016, the overall age-adjusted and sex-adjusted prevalence of heart disease and stroke was 4.80% (95% CI 4.61% to 4.98%) and 1.25% (95% CI 1.13% to 1.36%), respectively. Trend analyses suggested a significant decline in the age-adjusted and sex-adjusted prevalence of heart disease (P for trend <0.001) and a non-significant decline in the age-adjusted and sex-adjusted prevalence of stroke (P for trend=0.058) from 2005 to 2016. Nevertheless, the total number of adults suffering from heart disease and stroke increased by 8.9% and 20.2% over the study period, respectively. Moreover, the age-adjusted and sex-adjusted prevalence of heart disease and stroke varied widely across all health regions, and both of them tended be higher among those with lower income. The SII and RII indicated that there were persistent absolute and relative socioeconomic inequalities in heart disease and stroke across all surveys (eg, SII for heart disease in both sexes, 2005: 0.04 (95% CI 0.03 to 0.04); 2015/2016: 0.03 (95% CI, 0.02 to 0.04); RII for heart disease in both sexes, 2005: 1.99 (95% CI 1.75 to 2.27); 2015/2016: 1.77 (95% CI 1.52 to 2.08).

Conclusion

Geographical and socioeconomic disparities should be taken into account during the further efforts to strengthen preventive measures and optimise healthcare resources for heart disease and stroke in Canada.

Timing of Nerve Recovery After Nerve Grafting in Obstetrical Brachial Plexus Palsy Patients With Isolated Upper Trunk Neuromas

BACKGROUND

The timing of nerve recovery after nerve grafting in obstetrical brachial plexus palsy patients has not been well reported. One prior study reported a return to baseline function at 3 to 6 months postoperatively. However, there is a paucity of studies to corroborate this timing, and there have been no studies delineating the timeline to obtain clinically meaningful function.

METHODS

OBPP patients with upper trunk neuromas-in-continuity who were treated with resection and sural nerve grafting at a single institution were studied. Time to return to baseline function was assessed by Active Movement Scale (AMS) scores preoperatively and postoperatively. Time to clinically meaningful function, defined as an AMS score of ≥6, was also assessed.

RESULTS

Eleven patients with isolated upper trunk neuromas-in-continuity underwent excision and reversed sural nerve grafting. Three of 11 patients also underwent spinal accessory to suprascapular nerve transfers. Average age at surgery was 9.8 ± 1.9 months. One patient did not have follow-up data and was excluded. Average follow-up was 37.1 ± 16.8 months. Average return to baseline AMS score was approximately 4 to 8 months for shoulder abduction, shoulder flexion, shoulder external rotation, elbow flexion, and forearm supination. Clinically meaningful function was obtained in most patients between 9 and 15 months. The remaining patients who did not achieve clinically meaningful function had all obtained scores of 5, which reflects less than one half normal range of motion against gravity.

CONCLUSIONS

Nerve recovery after surgical intervention in OBPP patients who undergo resection of an upper trunk neuroma-in-continuity and nerve grafting is more rapid than in adults but longer than previously reported in OBPP literature. This study provides an important data point in delineating the timeline of nerve recovery.

Profiles of Depressive Symptoms and Diabetes Distress in Preadolescents With Type 1 Diabetes

OBJECTIVES

Diabetes distress and depressive symptoms are common psychosocial concerns for people with diabetes. These are related, yet distinct, mood states, which have each been related to diabetes management and glycated hemoglobin (A1C) among adolescents and adults with diabetes. However, they have not been examined concurrently in preadolescents with type 1 diabetes. Understanding the overlaps and distinctions between diabetes distress and depressive symptoms in youth would help guide decisions about psychosocial screening in diabetes clinical practice. In this study, we aimed to categorize preadolescents based on clinical cutoffs of concurrently administered measures of depressive symptoms and diabetes distress, and identify clinical and demographic characteristics of each group.

METHODS

One hundred eighty youth (age range, 9 to 13 years; age [mean ± standard deviation], 11.3±1.3 years; 55% female; 56% Caucasian; mean A1C, 8.4±1.6% [68 mmol/mol]) completed measures of diabetes distress, depressive symptoms and quality of life. Daily blood glucose monitoring frequency was calculated from meter download. A1C values were obtained from electronic medical records.

RESULTS

Depressive symptoms and diabetes distress each significantly correlated with A1C and quality of life. Although most (69%) participants had no clinically significant elevations in either diabetes distress or depressive symptoms, 14% had elevated depressive symptoms only and 17% had elevated distress without concurrent elevated depressive symptoms. Groups differed based on A1C, quality of life and insurance status.

CONCLUSIONS

Routine assessment of both depressive symptoms and diabetes distress may help to identify preadolescents with type 1 diabetes who require psychosocial support.

A Difference-in-Difference Study Evaluating the Effect of Minimum Wage Policy on Body Mass Index and Related Health Behaviors

Minimum wage laws are a promising policy lever to promote health equity, but few rigorous evaluations have tested whether and how minimum wage policy affects health outcomes. This paper describes an ongoing difference-in-difference study evaluating the health effects of the 2017 Minneapolis Minimum Wage Ordinance, which incrementally increases the minimum wage to $15/hr. We present: (1) the conceptual model guiding the study including mediating mechanisms, (2) the study design, and (3) baseline findings from the study, and (4) the analytic plan for the remainder of the study. This prospective study follows a cohort of 974 low-wage workers over four years to compare outcomes among low-wage workers in Minneapolis, Minnesota, and those in a comparison city (Raleigh, North Carolina). Measures include height/weight, employment paystubs, two weeks of food purchase receipts, and a survey capturing data on participant demographics, health behaviors, and household finances. Baseline findings offer a profile of individuals likely to be affected by minimum wage laws. While the study is ongoing, the movement to increase local and state minimum wage is currently high on the policy agenda; evidence is needed to determine what role, if any, such policies play in improving the health of those affected.

