Series: Public engagement with research. Part 2: GPs and primary care researchers working inclusively with minoritised communities in health research to help address inequalities

Public engagement in health research is vital for addressing health disparities and promoting inclusivity among minoritised communities who often face barriers to accessing healthcare. Minoritised communities are groups, which have been made minorities by a dominant culture, race, ethnic group and/or social class and may experience health inequalities as a result. By incorporating diverse perspectives and lived experiences of minoritised communities, this approach aims to achieve contextually relevant research outcomes that reduce health inequalities and improve overall well-being. However, underrepresentation and lack of inclusivity challenges persist, necessitating the establishment of inclusive partnerships and grassroots participatory methodologies.

To foster inclusive public engagement, it is important to overcome structural and cultural barriers, address socioeconomic challenges, and build trust with minoritised communities. This can be achieved by promoting a cultural shift that values inclusivity, providing comprehensive training to researchers, and collecting rigorous data on engagement demographics for transparency and accountability. Involving minoritised communities in decision-making through participatory research approaches enhances trust and yields successful outcomes. Additionally, allocating sufficient resources, collaborating in co-production, and prioritising the diverse needs and perspectives of stakeholders contribute to fostering inclusive public engagement in research.

Overall, inclusive engagement practices particularly in primary care research have the potential to reduce health inequalities and cater to the unique requirements of minoritised communities, thereby creating more impactful outcomes and promoting equitable healthcare access.

Inequalities in sexual and reproductive outcomes among women aged 16-24 in England (2012-2019)

BACKGROUND

Women aged 16-24 in England have a high burden of sexual and reproductive morbidity, with particularly poor outcomes among people living in more deprived areas (including racially minoritised populations). This analysis used national data to examine the disparities within sexual and reproductive outcomes among this population and to assess whether the patterns of inequality were consistent across all outcomes.

METHODS

Within this ecological study, univariable and multivariable Poisson regression analyses of neighbourhood-level data from national data sets were carried out to investigate the relationships of deprivation and ethnicity with each of six dependent variables: gonorrhoea and chlamydia testing rates, gonorrhoea and chlamydia test positivity rates, and abortion and repeat abortion rates.

RESULTS

When comparing Index of Multiple Deprivation (IMD) decile 1 (most deprived) and IMD decile 10 (least deprived), chlamydia (RR 0.65) and gonorrhoea (0.79) testing rates, chlamydia (0.70) and gonorrhoea (0.34) positivity rates, abortion rates (0.45) and repeat abortion rates (0.72) were consistently lower in IMD decile 10 (least deprived). Similarly, chlamydia (RR 1.24) and gonorrhoea positivity rates (1.92) and repeat abortion rates (1.31) were higher among black women than white women. Results were similar when both ethnicity and deprivation were incorporated into multivariable analyses.

CONCLUSION

We found similar patterns of outcome inequality across a range of sexual and reproductive outcomes, despite multiple differences in the drivers of each outcome. Our analysis suggests that there are broad structural causes of inequality across sexual and reproductive health that particularly impact the health of deprived and black populations.

The Alcohol Harm Paradox in Periodontitis

Individuals of lower socioeconomic position (SEP) experience a greater rate of alcohol-related harms, yet they consume equal or lower amounts of alcohol than higher-SEP individuals. This phenomenon, called the "alcohol harm paradox" (AHP), gained attention recently, and different mechanisms have been proposed to explain it. Since both SEP and alcohol have been suggested to be associated with periodontitis risk, we conducted a secondary analysis using data from the National Health and Nutrition Examination Survey 2011 to 2012 and 2013 to 2014 cycles, aiming to examine 1) whether the association between alcohol consumption and periodontitis is modified by SEP and 2) the extent to which the effect of SEP inequalities on periodontitis is mediated by and/or interacts with alcohol consumption. We set educational attainment as the main SEP proxy and tested the poverty income ratio in subsequent sensitivity analyses. Effect measure modification analysis was employed, considering heavy drinking as exposure, and causal mediation analysis based on the potential outcome's framework decomposed the effect of SEP on periodontitis in proportions attributable to mediation and interaction. Models were fitted using binary logistic regression and adjusted for sex, ethnicity, age, body mass index, smoking status, diabetes, binge drinking, and regular preventive dental visits. The analytical sample comprised 4,057 participants. After adjusting for covariates, less educated heavy drinkers presented 175% (odds ratio, 2.75; 95% confidence interval [CI], 2.04-3.72) higher odds of periodontitis than their counterparts, and super-additive associations were found (relative excess risk due to interaction: 1.35; 95% CI, 0.49-2.20). Additionally, -69.5% (95% CI, -122.1% to -16.8%) of the effects of education on periodontitis were attributable to interaction with heavy drinking, consistent with the AHP. No contribution was found for the mechanism of mediation. Heavy drinking disproportionately impacts the occurrence of periodontitis in lower-SEP individuals. Lower-SEP individuals seem to experience differential effects of heavy drinking on periodontitis.

Inequalities in Healthcare Access, Experience and Outcomes in Adults With Inflammatory Bowel Disease: A Scoping Review

BACKGROUND

Inflammatory bowel diseases (IBDs) are incurable diseases that require lifelong access to health services. Accumulating evidence of inequalities in health care access, experience, and outcomes for individuals with IBD is apparent. This review aimed to describe the inequalities in healthcare access, experiences, and outcomes of care for adults with IBD, to identify research gaps, and to identify future research priorities in this area.

METHODS

A scoping review was conducted to retrieve quantitative, qualitative, and mixed methods evidence from 3 databases (EMBASE, Medline, and CINAHL) published between January 1, 2000, and September 27, 2023.

RESULTS

Fifty-one studies met the criteria for inclusion. The majority (42 of 51) focused on IBD health outcomes, followed by healthcare access (24 of 51). Significantly fewer investigated patient experiences of IBD healthcare (8 of 51). Most available studies reported on race/ethnic disparities of healthcare (33 of 51), followed by inequalities driven by socioeconomic differences (12 of 51), rurality (7 of 51), gender and sex (3 of 51), age (2 of 51), culture (2 of 51), literacy (1 of 51), and sexuality (1 of 51). Inflammatory bowel disease patients from Black, Asian, and Hispanic ethnic groups had significantly poorer health outcomes. A lack of research was found in the sexual and gender minority community (1 of 51). No research was found to investigate inequalities in IBD patients with learning disabilities or autism.

CONCLUSIONS

Further research, particularly utilizing qualitative methods, is needed to understand health experiences of underserved patient populations with IBD. Cultural humility in IBD care is required to better serve individuals with IBD of Black and Asian race/ethnicity. The lack of research amongst sexual and gender minority groups with IBD, and with learning disabilities, poses a risk of creating inequalities within inequalities.

Role of Grassroots Public Health Leadership in Bedouin Society in Israel in Reducing Health Disparities

Introduction

Negev Bedouin settlements suffer from poor infrastructure, and the population's health status is low across all indicators. While it is difficult for Bedouin citizens of Israel to integrate into the Israeli employment market, integrating this population into the health system is far-reaching. The aim of this study is to analyze the barriers and motivational factors experienced by Bedouin doctors to promote public health in the Bedouin community in southern Israel and to examine the perceptions these doctors have around the concept of leadership in a public health setting.