Inequality in health insurance coverage before and after the Affordable Care Act

This study examines how the Affordable Care Act (ACA) affected income related inequality in health insurance coverage in the United States. Analyzing data from the American Community Survey (ACS) from 2010 through 2018, we apply difference-in-differences, and triple-differences estimation to the Recentered Influence Function OLS estimation. We find that the ACA reduced inequality in health insurance coverage in the United States. Most of this reduction was a result of the Medicaid expansion. Additional decomposition analysis shows there was little change in inequality of coverage through an employer plan, and a decrease in inequality for coverage through direct purchase of health insurance. These results indicate that the insurance exchanges also contributed to declining inequality in health insurance coverage.

Explaining the gaps in psychological distress and suicidal behaviours between non-Indigenous and Indigenous adults living off-reserve in Canada: a cross-sectional study

BACKGROUND

Indigenous people are disproportionately affected by mental health issues in Canada. We investigated factors underlying the difference in psychological distress and suicidal behaviours between non-Indigenous and Indigenous populations living off-reserve in Canada.

METHODS

We conducted a cross-sectional study using data from the 2012 Canadian Community Health Survey - Mental Health. Respondents were aged 18 years and older. We measured the variation in psychological distress (10-item Kessler Psychological Distress Scale scores, ranging from 10 [no distress] to 50 [severe distress]) and the prevalence of lifetime suicidal ideation and suicide plan between the Indigenous and non-Indigenous populations and explained these differences using the Blinder-Oaxaca approach.

RESULTS

The overall response rate for the survey was 68.9%, comprising 18 300 respondents (933 Indigenous and 17 367 non-Indigenous adults). We found lower mean psychological distress scores among non-Indigenous people than among Indigenous people (15.1 v. 16.1, p < 0.001) and a lower prevalence of lifetime suicidal ideation (9.2% v. 16.8%, p < 0.001) and plan (2.3% v. 6.8%, p < 0.001). We found that if socioeconomic status among Indigenous people were made to be similar to that of the non-Indigenous population, the differences in mean psychological distress scores and prevalence of lifetime suicidal ideation and suicide plan would have been reduced by 25.7% (women 20.8%, men 36.9%), 10.2% (women 11.2%, men 11.9%) and 5.8% (women 7.8%, men 8.1%), respectively.

INTERPRETATION

Socioeconomic factors account for a considerable proportion of the variation in mental health outcomes between non-Indigenous and Indigenous populations in Canada. Improving socioeconomic status among Indigenous people through plans like income equalization may reduce the gap in mental health outcomes between the 2 populations in Canada.

Inequities in curative health-care utilization among the adult population (20-59 years) in India: A comparative analysis of NSS 71st (2014) and 75th (2017-18) rounds

OBJECTIVE

The study attempts (a) to compute the degree of socio-economic inequity in health care utilization and (b) to decompose and analyze the drivers of socio-economic inequity in health care utilization among adults (20-59 years) in India during the periods 2014 and 2017-18.

DATA SOURCE

The analysis has been done by using the unit level data of Social Consumption: Health (Schedule number 25.0), of National sample Survey (NSS), corresponding to the 71st and 75th rounds.

METHODS

Odds ratios were computed through logistic regression analysis to examine the effect of the socio-economic status on the health seeking behaviour of the ailing adult population in India. Concentration Indices (CIs) were calculated to quantify the magnitude of socio-economic inequity in health care utilization. Further, the CIs were decomposed to find out the share of the major contributory factors in the overall inequity.

RESULTS

The regression results revealed that socio-economic status continues to show a strong association with treatment seeking behavior among the adults in India. The positive estimates of CIs across both the rounds of NSS suggested that health care utilization among the adults continues to be concentrated within the higher socio-economic status, although the magnitude of inequity in health care utilization has shrunk from 0.0336 in 2014 to 0.0230 in 2017-18. However, the relative contribution of poor economic status to the overall explained inequities in health care utilisation observed a rise in its share from 31% in 2014 to 45% in 2017-18.

CONCLUSION

To reduce inequities in health care utilization, policies should address issues related to both supply and demand sides. Revamping the public health infrastructure is the foremost necessary condition from the supply side to ensure equitable health care access to the poor. Therefore, it is warranted that India ramps up investments and raises the budgetary allocation in the health care infrastructure and human resources, much beyond the current spending of 1.28% of its GDP as public expenditure on health. Further, to reduce the existing socio-economic inequities from the demand side, there is an urgent need to strengthen the redistributive mechanisms by tightening the various social security networks through efficient targeting and broadening the outreach capacity to the vulnerable and marginalized sections of the population.

Family income and insufficient medical care: A prospective study of alternative explanations

Aims: Equity of access to medical care is a central objective in socialised and national health insurance systems. Based on a national panel survey of Icelandic adults, the study examined the effects of family income on insufficient medical care and whether income-related differences were explained by overall financial strain, health-care cost burden, cultural variables or barriers related to health-system obstacles or experiences. Methods: The study used two-wave panel data from national postal health surveys of Icelandic adults aged 18-75. Insufficient medical care was assessed in terms of both reported delay/cancellation of physician care and estimated underutilisation when comparing actual and professionally recommended physician visits. Results: The study found that individuals with lower family incomes were more likely to delay or cancel a needed physician visit and underutilise medical care compared to their higher-income counterparts. High relative out-of-pocket costs, overall financial strain and negative experiences of medical care fully accounted for the disadvantaged medical access of lower-income individuals. The most important explanatory variable was out-of-pocket costs, as it affected insufficient medical care both directly and indirectly by compounding economic difficulties in the family. Attitudes, beliefs and health-related behaviours had limited effects on insufficient medical care and did not account for income-related differences. Conclusions: Poorer access to needed medical care among lower-income individuals was explained by high relative out-of-pocket costs, overall financial strain and negative medical-care experiences. Efforts to reduce income differences in access to needed medical care should address these factors.

Does household income mediate the association between education and health in Canada?