Methods

We conducted semi-structured interviews with Bedouin doctors from the Negev Bedouin community and analyzed them using thematic analysis.

Results

Most interviewees saw themselves as leaders whose role was to improve public health in their community. They stressed the need for health leadership in Negev Bedouin society, and their desire to lead change in the community from within. All interviewees had grown used to a different way of life and a higher standard of living, and as a result, had difficulty returning home. Interviewees presented that trust in the health system is a critical factor for the success of health promotion programs. However, they noted the evolving trends of general mistrust in the government and its institutions that form the infrastructure for mistrust in the health system. Lack of time and workload were barriers to exercising leadership. Interviewees reported their perception of how socioeconomic status, the standard of living, and lack of infrastructure, education, and training affect health outcomes and collaboration potential.

Discussion

This study presents a unique perspective on the views of doctors from the Negev Bedouin population on their involvement with grassroots leadership as a strategy to reduce health disparities in this community.

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.

Understanding Health Inequalities Research Capacities: Insights and Recommendations From Comparing Two High Income Settings

Generating evidence on health inequalities (HI) is necessary to raise awareness of these issues, describe and monitor their evolution, analyze their causes, and inform interventions aiming to improve health equity. Yet not all cities and countries have the capacity to produce this type of research. Recent research provides new contextual and causal insights into this research production process, and in-depth understanding on why and how this type of research is produced in certain settings. This article aims to analyze two recent case studies that have uniquely explored this process in two high producers of HI research and high-income country settings to identify learning and distil recommendations, which may be insightful for other settings. Expanding and investing in this line of research is critical, particularly in places with lower HI research output and related capacity, in order to identify key contextual conditions and mechanisms that may enable or hinder this process. This new knowledge could guide the development of new HI research capacity strengthening strategies to foster this research in different settings, worldwide. More understanding is also needed on the relationship between HI research, policy, and action in order to tackle HI.

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study

BACKGROUND AND AIM

Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid.

METHODS

An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration.

FINDINGS

Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources.

CONCLUSION

We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma.

PATIENT OR PUBLIC CONTRIBUTION

This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

A scoping study on the social determinants of health and sugar consumption in the context of policy approaches for improving population health

OBJECTIVES

To conduct a scoping review of existing research on the social determinants of health, sugar consumption and public health policy responses to address or improve health outcomes.

METHODS

A total of 13 categories were developed to reflect the authors' interest in the overall focus on the social determinants of health, sugar as an independent risk factor, upstream policy action ('whole populations'), downstream policy action ('targeted') and two contemporary policy strategies (namely 'Vulnerable populations' and 'Proportionate Universalism'). The search strategy was then performed on MEDLINE (via Ovid) and Web of Science, and was limited to the English language. No time limits prior to when the database search was conducted in 2022 were set to explore the full extent of the literature in this field.

RESULTS

Five hundred and sixty articles were retrieved, of which 181 met the criteria for review. When all categories were applied, the findings showed that 76% of papers focusing on sugar consumption as a risk factor for non-communicable diseases (NCDs) mentioned the social determinants of health. The majority of studies (60%) recommended downstream interventions, with 40% recommending 'upstream' interventions. A limited proportion (12%) of research work was published in dental journals. Research had been done using predominantly quantitative methods (66% of articles), with 24% of studies adopting a mixed methods approach, and 8% being exclusively qualitative. Research on contemporary strategies for sugar reduction were focused on the 'Global North' and 98% of papers used individual level data focused on targeted approaches, highlighting that there is little direct evidence for contemporary strategies aimed at reducing sugar consumption.

CONCLUSIONS

Whilst the majority of public and dental health research argues that there is a need to address the social determinants of health, the findings from this study highlight that very few empirical studies have been designed to directly inform contemporary strategies for sugar reduction. More research is therefore needed that can directly assess the evidence for contemporary strategies in public health policy.

When nursing education becomes political: Norm-critical perspectives in a campus-based clinical learning environment

Nursing education is in the process of incorporating critical thinking, social justice, and health inequality perspectives into educational structures, aspiring to help nursing students develop into professional nurses prepared to provide equal care. Norm criticism is a pedagogical philosophy that promotes social justice. This qualitative case study aimed to gain an understanding of and elaborate on an educational development initiative in which norm criticism was incorporated into the composition of a new campus-based clinical learning environment for nursing education. By analyzing documents and interviews with the help of reflexive thematic analysis three themes were generated: "Intention to educate beyond nursing education," "Educating in alliance with society," and "The educative ambiguity of the Clinical Learning Centre." The case study indicates that the incorporation of norm criticism into a campus-based clinical learning environment may encourage nursing students to evolve social skills for nursing practice that support health equality within healthcare. By collaborating with society, nursing education can considerably improve its educational frameworks in alignment with societal demands. However, the inclusion of norm criticism in a setting such as a campus-based clinical learning environment entails a clash with established institutionalized norms and being perceived as too proximate to politics.

The role of differential exposure and susceptibility to heavy drinking linking income inequalities and tooth loss: An investigation of the alcohol harm paradox using a four-way decomposition analysis

OBJECTIVES

To examine the extent to which the effect of income inequalities on tooth loss is attributable to differential exposure and susceptibility to heavy drinking in older Brazilian adults.

METHODS

We conducted a secondary analysis using data from The Brazilian Longitudinal Study of Ageing (ELSI-Brazil 2015-2016), a nationally representative sample of community-dwelling people aged 50 years and over. Causal mediation analysis based on the counterfactual outcome framework decomposed the effect of income on tooth loss mediated by heavy drinking into four components (four-way decomposition): controlled direct effect (neither mediation nor interaction), reference interaction (interaction only), mediated interaction (both mediation and interaction) and pure indirect effect (mediation only). Proportions of effect attributable to each component were calculated to estimate the differential exposure (the sum of the third and fourth components) and differential susceptibility (the sum of the second and third components) to heavy drinking.

RESULTS

The analytical sample comprised 8114 participants. After adjusting for covariates, 7.3% (95% CI: 3.8%; 10.9%) and -39.5% (95% CI: -75.8%; -3.3%) of the effects of income on tooth loss were attributable to differential exposure and susceptibility to heavy drinking, respectively, consistent with the alcohol harm paradox. When setting non-functional dentition as outcome, only the effect of differential susceptibility remained (-81.7% [95% CI: -128.2%; -35.2%]).

CONCLUSION

Our findings suggest that individuals of low-income groups appear to be more susceptible to the effects of heavy drinking on tooth loss.

Income disparities in loss in life expectancy after colon and rectal cancers: a Swedish register-based study

BACKGROUND

Differences in the prognosis after colorectal cancer (CRC) by socioeconomic position (SEP) have been reported previously; however, most studies focused on survival differences at a particular time since diagnosis. We quantified the lifetime impact of CRC and its variation by SEP, using individualised income to conceptualise SEP.