Objectives: The study aim was to investigate whether household income mediates the association between education and health in a nationally representative sample of Canadian adults. Methods: The data came from the Longitudinal and International Study of Adults linked to income data from the Canada Revenue Agency. Odds ratios and predicted probabilities from binary logistic regression models were used to describe associations between education and (a) self-rated health, (b) longstanding illness or health problem, (c) emotional, psychological or mental health problem and (d) symptoms of psychological distress. The Karlson-Holm-Breen decomposition method was used to investigate the potentially mediating role of household income in these associations. The analyses were conducted separately for women and men. Results: Education was significantly associated with all four health indicators for both women and men. Of the four health indicators, education was most strongly associated with self-rated health for both women and men. Education was more strongly associated with self-rated health and the presence of an emotional, psychological or mental health problem for women than for men. Curiously, men with a postgraduate degree were significantly more likely than men with a bachelor degree to report symptoms of psychological distress. Only modest proportions of the associations between education and health could be attributed to differences in household income. Education and household income manifested independent associations with all four health indicators among women and with three of four health indicators among men. Conclusions: Education and household income are joint and independent predictors of health in Canada. Accordingly, both should be included in research on socioeconomic health inequalities in this context.

Dentistry's social contract is at risk

BACKGROUND

The implications of the social contract for medicine and those it serves has been debated by bioethicists, political scientists, and physicians. Far less attention, however, has been given to dentistry's social contract.

METHODS

The existing literature from medicine is used to explore the social contract and the role of dentistry in today's society, focusing on several areas of interest.

RESULTS

The authors' analysis discusses the history of the social contract and its implications for professionalism. The authors examine the failure of the dental profession to adequately address population needs and inequities in oral health, situating this in the context of an increasingly commodified, commercialized, cosmetically oriented, and proprietary culture in the profession. The authors highlight the important role of organized dentistry in facilitating change and renewing the social contract.

CONCLUSIONS

The authors conclude that reforms are necessary for dentistry to remain a profession.

PRACTICAL IMPLICATIONS

The authors' findings may inform oral health policies and underscore the need for change among dental providers and organized dentistry to maintain dentistry's professional status.

Healthcare provider perspectives on inequities in access to care for patients with inherited bleeding disorders

INTRODUCTION

The ways in which social determinants of health affect patients with inherited bleeding disorders remains unclear. The objective of this study was to understand healthcare provider perspectives regarding access to care and diagnostic delay amongst this patient population.

METHODS

A healthcare provider survey comprising 24 questions was developed, tested, and subsequently disseminated online with recruitment to all members of The Association of Hemophilia Clinic Directors of Canada (N = 73), members of the Canadian Association of Nurses in Hemophilia Care (N = 40) and members of the Canadian Physiotherapists in Hemophilia Care (N = 44).

RESULTS

There were 70 respondents in total, for a total response rate of 45%. HCPs felt that there were diagnostic delays for patients with mild symptomatology (71%, N = 50), women presenting with abnormal uterine bleeding as their only or primary symptom (59%, N = 41), and patients living in rural Canada (50%, N = 35). Fewer respondents felt that factors such as socioeconomic status (46%, N = 32) or race (21%, N = 15) influenced access to care, particularly as compared to the influence of rural location (77%, N = 54).

DISCUSSION

We found that healthcare providers identified patients with mild symptomatology, isolated abnormal uterine bleeding, and residence in rural locations as populations at risk for inequitable access to care. These factors warrant further study, and will be investigated further by our group using our nation-wide patient survey and ongoing in-depth qualitative patient interviews.

Comparing the education gradient in health deterioration among the elderly in six OECD countries

Inequalities in health by educational attainment are persistent both over time and across countries. However, their magnitudes, evolution, and main drivers are not necessarily consistent across jurisdictions. We examine the health deterioration-education gradient among older adults in the United States, Canada, France, the Netherlands, Spain and Italy, including how it changes over time between 2004 and 2010. Using longitudinal survey data, we first assess how rates of health deterioration in terms of poor health, difficulties with activities of daily living, and chronic conditions vary by educational attainment. We find systematic differences in rates of health deterioration, as well as in the health deterioration-education gradients, across countries. We then examine how potential confounders, including demographic characteristics, income, health care utilisation and health behaviours, affect the health deterioration-education gradient within countries over time. We demonstrate that while adjusting for confounders generally diminishes the health deterioration-education gradient, the impacts of these variables vary somewhat across countries. Our findings suggest that determinants of, and policy levers to affect, the health deterioration-education gradient likely vary across countries and health systems.

Inequity in inpatient services utilization: a longitudinal comparative analysis of middle-aged and elderly patients with the chronic non-communicable diseases in China

Background

Aging and the chronic non-communicable diseases (NCDs) challenge the Chinese government in the process of providing hospitalization services fairly and reasonably. The Chinese government has developed the basic medical insurance system to solve the problem of “expensive medical cost and difficult medical services” for vulnerable groups and alleviate the unfair phenomenon. However, few studies have confirmed its effect through longitudinal comparison. This study aimed to explore the trend in the inequity of inpatient use among middle-aged and elderly individuals with NCDs in China.

Methods

This longitudinal comparative study was based on CHARLS data in 2011, 2013 and 2015. Concentration index (CI) was used to measure the variation trend of inequity of inpatient services utilization, while the decomposition method of the CI was applied to measure the factors contributing to inequity in inpatient services utilization. The effect of each factor on the change of inequity in inpatient services utilization was divided into the change of the elasticity and the change of inequality using the Oaxaca-type decomposition method.

Results

The affluent middle-aged and elderly patients with NCDs used more inpatient services than poor groups. The per capita household consumption expenditure (PCE) and Urban Employee Basic Medical Insurance (UEBMI) contributed to the decline in pro-rich inequality of inpatient use, while the New Rural Cooperative Medical Scheme (NRCMS) contributed to the decline in pro-poor inequality of inpatient use.

Conclusions

There was a certain degree of pro-rich unfairness in the probability and frequency of inpatient services utilization for middle-aged and elderly individuals with NCDs in China. The decrease of pro-wealth contribution of PCE and UEBMI offset the decrease of pro-poor contribution of NRCMS, and improved the equity of inpatient services utilization, favoring poor people.

Inequality in the health services utilization in rural and urban china: A horizontal inequality analysis

BACKGROUND

Inequality in health and health care remains a rather challenging issue in China, existing both in rural and urban area, and between rural and urban. This study used nationally representative data to assess inequality in both rural and urban China separately and to identify socioeconomic factors that may contribute to this inequality.

METHODS

This study used 2008 National Health Services Survey data. Demographic characteristics, income, health status, medical service utilization, and medical expenses were collected. Horizontal inequality analysis was performed using nonlinear regression method.

RESULTS

Positive inequity in outpatient services and inpatient service was evident in both rural and urban area of China. Greater inequity of outpatient service use in urban than that in rural areas was evident (horizontal inequity index [HI] = 0.085 vs 0.029). In contrast, rural areas had greater inequity of inpatient service use compared to urban areas (HI = 0.21 vs 0.16). The decomposition analysis found that the household income made the greatest pro-rich contribution in both rural and urban China. However, chronic diseases and aging were also important contributors to the inequality in rural area.

CONCLUSION

The inequality in health service in both rural and urban China was mainly attributed to the household income. In addition, chronic disease and aging were associated with inequality in rural population. Those findings provide evidences for policymaker to develop a sustainable social welfare system in China.

Socioeconomic inequalities in psychological distress and suicidal behaviours among Indigenous peoples living off-reserve in Canada

BACKGROUND

Indigenous peoples in Canada have high rates of psychological distress and suicide. We sought to assess the socioeconomic inequalities in psychological distress and suicidal behaviours, and the factors that explain them within Indigenous peoples living off-reserve.

METHODS

Using the nationally representative 2012 Aboriginal Peoples Survey collected from Indigenous adults living off-reserve in Canada, we measured income-related inequalities in psychological distress (measured on the 10-item Kessler Psychological Distress Scale) and suicidal behaviours (suicidal ideation and suicide attempt) and identified factors contributing to these inequalities using the concentration index (C) approach.

RESULTS

Among 14 410 individuals representing 600 750 Indigenous adults (aged ≥ 18 yr) living off-reserve in Canada, the mean score of psychological distress was 16.1; 19.4% reported lifetime suicidal ideation and 2.2% reported a lifetime suicide attempt. Women had higher psychological distress scores (mean score 16.7 v. 15.2, p < 0.001), and prevalence of suicidal ideation (21.9% v. 16.1%, p < 0.001) and suicide attempts (2.3% v. 2.0%, p = 0.002) than men. Poorer individuals disproportionately experienced higher psychological distress (C = -0.054, 95% confidence interval [CI] -0.057 to -0.050), suicidal ideation (C _n = -0.218, 95% CI -0.242 to -0.194) and suicide attempts (C _n = -0.327, 95% CI -0.391 to -0.263). Food insecurity and income, respectively, accounted for 40.2% and 13.7% of the psychological distress, 26.7% and 18.2% of the suicidal ideation and 13.4% and 7.8% of the suicide attempts concentrated among low-income Indigenous peoples.

INTERPRETATION

Substantial income-related inequalities in psychological distress and suicidal behaviours exist among Indigenous peoples living off-reserve in Canada. Policies designed to address major contributing factors such as food insecurity and income may help reduce these inequalities.

Fruit and Vegetable Purchases in Farmer's Market Stands: Analysing Survey and Sales Data

Farmers' market implementation holds promise for increasing access to healthy foods. Although rarely measured, purchase data constitute an intermediate outcome between food environment and actual consumption. In a study conducted with two seasonal Fruits and Vegetables (FV) stands in a disadvantaged area of Montréal (Canada), we analysed how accessibility, perception, and mobility-related factors were associated with FV purchase. This analysis uses a novel measure of FV purchasing practices based on sales data obtained from a mobile application. A 2016 survey collected information on markets' physical access, perceived access to FV in the neighbourhood, usual FV consumption and purchases. Multivariate models were used to analyse three purchasing practice indicators: number of FV portions, FV variety and expenditures. Average shoppers purchased 12 FV portions of three distinct varieties and spent 5$. Shoppers stopping at the market on their usual travel route spent less (p = 0.11), bought fewer portions (p = 0.03) and a lesser FV variety (p < 0.01). FV stands may complement FV dietary intake. Individuals for whom the market is on their usual travel route might make more frequent visits and, therefore, smaller purchases. The novel data collection method allowed analysis of multiple purchase variables, is precise and easy to apply at unconventional points of sales and could be transposed elsewhere.

Inequality in geographical distribution of hospitals and hospital beds in densely populated metropolitan cities of Iran

Background

This study aims to assess geographical distribution of hospitals and extent of inequalities in hospital beds against socioeconomic status (SES) of residents of five metropolitan cities in Iran.

Methods

A cross-sectional analysis was conducted to measure geographical inequality in hospital and hospital bed distributions of 68 districts in five metropolitan cities during 2016 using geographic information system (GIS), and Gini and Concentration indices. Correlation analysis was performed to show the relationship between the SES and inequality in hospital beds densities.

Results

The study uncovered marked inequalities in hospitals and hospital beds distributions. The Gini indices for hospital beds were greater than 0.55. The aggregated concentration indices for public and private hospital beds were 0.33 and 0.49, respectively. The GIS revealed that 216 (70.6%) hospitals were located in two highest socioeconomic status classes in the cities. Only 29 (9.5%) hospitals were located in the lowest class. The public, private, and the cumulative hospitals beds distributions in Tehran and Esfahan showed significant (p < 0.05) positive correlation with SES of the residents.

Conclusions

The high inequalities in hospital and hospital beds distributions in our study imply an overlooked but growing concern for geographical access to healthcare in rapidly urbanizing metropolitan cities in Iran. Thus, regardless of ownership, decision-makers should emphasize the disadvantaged areas in metropolitan cities when need arises for the establishment of new healthcare facilities in order to ensure fairness in healthcare. The metropolitan cities and rapid urbanization settings in other countries could learn lessons to reduce or prevent similar issues which might have hampered access to healthcare.