METHODS

Data included all adults with a first-time diagnosis of colon or rectal cancers in Sweden between 2008 and 2021. The analysis was done separately for colon and rectal cancers using flexible parametric models. For each cancer and income group, we estimated the life expectancy in the absence of cancer, the life expectancy in the presence of cancer and the loss in life expectancy (LLE).

RESULTS

We found large income disparities in life expectancy after a cancer diagnosis, with larger differences among the youngest patients. Higher income resulted in more years lost following a cancer diagnosis. For example, 40-year-old females with colon cancer lost 17.64 years if in the highest-income group and 13.68 years if in the lowest-income group. Rectal cancer resulted in higher LLE compared with colon cancer. Males lost a larger proportion of their lives. All patients, including the oldest, lost more than 30% of their remaining life expectancy. Based on the number of colon and rectal cancer diagnoses in 2021, colon cancer results in almost double the number of years lost compared with rectal cancer (24 669 and 12 105 years, respectively).

CONCLUSION

While our results should be interpreted in line with what individualised income represents, they highlight the need to address inequalities.

Social Disadvantage and Multimorbidity Including Oral Conditions in the United States

Existing studies on multimorbidity have largely excluded oral diseases in multimorbidity prevalence estimates. The reason behind this is somewhat unclear, as chronic oral conditions are highly prevalent, affecting over half the global population. To address this gap, we examined the relationship between social disadvantage and multimorbidity, stratifying by the inclusion and exclusion of oral conditions. For participants aged 30 y and over (n = 3,693), cross-sectional analysis was carried out using the US National Health and Nutrition Survey (2013-2014). Multimorbidity was defined as having 2 or more chronic conditions. Five medical conditions were examined: diabetes, asthma, arthritis, cardiovascular disease, and depression, as well as 4 oral health conditions: caries, periodontal disease, number of teeth, and edentulousness. Education and income poverty ratio were selected as measures of social disadvantage. Multimorbidity prevalence estimates according to social disadvantage were analyzed on an absolute and relative scale using inverse probability treatment weighting (IPTW), adjusting for age, sex, and ethnicity. The inclusion of oral health conditions in the assessment of multimorbidity increased the overall prevalence of multimorbidity from 20.8% to 53.4%. Findings from IPTW analysis demonstrated clear social gradients for multimorbidity estimates stratified by the exclusion of oral conditions. Upon inclusion of oral conditions, the prevalence of multimorbidity was higher across all social groups for both education and income. Stratifying by the inclusion of oral conditions, the mean probability of multimorbidity was 27% (95% confidence interval [CI], 23%-30%) higher in the low-education group compared to the high-education group. Similarly, the mean probability of multimorbidity was 44% (95% CI, 40%-48%) higher in the low-income group. On a relative scale, low education was associated with a 1.52 times (95% CI, 1.44-1.61) higher prevalence of multimorbidity compared to high education. Low income was associated with a 2.18 (95% CI, 1.99-2.39) higher prevalence of multimorbidity. This novel study strongly supports the impact of chronic oral conditions on multimorbidity prevalence estimates.

Socioeconomic-Status-Based Disrespect, Discrimination, Exclusion, and Shaming: A Potential Source of Health Inequalities?

Observing an association between socioeconomic status (SES) and health reliably leads to the question, "What are the pathways involved?" Despite enormous investment in research on the characteristics, behaviors, and traits of people disadvantaged with respect to health inequalities, the issue remains unresolved. We turn our attention to actions of more advantaged groups by asking people to self-report their exposure to disrespect, discrimination, exclusion, and shaming (DDES) from people above them in the SES hierarchy. We developed measures of these phenomena and administered them to a cross-sectional U.S. national probability sample (N = 1,209). Consistent with the possibility that DDES represents a pathway linking SES and health, the SES→health coefficient dropped substantially when DDES variables were controlled: 112.9% for anxiety, 43.8% for self-reported health, and 49.4% for cardiovascular-related conditions. These results illustrate a need for a relational approach emphasizing the actions of more advantaged groups in shaping health inequities.

Contribution of causes of death to changing inequalities in life expectancy by income in Finland, 1997-2020

BACKGROUND

Socioeconomic inequalities in mortality originate from different causes of death. Alcohol-related and smoking-related deaths are major drivers of mortality inequalities across Europe. In Finland, the turn from widening to narrowing mortality disparities by income in the early 2010s was largely attributable to these causes of death. However, little is known about recent inequalities in life expectancy (LE) and lifespan variation.

METHODS

We used individual-level total population register-based data with annual information on disposable household income and cause-specific mortality for ages 30-95+, and assessed the contribution of smoking on mortality using the Preston-Glei-Wilmoth method. We calculated trends in LE at age 30 and SD in lifespan by income quintile in 1997-2020 and conducted age and cause-of-death decompositions of changes in LE.

RESULTS

Disparity in LE and lifespan variation by income increased in 2015-2020, largely attributable to the stagnation of both measures in the lowest income quintile. The LE gap between the extreme quintiles in 2018-2020 was 11.2 (men) and 5.9 (women) years, of which roughly 40% was attributable to alcohol and smoking. However, the recent widening of the gap and the stagnation in LE in the lowest quintile over time were not driven by any specific cause-of-death group.

CONCLUSIONS

After a decade of narrowing inequalities in LE and lifespan variation in Finland, the gaps between income groups are growing again. Increasing LE disparity and stagnating mortality on the lowest income levels are no longer attributable to smoking and alcohol-related deaths but are more comprehensive, originating from most cause-of-death groups.

GP access for inclusion health groups: perspectives and recommendations

BACKGROUND

General practice has seen the widespread adoption of remote consulting and triage systems. There is a lack of evidence exploring how inclusion health populations have been impacted by this transformation.

AIM

This study aimed to explore the post-pandemic GP access for inclusion health populations, through the lens of those with lived experience, and identify practical recommendations for improving access for this population.

DESIGN & SETTING

A mixed methods study exploring the direct experience of people from inclusion health groups trying to access GP care in 13 practices in east London.

METHOD

A mystery shopper exercise involving 39 in-person practice visits and 13 phone-calls were undertaken. The findings were reflected upon by a multidisciplinary stakeholder group which identified recommendations for improvements.

RESULTS

Only 31% of the mystery shopper visits (n=8) resulted in registration and the offer of an appointment to see a GP for an urgent problem. None of the mystery shoppers was able to book an appointment over the phone but 10/13 felt that they would be able to register and make an appointment if they followed the receptionist's instructions. Most mystery shoppers felt respected, listened to and understood the information provided to them. Just under half of the practices (46%, n=6) received positive comments on how accessible and supportive their spaces felt.Practice and system-level recommendations were identified by the stakeholder group.

CONCLUSION

Ongoing GP access issues persist for inclusion health populations. We identified practice and system level recommendations for improving access for this vulnerable population.

Nordic paradox in action: The complicated relation between social mobility and health inequalities in an international comparative study

AIMS

Socio-economic inequalities originate from several channels, one of which is family origins, with clear effects on people's health. This paper aims to evaluate the role played by social mobility in determining health inequalities, relying on Blau and Duncan's status attainment model and focusing specifically on two moments of social reproduction of inequalities: one inter-generational, based on the transmission of resources from the family of origin, the other intra-generational, related to the capitalisation of economic resources to maximise well-being.