Economic Inequality in Life Satisfaction and Self-perceived Health in Iranian Children and Adolescents: The CASPIAN IV Study

Background:

The purpose of this study was to assess socioeconomic status (SES) inequality in life satisfaction (LS) and good self-perceived health (SPH) in Iranian children and adolescents.

Methods:

This nationwide study was conducted as part of a fourth national school-based surveillance program performed on 14880 students aged 6–18 years who were living in urban and rural areas of 30 provinces of Iran between 2011 and 2012. Using principle component analysis, the SES of participants was constructed as single variable. SES inequality in LS and good SPH across the SES quintiles was assessed using the concentration index (C) and slope index of inequality (SII). The determinants of this inequality are investigated by the Oaxaca Blinder decomposition method.

Results:

Frequency of LS along with the SES quintiles shifted significantly from 73.28% (95% CI: 71.49, 75.08) in the lowest quintile to 86.57% (95% CI:85.20, 87.93) in the highest SES quintile. Frequency of favorable SPH linearly increased from lowest SES quintile (76.18% (95% CI: 74.45, 77.92)) to highest SES quintile (83.39% (95% CI: 81.89, 84.89)). C index for LS and good SPH was negative, which suggests inequality was in favor of high SES group. SII for LS and SPH was 15.73 (95% CI: 12.10, 19.35) and 8.21 (95% CI: 5.46, 10.96)]. Living area and passive smoking were the most contributed factors in SES inequality of LS. Also passive smoking and physical activity were the most contributed factors in SES inequality of SPH.

Conclusions:

SES inequality in LS and good SPH was in favor of high SES group. These findings are useful for health policies, better programming and future complementary analyses.

Social determinants of health and self-rated health status: A comparison between women with HIV and women without HIV from the general population in Canada

BACKGROUND

Women living with HIV (WLWH) continue to experience poorer outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health. We compared socio-structural determinants of health and self-rated health between WLWH and expected general population values.

METHODS

Prevalences of socio-structural determinants and self-rated health were estimated from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Prevalences were also estimated from 46,831 general population women (assumed HIV-negative) in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. Standardized prevalence differences (SPDs) and 95% confidence intervals (CI) were reported.

RESULTS

Compared to general population women, a higher proportion of WLWH reported annual personal income <$20,000 (SPD 42.2%; 95% CI: 39.1, 45.2), indicating that 42.2% of WLWH experienced this low income, in excess of what would be expected of Canadian women of similar ages/ethnoracial backgrounds. A higher proportion of WLWH reported severe food insecurity (SPD 43.9%; 40.2, 47.5), poor perceived social support (SPD 27.4%; 22.2, 33.0), frequent racial (SPD 36.8%; 31.9, 41.8) and gender (SPD 46.0%; 42.6, 51.6) discrimination, and poor/fair self-rated health (SPD 12.2%; 9.4, 15.0).

CONCLUSIONS

Significant socio-structural inequalities and lower self-rated health were found among WLWH compared to general population women. Such inequities support the integration of a social-determinants approach, social service delivery, and programming into HIV care, with additional resource allocation tailored to the particular needs of WLWH.

Care of acute conditions and chronic diseases in Canada and the United States: Rapid systematic review and meta-analysis

This study tested the hypothesis that socioeconomically vulnerable Canadians with diverse acute conditions or chronic diseases have health care access and survival advantages over their counterparts in the USA. A rapid systematic review retrieved 25 studies (34 independent cohorts) published between 2003 and 2018. They were synthesized with a streamlined meta-analysis. Very low-income Canadian patients were consistently and highly advantaged in terms of health care access and survival compared with their counterparts in the USA who lived in poverty and/or were uninsured or underinsured. In aggregate and controlling for specific conditions or diseases and typically 4 to 9 comorbid factors or biomarkers, Canadians' chances of receiving better health care were estimated to be 36% greater than their American counterparts (RR=1.36, 95% CI 1.35-1.37). This estimate was significantly larger than that based on general patient or non-vulnerable population comparisons (RR=1.09, 95% CI 1.08-1.10). Contrary to prevalent political rhetoric, three studies observed that Americans experience more than twice the risk of long waits for breast or colon cancer care or of dying while they wait for an organ transplant (RR=2.36, 95% CI 2.09-2.66). These findings were replicated across externally valid national studies and more internally valid, metropolitan or provincial/state comparisons. Socioeconomically vulnerable Canadians are consistently and highly advantaged on health care access and outcomes compared to their American counterparts. Less vulnerable comparisons found more modest Canadian advantages. The Affordable Care Act ought to be fully supported including the expansion of Medicaid across all states. Canada's single payer system ought to be maintained and strengthened, but not through privatization.

Lifestyle and socio-economic inequalities in diabetes prevalence in South Africa: A decomposition analysis

BACKGROUND

Inequalities in diabetes are widespread and are exacerbated by differences in lifestyle. Many studies that have estimated inequalities in diabetes make use of self-reported diabetes which is often biased by differences in access to health care and diabetes awareness. This study adds to this literature by making use of a more objective standardised measure of diabetes in South Africa. The study estimates socio-economic inequalities in undiagnosed diabetes, diagnosed diabetes (self-reported), as well as total diabetes (undiagnosed diabetics + diagnosed diabetics). The study also examines the contribution of lifestyle factors to diabetes inequalities in South Africa.

METHODS

This cross sectional study uses data from the 2012 South African National Health and Nutrition Examination Survey (SANHANES-1) and applies the Erreygers Concentration Indices to assess socio-economic inequalities in diabetes. Contributions of lifestyle factors to inequalities in diabetes are assessed using a decomposition method.

RESULTS

Self-reported diabetes and total diabetes (undiagnosed diabetics + diagnosed diabetics) were significantly concentrated amongst the rich (CI = 0.0746; p < 0.05 and CI = 0.0859; p < 0.05). The concentration index for undiagnosed diabetes was insignificant but pro-poor. The decomposition showed that lifestyle factors contributed 22% and 35% to socioeconomic inequalities in self-reported and total diabetes, respectively.

CONCLUSION

Diabetes in South Africa is more concentrated amongst higher socio-economic groups when measured using self-reported diabetes or clinical data. Our findings also show that the extent of inequality is worse in the total diabetes outcome (undiagnosed diabetics + diagnosed diabetics) when compared to the self-reported diabetes outcome. Although in comparison to other determinants, the contribution of lifestyle factors was modest, these contributions are important in the development of policies that address socio-economic inequalities in the prevalence of diabetes.

Transnational wealth-related health inequality measurement

The study of international differences in wealth-related health inequalities has traditionally consisted of country-by-country comparisons using own-country relative measures of socioeconomic status, which effectively ignores absolute differences in both wealth and health that can differ between and within countries. To address these limitations, we propose an alternative approach: that of constructing a transnational measure of wealth-related health inequality. To illustrate the limitations of the country-by-country approach, we simulate the impact of changes in wealth and health inequalities both between and within countries on cross-country measures of health inequality and find at least five errors that may arise using country-by-country methods. We then empirically demonstrate the transnational approach to wealth-related health inequalities between and within Haiti and the Dominican Republic, the two constituent countries of the island of Hispaniola, using data from their respective Demographic and Health Surveys. Transnational socioeconomic rankings reveal a large and increasing divergence in wealth between the two countries, which would be ignored using the county-by-country approach. We find that wealth-related inequalities in long-term children’s health outcomes are larger than inequalities in short-term health outcomes, and decompositions of the influence of place-based variables on these inequalities reveal country of residence to be the most important factor for long-term outcomes, while urban/rural residence and subnational regions are more important for short-term health outcomes. The significance of this novel methodological approach in relation to conventional health inequality research, including hidden dimensions of wealth-related health inequalities, for example the urbanized “middle class” distribution of HIV and a hidden unequal burden of wasting among children uncovered by the transnational approach are discussed, and errors in gauging changes in inequality over time using a country-by-country approach are highlighted. Using the transnational approach can help to measure important trends in wealth-related health inequalities across countries that more commonly used methods traditionally overlook.

•

Simulated data reveals limitations in measuring health inequalities across countries.

•

We calculate transnational measures of SES-related health inequalities for Hispaniola.

•

Country residence drives child health inequalities, subregions drive HIV inequality.

•

Hidden HIV and wasting inequalities are uncovered with the transnational approach.

•

Country-by-country methods misidentify secular transnational inequality trends.

Explaining mental health inequalities in Northern Sweden: a decomposition analysis

Background: There has been a substantial increase of income inequalities in Sweden over the last 20 years, which also could be reflected in health inequalities, including mental health inequalities. Despite the growing body of literature focusing on health inequalities in Sweden, income-related inequalities in mental health have received little attention. Particularly scarce are research from Northern Sweden and examinations of the social determinants of health inequalities.

Objectives: The present study seeks to provide evidence regarding inequalities in mental health in Northern Sweden. The specific aims were to (1) quantify the income-related inequality in mental health in Northern Sweden, and (2) determine the contribution of social determinants to the inequality.

Methods: The study population comprised 25,646 participants of the 2014 Health on Equal Terms survey in the four northernmost counties of Sweden, aged 16 to 84 years old. Income-related inequalities in mental health were quantified by the concentration index and further decomposed by applying Wagstaff-type decomposition analysis.

Results: The overall concentration index of mental health in Northern Sweden was

−0.15 (95% CI: −0.17 to −0.13), indicating income inequalities in mental health disfavoring the less affluent population. The decomposition analysis results revealed that socio-economic conditions, including employment status (31%), income (22.6%), and cash margin (14%), made the largest contribution to the pro-rich inequalities in mental health. The second-largest contribution came from demographic factors, mainly age (11.3%) and gender (6%). Psychosocial factors were of smaller importance, with perceived discrimination (8%) and emotional support (3.4%) making moderate contributions to the health inequalities. Conclusions: The present study demonstrates substantial income-related mental health inequalities in Northern Sweden, and provides insights into their underpinnings. These findings suggest that addressing the root causes is essential for promoting mental health equity in this region.

Promoting access to fresh fruits and vegetables through a local market intervention at a subway station

OBJECTIVE

Alternative food sources (AFS) such as local markets in disadvantaged areas are promising strategies for preventing chronic disease and reducing health inequalities. The present study assessed how sociodemographic characteristics, physical access and fruit and vegetable (F&V) consumption are associated with market use in a newly opened F&V market next to a subway station in a disadvantaged neighbourhood.

DESIGN

Two cross-sectional surveys were conducted among adults: (i) on-site, among shoppers who had just bought F&V and (ii) a telephone-based population survey among residents living within 1 km distance from the market.

SETTING

One neighbourhood in Montreal (Canada) with previously limited F&V offerings.

SUBJECTS

Respectively, 218 shoppers and 335 residents completed the on-site and telephone-based population surveys.

RESULTS

Among shoppers, 23 % were low-income, 56 % did not consume enough F&V and 54 % did not have access to a car. Among all participants living 1 km from the market (n 472), market usage was associated (OR; 95 % CI) with adequate F&V consumption (1·86; 1·10, 3·16), living closer to the market (for distance: 0·86; 0·76, 0·97), having the market on the commute route (2·77; 1·61, 4·75) and not having access to a car (2·96; 1·67, 5·26).

CONCLUSIONS

When implemented in strategic locations such as transport hubs, AFS like F&V markets offer a promising strategy to improve F&V access among populations that may be constrained in their food acquisition practices, including low-income populations and those relying on public transportation.