METHODS

Multi-group models of structural equations were used to examine the direct and indirect effects of parental cultural background, education and economic conditions of respondents on self-perceived health in 28 countries, relying on the European Social Survey (N=38,879).

RESULTS

Overall, the results confirmed the presence of an inter-generational transmission of social and health status. Different models of transmission of health inequalities emerged among the countries considered. Countries characterised by a social democratic welfare regime showed higher social mobility and fewer health inequalities, although in correspondence with a prominent role of economic factors in determining health conditions. On the other hand, in countries where social mobility is lower, health inequalities are more pronounced, yet driven by factors others than economics, such as socio-cultural origins.

CONCLUSIONS

The presence of a higher economic-health gradient in social democratic countries - notwithstanding their egalitarian and universal welfare policies - provides support for the existence of a Nordic paradox in relation to health inequalities.

Socio-economic inequalities in smoking and drinking in adolescence: Assessment of social network dynamics

AIMS

We investigated whether (1) adolescents selected friends with a similar socio-economic status (SES), (2) smoking and alcohol consumption spread in networks and (3) the exclusion of non-smokers or non-drinkers differed between SES groups.

DESIGN

This was a longitudinal study using stochastic actor-oriented models to analyze complete social network data over three waves.

SETTING

Eight Hungarian secondary schools with socio-economically diverse classes took part.

PARTICIPANTS

This study comprised 232 adolescents aged between 14 and 15 years in the first wave.

MEASUREMENTS

Self-reported smoking behavior, alcohol consumption behavior and friendship ties were measured. SES was measured based upon entitlement to an income-tested regular child protection benefit.

FINDINGS

Non-low-SES adolescents were most likely to form friendships with peers from their own SES group [odds ratio (OR) = 1.07, 95% confidence interval (CI) = 1.02-1.11]. Adolescents adjusted their smoking behavior (OR = 24.05, 95% CI = 1.27-454.86) but not their alcohol consumption (OR = 1.65, 95% CI = 0.62-4.39) to follow the behavior of their friends. Smokers did not differ from non-smokers in the likelihood of receiving a friendship nomination (OR = 0.98, 95% CI = 0.87-1.10), regardless of their SES. Alcohol consumers received significantly more friendship nominations than non-consumers (OR = 1.16, 95% CI = 1.01-1.33), but this association was not significantly different according to SES.

CONCLUSIONS

Hungarian adolescents appear to prefer friendships within their own socio-economic status group, and smoking and alcohol consumption spread within those friendship networks. Socio-economic groups do not differ in the extent to which they encourage smoking or alcohol consumption.

How do we measure unmet need within sexual and reproductive health? A systematic review

BACKGROUND

Addressing health inequality with sexual and reproductive health requires an understanding of unmet need within a range of populations. This review examined the methods and definitions that have been used to measure unmet need, and the populations most frequently assessed.

METHODS

Five databases (PubMed, Web of Science, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Health Management and Policy Database (HMIC)) were searched for studies that described quantitative measurement of unmet need within sexual and/or reproductive health between 2010 and 2021. A narrative synthesis was then undertaken to ascertain themes within the literature.

RESULTS

The database search yielded 19,747 papers; 216 papers were included after screening. 190 studies assessed unmet reproductive health need, of which 137 were analyses of trends among people living in low/lower-middle income countries; 181 used cross-sectional data, with only nine analyses being longitudinal. Eighteen studies analysed unmet sexual health need, of which 12 focused on high and upper-middle income populations. 16 papers used cross-sectional analyses. The remaining 10 studies examined unmet need for a combination of sexual and reproductive health services, eight among populations from upper-middle or high income countries. All were cross-sectional analyses. 165 studies used the Demographic and Health Surveys (DHS) definition of unmet need; no other standardised definition was used among the remaining papers.

DISCUSSION

There is a significant focus on unmet need for contraception among women in low income countries within the published literature, leaving considerable evidence gaps in relation to unmet need within sexual health generally and among men in particular, and unmet reproductive health need in high income settings. In addition, using an increased range of data collection methods, analyses and definitions of unmet need would enable better understanding of health inequality in this area.

Informal care and mental health in Germany: What are the differences between non-migrants and ethnic German immigrants? A longitudinal comparative analysis

OBJECTIVE

In aging Germany, a large part of care is provided by informal caregivers. We aimed to analyze the main drivers of the mental health of caregivers and their intersection with migration status.

METHODS

Using panel data covering 18 years (n = 25,659 individuals, aged 16 to 103 years; mean age of 49.5 years) and applying linear regression models we investigated the association between informal caregiving and mental health. We compared non-migrant Germans (NMG) and ethnic German immigrants (EGI), who are the oldest immigrant group in Germany. Informal caregiving was defined as living with a person in need of care or by providing care for ≥2 h per day; the main health outcomes were mental health and mental health changes, measured by a metric scale of six items.

RESULTS

Even accounting for selection into caregiving, short-term care seemed to be disadvantageous only for NMG, while long-term care was generally associated with poorer mental health, with a particular disadvantage for EGI. Socio-economic characteristics and personality traits affected mental health changes, but only weakly the caregiving-health association.

CONCLUSION

Informal caregiving presents a health burden which is not explained by socio-economic characteristics and personality, but by migration status. Policies to promote health in an aging society need to consider differences in short- and long-term care provision and between migrants and the non-migrants.

Unlocking the mechanisms of change in the MAMAACT intervention to reduce ethnic disparity in stillbirth and newborns' health: integration of evaluation findings

Ethnic disparities in stillbirth exist in Europe and suboptimal care due to miscommunication is one contributing cause. The MAMAACT intervention aimed to reduce ethnic disparity in stillbirth and newborns' health through improved management of pregnancy complications. The intervention encompassed training of antenatal care midwives in cultural competencies and intercultural communication combined with health education materials for the expecting parents about symptoms of pregnancy complications. The evaluation consisted of a qualitative in-depth implementation analysis and a process evaluation embedded in a cluster randomized trial including 19 of 20 maternity wards in Denmark. In this article, the findings from the different evaluation perspectives are integrated. The integration follows the principles of realist evaluation by analyzing to what extent the MAMAACT activities were generating mechanisms of change in interaction with the context. The integration analysis shows that the health education materials in the MAMAACT intervention contributed to heightened health literacy concerning pregnancy complications among pregnant women. Additionally, the training of midwives in cultural competency and intercultural communication raised awareness among midwives. Nonetheless, the exclusive emphasis on midwives and the inflexibility in care provision hindered them from changing their communication practices. To enhance the cultural competence in maternity care, it is essential to implement more comprehensive initiatives involving healthcare professionals in maternity care at all levels, from pregraduate to postgraduate. Adequate interpreter services and management support should also be ensured. Currently, the Danish antenatal care system faces challenges including inadequate information transfer between healthcare sectors, insufficient differentiation of care, and inflexibility in midwife scheduling. This results in a lack of responsiveness to the individual needs of women with immigrant backgrounds, potentially reproducing health inequities.

Time poverty, health and health-related behaviours in a Southern European city: a gender issue

BACKGROUND

Despite its growing interest, time poverty is a neglected issue in public health analysis and policies. The objectives of this study were: (1) to analyse gender differences in paid, unpaid and total working time; (2) to identify gender differences in the factors related to time poverty; and (3) to examine gender differences in the relationship between time poverty, health and health-related behaviours in the city of Barcelona (Spain).

METHODS

Cross-sectional study based on salaried workers aged 16-64 years interviewed in the 2021 Barcelona Health Survey (695 men and 713 women). Time poverty was defined as the top tercile of the total paid and unpaid work. Dependent variables were self-perceived health status, mental health, sleep time, sleep quality and leisure time physical activity.

RESULTS

Women were more likely to be time poor. In both sexes, time poverty was related to the number of children. Whereas among men time poverty was not associated with any health indicators, among women it was related to poor mental health status (aOR=2.11, 95% CI 1.39 to 3.20), short sleep (aOR=1.54, 95% CI 1.05 to 2.25), poor sleep quality (aOR=1.83, 95% CI 1.25 to 2.68) and low leisure time physical activity (aOR=1.50, 95% CI 1.00 to 2.26).

CONCLUSIONS

This study suggests that time use can be an important social determinant of health and of gender inequalities in health. At the local level, in many European cities, time poverty could be reduced, among other interventions, by increasing affordable and good quality public services for the care of dependent persons.

The Danish Health Survey among Marginalized People: Study design and respondent characteristics

AIM

The Danish Health Survey among Marginalized People is a nationwide health survey targeting people in marginalized life situations in Denmark. The aim of this paper is to present the study design, data collection methods and respondent characteristics of the survey, which was conducted in 2007, 2012, 2017 and 2022.

METHODS

The survey applies an outreach data collection approach which entails reaching out to social services (public and private) asking for their help with distributing self-administered paper questionnaires among their users. Themes include self-rated health, mental health, morbidity, pain, oral health, health behaviours, gambling problems, social relations, violence, sexual harassment and assault, suicide, and source of income.

RESULTS

The overall number of respondents has decreased slightly from 2007 (1290) to 2022 (1134). In all survey waves, men were overrepresented among the respondents. In 2007, women represented only 28%, which increased to 37% in 2022. There have been remarkable changes in the age distribution among respondents between 2007 and 2022. For example, the oldest age group (55-80 years) accounted for 15% of the respondents in 2007 and 40% in 2022.

CONCLUSIONS

Conducting surveys among marginalized people entails methodological challenges and ethical considerations. However, continually attempting to reach marginalized people in surveys by tailoring data collection strategies to their specific life situation is essential to gain insight into their health and well-being.

Patients' experiences of GP consultations following the introduction of the new GP contract in Scotland: a cross-sectional survey

BACKGROUND

The new Scottish GP contract commenced in April 2018 with a stated aim of mitigating health inequalities.

AIM

To determine the health characteristics and experiences of patients consulting GPs in deprived urban (DU), affluent urban (AU), and remote and rural (RR) areas of Scotland.

DESIGN AND SETTING

In 2022, a postal survey of a random sample of adult patients from 12 practices who had consulted a GP within the previous 30 days was undertaken.

METHOD

Patient characteristics and consultation experiences in the three areas (DU, AU, RR) were evaluated using validated measures including the Consultation and Relational Empathy (CARE) Measure and Patient Enablement Instrument (PEI).

RESULTS

In total, 1053 responses were received. In DU areas, multimorbidity was more common (78% versus 58% AU versus 68% RR, P<0.01), complex presentations (where the consultation addressed both psychosocial and physical problems) were more likely (16% versus 10% AU versus 11% RR, P<0.05), and more consultations were conducted by telephone (42% versus 31% AU versus 31% RR, P<0.01). Patients in DU areas reported lower satisfaction (82% DU completely, very, or fairly satisfied versus 90% AU versus 86% RR, P<0.01), lower perceived GP empathy (mean CARE score 38.9 versus 42.1 AU versus 40.1 RR, P<0.05), lower enablement (mean PEI score 2.6 versus 3.2 AU versus 2.8 RR, P<0.01), and less symptom improvement (P<0.01) than those in AU or RR areas. Face-to-face consultations were associated with significantly higher satisfaction, enablement, and perceived GP empathy than telephone consultations in RR areas (all P<0.05).

CONCLUSION

Four years after the start of the new GP contract in Scotland, patients' experiences of GP consultations suggest that the inverse care law persists.

A paradox of problems in accessing general practice: a qualitative participatory case study

BACKGROUND

Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity.

AIM

To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access.

DESIGN AND SETTING

A qualitative participatory case study in an area of northwest England.

METHOD

A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al's theory of access, allowed the team to identify complexities and relationships between interrelated problems.

RESULTS

This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities.

CONCLUSION

Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.

Socioeconomic status and incident depressive symptoms among older adults: A 3-year longitudinal study from the Japan Gerontological Evaluation Study

OBJECTIVES

The association between socioeconomic status (SES) and the onset of depressive symptoms has attracted considerable attention. However, few studies have simultaneously examined the association of multiple SES indicators, including "assets," with the onset of depressive symptoms. Therefore, this study examined the association of four SES indicators in old age ('years of education' 'equivalent income,' 'equivalent assets,' and 'the longest-held job') with new-onset depressive symptoms in a large Japanese dataset.

METHODS

This longitudinal study used panel data of cognitively and physically independent older adults from the Japan Gerontological Evaluation Study (JAGES) conducted in 2013 and 2016. Multivariate logistic regression analysis was conducted to examine the association of each SES indicator with new-onset depressive symptoms, and odds ratios and 95% confidence intervals (CIs) were calculated.

RESULTS

We analyzed the data of 40,257 older adults, with a mean age (± standard deviation) of 72.9 (±5.5) years. In the follow-up survey, 4292 older adults had new-onset depression symptoms (10.7%). 39.3% had 10-12 years of education. 36.9% had an equivalent income of up to JPY 1.99 million. 24.4% had equivalent assets of JPY 4-17.99 million. Most had a clerical job for the long time. Furthermore, fewer years of education (males: OR = 1.42, 95% CI = 1.22-1.64, p-value <0.001/females: 1.26, [1.09-1.47], p = 0.002), lower income (males: 1.64, [1.34-2.01], p < 0.001/females: 1.82, [1.49-2.22], p < 0.001), and fewer assets (males: 1.40, [1.16-1.68], p < 0.001/females: 1.21, [1.02-1.42], p = 0.025) resulted in higher odds of having new-onset depressive symptoms, even when other SES indicators were entered simultaneously.

CONCLUSIONS

All four SES indicators have an independent association with the development of new-onset depressive symptoms among older adults, reflecting different aspects of SES. The association between the "longest-held job" and new-onset depressive symptoms can be largely explained by other SES indicators. A multifaceted and lifetime approach is required to prevent the onset of depressive symptoms in old age.