Equity in the quality of hospital services in Iran

Background: Providing fair access to high-quality healthcare services is one of the most important goals of health systems. This study was conducted between 2012 and 2013 to determine the level of equity in the quality of hospital services in Iran. Methods: In this cross-sectional study, 1,003 patients were chosen from 100 hospitals in Iran with multi-stage random cluster sampling. Concentration index was calculated to determine equity of healthcare quality from patients' viewpoint. Furthermore, the equity of hospital services' quality was investigated from experts' perspective by calculating Gini index based on the hospitals' accreditation scores. Analyzing the related factors was done by logistic regression. The significance level was set at α=0.05. Data were analyzed using Excel v.2010, SPSS v.21, and Stata v.8. Results: There was a significant inequity in the quality of hospital services in both patients' and experts' point of view. In fact, concentration index (95% confidence interval) for the quality of healthcare was significant, 0.128 (0.080, 0.176), indicating better quality of services for those with higher economic status from patients' point of view. Furthermore, Gini index (95% confidence interval) for hospitals' accreditation scores was 0.166 (0.156, 0.176), meaning that there was inequity in hospital services quality from experts' point of view. Conclusion: The significant inequality observed in the quality of hospital care based on the economic status of the patients highlights the necessity of the supportive policies aiming at reduction of this condition.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (C_Erreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the C_Erreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.

Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data

BACKGROUND

The burden of multimorbidity is a growing clinical and health system problem that is known to be associated with socioeconomic status, yet our understanding of the underlying determinants of inequalities in multimorbidity and longitudinal trends in measured disparities remains limited.

METHODS

We included all adult respondents from four cycles of the Canadian Community Health Survey (CCHS) (between 2005 to 2011/12), linked at the individual-level to health administrative data in Ontario, Canada (pooled n = 113,627). Multimorbidity was defined at each survey response as having ≥2 (of 17) high impact chronic conditions, based on claims data. Using a decomposition method of the Erreygers-corrected concentration index (CErreygers), we measured household income inequality and the contribution of the key determinants of multimorbidity (including socio-demographic, socio-economic, lifestyle and health system factors) to these disparities. Differences over time are described. We tested for statistically significant changes to measured inequality using the slope index (SII) and relative index of inequality (RII) with a 2-way interaction on pooled data.

RESULTS

Multimorbidity prevalence in 2011/12 was 33.5% and the CErreygers was - 0.085 (CI: -0.108 to - 0.062), indicating a greater prevalence among lower income groups. In decomposition analyses, income itself accounted more than two-thirds (69%) of this inequality. Age (21.7%), marital status (15.2%) and physical inactivity (10.9%) followed, and the contribution of these factors increased from baseline (2005 CCHS survey) with the exception of age. Other lifestyle factors, including heavy smoking and obesity, had minimal contribution to measured inequality (1.8 and 0.4% respectively). Tests for trends (SII/RII) across pooled survey data were not statistically significant (p = 0.443 and 0.405, respectively), indicating no change in inequalities in multimorbidity prevalence over the study period.

CONCLUSIONS

A pro-rich income gap in multimorbidity has persisted in Ontario from 2005 to 2011/12. These empirical findings suggest that to advance equality in multimorbidity prevalence, policymakers should target chronic disease prevention and control strategies focused on older adults, non-married persons and those that are physically inactive, in addition to addressing income disparities directly.

Are neighbourhood inequalities in adult health explained by socio-economic and psychosocial determinants in adolescence and the subsequent life course in northern Sweden? A decomposition analysis

This study explains neighbourhood deprivation inequalities in adult health for a northern Swedish cohort by examining the contribution of socio-economic and psychosocial determinants from adolescence (age 16), young adulthood (age 21) and midlife (age 42) to the disparity. Self-reported information from 873 participants was drawn from questionnaires, with complementary neighbourhood register data. The concentration index was used to estimate the inequality while decomposition analyses were run to attribute the disparity to its underlying determinants. The results suggest that socio-economic and psychosocial factors in midlife explain a substantial part, but also that the inequality can originate from conditions in adolescence and young adulthood.

The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys

Background

Socioeconomic inequalities in health have been documented in many countries including those in the Southern African Development Community (SADC). However, a comprehensive assessment of health inequalities and inequalities in the distribution of health risk factors is scarce. This study specifically investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries.

Methods

Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered. Other environmental factors were also considered. Socioeconomic status was assessed using household expenditures. Standardised and normalised concentration indices (CIs) were used to assess socioeconomic inequalities. A positive (negative) concentration index means a pro-rich (pro-poor) distribution where the variable is reported more among the rich (poor).

Results

Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa (CI = − 0.0573; p < 0.05), and marginally significant for Zambia (CI = − 0.0341; P < 0.1) and Zimbabwe (CI = − 0.0357; p < 0.1). Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health.

Conclusion

There is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, inter-sectoral action is required.

Local Income Inequality, Individual Socioeconomic Status, and Unmet Healthcare Needs in Ohio, USA

Purpose: Income inequality has been implicated as a potential risk to population health due to lower provision of healthcare services in deeply unequal countries or communities. We tested whether county economic inequality was associated with individual self-report of unmet healthcare needs using a state health survey data set. Methods: Adults residents of Ohio responding to the 2015 Ohio Medicaid Assessment Survey were included in the analysis. Ohio's 88 counties were classified into quartiles according to the Gini coefficient of income inequality. The primary outcome was a composite of self-reported unmet dental care, vision care, mental healthcare, prescription medication, or other healthcare needs within the past year. Unmet healthcare needs were compared according to county inequality quartile using weighted logistic regression. Results: The analytic sample included 37,140 adults. The weighted proportion of adults with unmet healthcare needs was 28%. In multivariable logistic regression, residents of counties in the highest (odds ratio [OR]=1.13, 95% confidence interval [CI]: 1.01-1.26; p=0.030) and second-highest (OR=1.16, 95% CI: 1.04-1.30; p=0.010) quartiles of income inequality experienced more unmet healthcare needs than residents of the most equal counties. Conclusion: Higher county-level income inequality was associated with individual unmet healthcare needs in a large state survey. This finding represents novel evidence for an individual-level association that may explain aggregate-level associations between community economic inequality and population health outcomes.

Comparing the effects of China's three basic health insurance schemes on the equity of health-related quality of life: using the method of coarsened exact matching

BACKGROUND

China has three basic health insurance schemes: Urban Employee Basic Medical Insurance (UEBMI), Urban Resident Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS). This study aimed to compare the equity of health-related quality of life (HRQoL) of residents under any two of the schemes.