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study

OBJECTIVE

The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica.

METHODS

A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'.

RESULTS

Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU.

CONCLUSIONS

This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.

Understanding people's experiences of the formal health and social care system for co-occurring heavy alcohol use and depression through the lens of relational autonomy: A qualitative study

BACKGROUND AND AIMS

Heavy alcohol use and depression commonly co-occur. However, health and social care services rarely provide coordinated support for these conditions. Using relational autonomy, which recognizes how social and economic contexts and relational support alter people's capacity for agency, this study aimed to (1) explore how people experience formal care provision for co-occurring alcohol use and depression, (2) consider how this context could lead to adverse outcomes for individuals and (3) understand the implications of these experiences for future policy and practice.

DESIGN

Semi-structured qualitative interviews underpinned by the methodology of interpretive description.

SETTING

North East and North Cumbria, UK.

PARTICIPANTS

Thirty-nine people (21 men and 18 women) with current or recent experience of co-occurring heavy alcohol use ([Alcohol Use Disorders Identification Test [AUDIT] score ≥ 8]) and depression ([Patient Health Questionnaire test ≥ 5] screening tools to give an indication of their current levels of alcohol use and mental score).

MEASUREMENTS

Semi-structured interview guide supported in-depth exploration of the treatment and care people had sought and received for heavy alcohol use and depression.

FINDINGS

Most participants perceived depression as a key factor contributing to their heavy alcohol use. Three key themes were identified: (1) 'lack of recognition' of a relationship between alcohol use and depression and/or contexts that limit people's capacity to access help, (2) having 'nowhere to go' to access relevant treatment and care and (3) 'supporting relational autonomy' as opposed to assuming that individuals can organize their own care and recovery. Lack of access to appropriate treatment and provision that disregards individuals' differential capacity for agency may contribute to delays in help-seeking, increased distress and suicidal ideation.

CONCLUSIONS

Among people with co-occurring heavy alcohol use and depression, lack of recognition of a relationship between alcohol use and depression and formal care provision that does not acknowledge people's social and economic context, including their intrinsic need for relational support, may contribute to distress and limit their capacity to get well.

Dying whilst on probation: a scoping review of mortality amongst those under community justice supervision

AIM

Data suggest mortality rates of those under community justice services such as probation or parole have been increasing year on year. Little is known about why and how these individuals are dying. This scoping review explores the causes and contributing factors of mortality in those under community justice supervision.

METHODS

Studies published between 2011 and 2021 were identified across CINAHL, Embase, Global Health, Ovid Medline and PsycINFO. Articles were included if they presented original data on either mortality rates among those under community justice supervision or risk factors associated with the mortality of those under community justice supervision.

RESULTS

Searches identified 101 unique articles of which 13 were included in the review. Articles were representative of five countries. All articles were either retrospective reviews or retrospective cohort studies. The studies fell into the categories of all-cause mortality, self-inflicted deaths or drug-related deaths.

CONCLUSION

Mortality rates of those under community justice supervision were found to be consistently higher than mortality rates for the general population regardless of cause of death. Factors identified as affecting mortality included history of drug use, history of self-harm and previous imprisonment including length of time in custody and experience of hospitalisation or solitary confinement while in custody.

Exploring the Influence of Social Class and Sex on Self-Reported Health: Insights from a Representative Population-Based Study

This study investigates the intricate interplay between social class, sex, and self-reported health (SRH) using data from the European Health Survey of Spain 2020 (EESE2020). Employing a cross-sectional design and a representative sample of 22,072 individuals, the analysis explores the persistence of disparities after adjusting for covariates, focusing on health-related variables. The study employs logistic regression models and directed acyclic graphs (DAGs) to delineate the direct effects of social class and sex on SRH, identifying a minimum adjustment set to control for confounding variables. Results reveal a gradient effect of social class on SRH, emphasizing the enduring impact of socioeconomic factors. Sex-based disparities in SRH diminish after considering additional health-related variables, highlighting the importance of a holistic approach. DAGs serve as transparent tools in disentangling complex relationships, guiding the identification of essential covariates. The study concludes that addressing health inequalities requires comprehensive strategies considering both individual health behaviours and socio-economic contexts. While recognizing limitations, such as the cross-sectional design, the findings contribute to a nuanced understanding of health disparities, informing evidence-based interventions and policies for a more equitable healthcare system.

Contrasted life trajectories: reconstituting the main population exposomes in French Guiana

In French Guiana, life expectancy is between 2 and 3 years below that of France, reflecting differences in mortality rates that are largely sensitive to primary healthcare and thus preventable. However, because poverty affects half of the population in French Guiana, global measurements of life expectancy presumably conflate at least two distinct situations: persons who have similar life expectancies as in mainland France and persons living in precariousness who have far greater mortality rates than their wealthier counterparts. We thus aimed to synthesize what is known about statistical regularities regarding exposures and sketch typical French Guiana exposomes in relation to health outcomes. We conducted a narrative review on common exposures in French Guiana and made comparisons between French Guiana and mainland France, between rich and poor in French Guiana, and between urban and rural areas within French Guiana. The most striking fact this panorama shows is that being a fetus or a young child in French Guiana is fraught with multiple threats. In French Guiana, poverty and poor pregnancy follow-up; renouncing healthcare; wide variety of infectious diseases; very high prevalence of food insecurity; psychosocial stress; micronutrient deficiencies; obesity and metabolic problems; and frequent exposure to lead and mercury in rural areas constitute a stunningly challenging exposome for a new human being to develop into. A substantial part of the population's health is hence affected by poverty and its sources of nutrition.

Intersectional analysis of inequalities in self-reported breast cancer screening attendance using supervised machine learning and PROGRESS-Plus framework

Background

Breast cancer is a critical public health concern in Spain, and organized screening programs have been in place since the 1990s to reduce its incidence. However, despite the bi-annual invitation for breast cancer screening (BCS) for women aged 45-69, significant attendance inequalities persist among different population groups. This study employs a quantitative intersectional perspective to identify intersectional positions at risk of not undergoing breast cancer screening in Spain.

Methods

Women were selected from the 2020 European Health Interview Survey in Spain, which surveyed the adult population (> 15 years old) living in private households (N = 22,072; 59% response rate). Inequality indicators based on the PROGRESS-Plus framework were used to disentangle existing social intersections. To identify intersectional groups, decision tree models, including classification and regression trees (CARTs), chi-squared automatic interaction detector (CHAID), conditional inference rees (CITs), and C5.0, along with an ensemble algorithm, extreme gradient boosting (XGBoost), were applied.

Results

XGBoost (AUC 78.8%) identified regional differences (Autonomous Community) as the most important factor for classifying BCS attendance, followed by education, age, and marital status. The C5.0 model (balanced accuracy 81.1%) highlighted that the relative importance of individual characteristics, such as education, marital status, or age, for attendance differs based on women's place of residence and their degree of interaction. The highest risk of not attending BCS was observed among illiterate older women in lower social classes who were born in Spain, were residing in Asturias, Cantabria, Basque Country, Castile and León, Extremadura, Galicia, Madrid, Murcia, La Rioja, or Valencian Community, and were married, divorced, or widowed. Subsequently, the risk of not attending BCS extends to three other groups of women: women living in Ceuta and Melilla; single or legally separated women living in the rest of Spain; and women not born in Spain who were married, divorced, or widowed and not residing in Ceuta or Melilla.