METHODS

Using data from the 5th National Health Services Survey of Shaanxi Province, China, coarsened exact matching method was employed to control confounding factors. We included a matched sample of 6802 respondents between UEBMI and URBMI, 34,169 respondents between UEBMI and NRCMS, and 36,928 respondents between URBMI and NRCMS. HRQoL was measured by EQ-5D-3L based on the Chinese-specific value set. Concentration index was adopted to assess health inequality and was decomposed into its contributing factors to explain health inequality.

RESULTS

After matching, the horizontal inequity indexes were 0.0036 and 0.0045 in UEBMI and URBMI, 0.0035 and 0.0058 in UEBMI and NRCMS, and 0.0053 and 0.0052 in URBMI and NRCMS respectively, which were mainly explained by age, educational and economic statuses. The findings demonstrated the pro-rich health inequity was much higher for the rural scheme than that for the urban ones.

CONCLUSION

This study highlights the need to consolidate all three schemes by administrating uniformly, merging funds pooling and benefit packages. Based on the contributing factors, strategies aim to facilitate health conditions of the elderly, narrow economic gap, and reduce educational inequity, are essential. This study will provide evidence-based strategies on consolidating the fragmented health schemes towards reducing health inequity in both China and other developing countries.

Clinical and Psychological Drivers of Perceived Health Status in Adults With Congenital Heart Disease

The factors having the greatest impact on self-reported health status in adults with congenital heart disease (ACHD) remain incompletely studied. We conducted a single-site, cross-sectional study of ACHD patients followed at the Center for ACHD at Washington University School of Medicine, including retrospectively gathered clinical data and psychometric and health status assessments completed at the time of enrollment. To identify primary drivers of perceived health status, we investigated the impact of the demographic, clinical, and psychological variables on self-reported health status as assessed using the Rand 36-Item Short Form Health Survey. Variables with significant associations within each domain were considered jointly in multivariable models constructed via stepwise selection. There was domain-specific heterogeneity in the variables having the greatest effect on self-reported health status. Depression was responsible for the greatest amount of variability in health status in all domains except physical functioning. In the physical functioning domain, depression remained responsible for 5% of total variability, the third most significant variable in the model. In every domain, depression more strongly influenced health status than did any cardiac-specific variable. In conclusion, depression was responsible for a significant amount of heterogeneity in all domains of self-perceived health status. Psychological variables were better predictors of health status than clinical variables.

Breast Cancer Care in California and Ontario: Primary Care Protections Greatest Among the Most Socioeconomically Vulnerable Women Living in the Most Underserved Places

BACKGROUND

Better health care among Canada's socioeconomically vulnerable versus America's has not been fully explained. We examined the effects of poverty, health insurance and the supply of primary care physicians on breast cancer care.

METHODS

We analyzed breast cancer data in Ontario (n = 950) and California (n = 6300) between 1996 and 2000 and followed until 2014. We obtained socioeconomic data from censuses, oversampling the poor. We obtained data on the supply of physicians, primary care and specialists. The optimal care criterion was being diagnosed early with node negative disease and received breast conserving surgery followed by adjuvant radiation therapy.

RESULTS

Women in Ontario received more optimal care in communities well supplied by primary care physicians. They were particularly advantaged in the most disadvantaged places: high poverty neighborhoods (rate ratio = 1.65) and communities lacking specialist physicians (rate ratio = 1.33). Canadian advantages were explained by better health insurance coverage and greater primary care access.

CONCLUSIONS

Policy makers ought to ensure that the newly insured are adequately insured. The Medicaid program should be expanded, as intended, across all 50 states. Strengthening America's system of primary care will probably be the best way to ensure that the Affordable Care Act's full benefits are realized.

Association of regional disparity of obstetrics and gynecologic services with children and infants mortality rates: A cross-sectional study

BACKGROUND

Equity in distribution of resources is considered as an important priority in health care systems. Equitable distribution of obstetrics and gynecology (Ob/Gyn) services in the country level is critical in maternal and neonatal health for qualitative promotion of maternal care in pregnancy, delivery, and post-delivery periods.

OBJECTIVE

The present study aimed at determining regional disparity of obstetrics and gynecology services and its association with children and infants mortality rates.

MATERIALS AND METHODS

This was a descriptive-analytical study conducted in 2015 to investigate distribution of Ob/Gyn services using three indicators of number of nursing and midwifery personnel, total Ob/Gyn specialists, and total delivery beds among 30 provinces of the country. Equity criteria in the present study included population, normal vaginal deliveries, cesarean sections, and total deliveries. Data were gathered using a researcher-made form and Stata 12 was used to calculate Gini coefficient. The association of Ob/Gyn services with children and infant mortality rates was investigated using SPSS package and linear regression test.

RESULTS

The lowest Gini coefficient was observed in distribution of nursing and midwifery personnel in delivery wards in terms of vaginal delivery (0.38 from 1) and the highest value was related to distribution of Ob/Gyn specialists in terms of vaginal delivery (0.73 from 1). Infant mortality was significantly associated with number of nursing and midwifery personnel in delivery wards, and total number of Ob/Gyn specialists.

CONCLUSION

Considering new population policies in Iran and increased fertility rate, it is recommended to facilitate accessibility of the required services for the women, particularly those of reproductive age.

Income-related inequalities in visual impairment and eye screening services in patients with type 2 diabetes

Objective

We aimed to measure income-related inequalities in visual impairment and use of eye screening services amongst Canadian living with type 2 diabetes, and to examine contribution of various socio-demographic factors to identified income-related inequalities.

Methods

We used data from the Survey on Living with Chronic Disease in Canada-Diabetes Component 2011 (SLCDC-DM) to derive the relative concentration index (RCI) and decomposition of the RCI.

Results

Individuals with lower income tended to have more visual impairment compared with those with higher income. The main contribution to the observed income inequality in visual impairment came from age and marital status. Regarding eye screening services, patients with higher income were more likely to use eye screening and preventive eye screening services. The main contributors to increased use were income, having private health insurance and patient's experience in discussing diabetic complications with health professionals.

Conclusion

Identified contributors of income-related inequality should be considered when health and healthcare policies are developed in order to minimize and mitigate the observed inequalities.