Conclusion

The combined use of decision trees and ensemble algorithms can be a valuable tool in identifying intersectional positions at a higher risk of not utilizing public resources and, thus, can aid substantially in developing targeted interventions to increase BCS attendance.

Impact of long-term care insurance on health inequality in older adults in China based on the concentration index approach

BACKGROUND

Several studies have shown that social security would reduce health inequalities. However, little was known about the relationship between long-term care insurance and health inequality. We aimed to evaluate the impact of long-term care insurance on health status and health inequality in older adults using a nationally representative cohort.

METHODS

Based on four waves of data from the China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, 2015 and 2018), we used the staggered difference in difference (DID) design with the order probit regression models and the concentration index approach as well as decomposition analysis to assess the contribution of long-term care insurance towards residents' health status and health inequality in older adults aged ≥65 y. We further used the semi-parametric DID model for robustness testing.

RESULTS

Long-term care insurance demonstrated its role, improving self-assessed health in the study population (βcoefficient: 0.090, 95% CI 0.087 to 0.092, p<0.001). The estimation results of the semi-parametric DID were consistent with those of the staggered DID. The income-related health concentration index was 0.0005, having a contribution rate of 1.639% to health inequality in older adults. Decomposition analysis revealed that different policies and residential areas were more influential on the observed health inequalities.

CONCLUSIONS

The findings implied that long-term care insurance has widened the health inequality while improving health status in older adults. Additional investment in more comprehensive insurance coverage and increased accessibility to enhance implementation of long-term care insurance is warranted to close the gap.

What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND

There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown.

OBJECTIVES

The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use.

DESIGN

Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool.

RESULTS

The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities.

CONCLUSIONS

Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

Primary care transformation in Scotland: a qualitative study of GPs' and multidisciplinary team members' views

BACKGROUND

The Scottish Government's vision to transform primary care includes expansion of the primary care multidisciplinary team (MDT), formalised in the new GP contract in April 2018.

AIM

To explore practitioners' views on the expansion of MDT working in Scotland.

DESIGN AND SETTING

Qualitative study with GPs and a range of MDT staff working in three different population settings in Scotland.

METHOD

In-depth semi-structured interviews were carried out by telephone with 8 GPs and 19 MDT staff between May and June 2022. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted to identify commonalities and divergences in the interviews.

RESULTS

Internal challenges facing MDT staff included adapting to the fast pace of primary care, building new relationships, training and professional development needs, line management issues, and monitoring and evaluation of performance. External challenges included the ongoing effects of the COVID-19 pandemic, lack of time, difficulties with hybrid working, and low staff morale. Most GPs reported that expansion of their roles as expert medical specialists had not yet happened because their workload had not decreased (and in many cases had increased). In deprived areas, insufficient resources to deal with the high numbers of patients with complex multimorbidity remained a key issue. Interviewees in remote and rural settings felt the new contract did not take into account the unique challenges of providing primary care services in such areas, and recruitment and accommodation were cited as particular problems.

CONCLUSION

Although there has been substantial expansion of the primary care MDT, which most GPs welcome, many challenges to effective implementation remain that must be addressed if transformation of primary care in Scotland is to become a reality.

The critical (micro)political economy of health: A more-than-human approach

The critical political economy of health offers different explanations for the social causes of health and the social factors determining the distribution of these causes. However, the relational, post-anthropocentric and monist ontology of the new materialisms overcomes this complexity, while retaining a critical focus. In this perspective, the social, economic and political relations of capitalism act upon bodies and other matter in everyday events, rather than as 'social structures'. Using a conceptual toolkit of 'affect', 'assemblage', 'capacity' and 'micropolitics', the paper asks the question: 'what does capitalism do?' The re-analysis of the social and economic relations of capitalism in terms of a production-assemblage and a market-assemblage reveals not only the workings of capitalist accumulation, but also how previously-unremarked more-than-human affects in these assemblages simultaneously produce uncertainty, waste and inequalities. This micropolitical economy of health is illustrated with examples from recent research, including a critical assessment of health inequalities during the Covid-19 pandemic.

Informal Employment Under the Skin: Informality and Health Inequalities Among Chilean Workers

Informal employment has been identified as an important social determinant of health. This article addresses the processes through which informal employment affects workers' health in Chile. The study's methodological approach was based on qualitative interviews with 34 formal and informal workers. The findings show how workers perceive informal employment as negatively affecting their mental and physical health through different dimensions of their living and working conditions. Incorporating a gender perspective proves to be integral to the analysis of these processes. The article concludes by discussing how neoliberalism underlies such vulnerability processes and negatively impacts on the population's health.

Social capital, food insecurity, and health outcomes in the US during the COVID-19 pandemic

AIMS

The purpose of this study was first, to investigate the harmful effects of food insufficiency on health outcomes - self-rated health (SRH) and self-assessed depressive symptoms - during the COVID-19 pandemic and, second, to test whether these effects fluctuated across the US in terms of state-level social capital.

METHODS

Data were drawn from the Census Household Pulse Survey (fielded between April 2020 and February 2021) consisting of community-dwelling American adults (N = 1.5M+). Social capital measures were taken from the 'Social Capital Project' sponsored by the US Congress. We estimated three-level mixed effects models to analyze multiple waves of repeated cross-sectional surveys.

RESULTS

Post-COVID-19 food insufficiency was significantly negatively associated with SRH and positively associated depression, adjusting for controls including food insufficiency prior to the onset of the pandemic. These relationships were also more pronounced in areas with higher aggregate social capital.

CONCLUSIONS

The health burdens of the new coronavirus disease have fallen disproportionately on the economically marginalized, as measured by food insufficiency. Contrary to the conventional literature, living in a state with a greater stock of social capital worsened its health effects.

Rheumatic heart disease burden, trends, and inequalities in Asia, 1990-2019

BACKGROUND

Rheumatic heart disease (RHD) is a serious global public health problem.

OBJECTIVES

This study aims to characterise the regional burden, trends, and inequalities of RHD in countries and territories in the Asian Region.

METHODS

The RHD disease burden was measured in terms of the numbers of cases and deaths, prevalence, disability-adjusted life years (DALYs), disability-loss healthy life years (YLDs), and years of life lost (YLLs) in 48 countries in the Asian Region. Data on RHD were extracted from the 2019 Global Burden of Disease. This study analysed changing trends in the burden between 1990 and 2019, quantified regional inequalities in mortality, and classified countries by 2019 YLLs.

RESULTS

There were an estimated 22 246 127 cases of RHD in the Asian Region in 2019 and 249 830 deaths. The prevalence of RHD in the Asian Region in 2019 was 9% lower than the global estimate, while mortality was 41% higher. The mortality rate for RHD in the Asian Region trended downwards from 1990 to 2019, with an average annual percentage change of -3.2% (95% UI -3.3 to -3.1). From 1990 to 2019, absolute inequality in RHD-related mortality decreased in the Asian Region while relative inequality increased. Of the 48 countries studied, twelve had the highest level of RHD YLLs in 2017 and the smallest reduction in YLLs from 1990 to 2019.

CONCLUSION

Although the burden of RHD in the Asian Region has steadily decreased since 1990, it remains a serious public health issue requiring greater attention. In the Asian Region, inequalities in the distribution of the RHD burden remain significant, with economically deprived countries typically bearing a greater share of the load.

Self-Reported Health Inequalities among Older Adults in Saudi Arabia

Considering the rising life expectancy, the growing population of older adults poses challenges in providing adequate healthcare services. Self-reported health is an important indicator of overall health, predicting morbidity and mortality. This study investigated self-reported health inequalities among older adults in Saudi Arabia and the underlying factors contributing to establishing such inequalities. The study utilized data from the 2018 Saudi Family Health Survey, focusing on 2023 respondents aged ≥60 years with complete data. Univariate, bivariate, and multivariate logistic regression analyses were employed to explore socio-economic factors linked to health inequalities. Additionally, concentration curves and indices were used to assess the magnitude of health inequalities among older adults. The findings indicate a higher prevalence of self-reported poor health among respondents aged ≥70 years and those with chronic diseases. Age, education, income level, marital status, and insurance coverage were other factors significantly linked to reporting poor health. Inequality analysis revealed a concentration of poor health among less educated individuals (concentration index = -0.261, p < 0.01). Both income- and education-based indices highlighted a concentration of poor health among men with lower income and education levels. Addressing healthcare inequalities among older adults requires targeted policy efforts, focusing on those aged ≥70, unmarried individuals, those without insurance coverage, those with chronic illnesses, and those with lower education levels. Targeted interventions for these groups can address their unique healthcare needs and promote equitable health outcomes.

Area-based social inequalities in adult mortality: construction of French deprivation-specific life tables for the period 2016-2018

Background

In order to tackle social inequalities in mortality, it is crucial to quantify them. We produced French deprivation-specific life tables for the period 2016-2018 to measure the social gradient in adult all-cause mortality.

Methods

Data from the Permanent Demographic Sample (EDP) were used to provide population and death counts by age, sex and deprivation quintile. The European Deprivation Index (EDI), applied at a sub-municipal geographical level, was used as an ecological measure of deprivation. Smoothed mortality rates were calculated using a one-dimensional Poisson counts smoothing method with P-Splines. We calculated life expectancies by age, sex and deprivation quintile as well as interquartile mortality rate ratios (MRR).

Results

At the age of 30, the difference in life expectancy between the most and least deprived groups amounted to 3.9 years in males and 2.2 years in females. In terms of relative mortality inequalities, the largest gaps between extreme deprivation groups were around age 55 for males (MRR = 2.22 [2.0; 2.46] at age 55), around age 50 in females (MRR = 1.77 [1.48; 2.1] at age 47), and there was a decrease or disappearance of the gaps in the very older adults.

Conclusions

There is a strong social gradient in all-cause mortality in France for males and females. The methodology for building these deprivation-specific life tables is reproducible and could be used to monitor its development. The tables produced should contribute to improving studies on net survival inequalities for specific diseases by taking into account the pre-existing social gradient in all-cause mortality.

Life expectancy inequalities between regions of China 2004-2020: contribution of age- and cause-specific mortality

Background

China's rapid economic and social development since the early 2000s has caused significant shifts in its epidemiological transition, potentially leading to health disparities across regions.

Objectives

This study employs Life Expectancy (LE) to assess health disparities and trends among China's eastern, central, and western regions. It also examines the pace of LE gains relative to empirical trends and investigates age and causes of death mortality improvement contributing to regional LE gaps.

Data and methods

Using a log-quadratic model, the study estimates LE in China and its regions from 2004 to 2020, using census and death cause surveillance data. It also utilizes the Human Mortality Database (HMD) and the LE gains by LE level approach to analyze China and its regions' LE gains in comparison to empirical trend of developed countries. The study investigates changes in LE gaps due to age and causes of death mortality improvements during two periods, 2004-2012 and 2012-2020, through the LE factor decomposition method.

Results

From 2000 to 2020, China's LE exhibited faster pace of gains compared to developed countries. While men's LE growth gradually aligns with empirical trends, women experience slightly higher growth rates. Regional LE disparities significantly reduced from 2004 to 2012, with a marginal reduction from 2012 to 2020. In the latter period, the changing LE gap aligns with expected trends in developed countries, with all Chinese regions surpassing empirical estimates. Cardiovascular diseases and malignant neoplasms emerged as the primary contributors to expanding regional LE gaps, with neurological disorders and diabetes playing an increasingly negative role.

Conclusion

LE disparities in China have consistently decreased, although at a slower pace in recent years, mirroring empirical trends. To further reduce regional LE disparities, targeted efforts should focus on improving mortality rates related to cardiovascular diseases, neoplasms, neurological disorders and diabetes, especially in the western region. Effective health interventions should prioritize equalizing basic public health services nationwide.

Interventions to tackle health inequalities in cardiovascular risks for socioeconomically disadvantaged populations: a rapid review

INTRODUCTION

Cardiovascular disease (CVD) has shown significant health inequalities for people with low socioeconomic status associated with more risk factors. This review was to synthesize interventions that targeted CVD risks and outcomes among socioeconomically disadvantaged populations and to understand the impact associated with these interventions.

SOURCES OF DATA

Cochrane CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL were searched for records published in the last decade using a systematic search strategy, complemented by screening the reference lists and citation indexes. Nineteen studies were included and a narrative synthesis with the effect direction plot was undertaken in which studies, interventions, participants and outcomes were examined according to the intervention type focusing on behaviours, lifestyle, education, medication and monitoring.

AREAS OF AGREEMENT

No universal definition of disadvantaged socioeconomic status was used with common factors relating to racial/ethnic minorities, low income and low or no health insurance. Mixed effects of interventions were reported on clinical outcomes including weight, body mass index, blood pressure, glycated haemoglobin and cholesterol.

AREAS OF CONTROVERSY

Inconsistent effect was reported due to a large variety of settings, participants and intervention components although they are considered necessary to address the complex health needs of socioeconomically disadvantaged populations.

GROWING POINTS

There is inadequate evidence to determine whether any of the intervention types are effective in optimising lipids management for socioeconomically disadvantaged populations.

AREAS TIMELY FOR DEVELOPING RESEARCH

Research is needed with mixed evidence using real world evaluation and lived experience combined with health economic evaluation, on both mental and physical health outcomes.

[Contextual characteristics and demand for health services among Brazilian adolescents: Brazilian National Health Survey, 2019]

This study aimed to describe the prevalence of demand for health services among Brazilian adolescents and to investigate its association with contextual characteristics of the territory. Study with data from the Brazilian National Health Survey, conducted in 2019, including 43,774 individuals aged from 10 to 19 years. Adolescent's information was obtained through a proxy resident of 18 years or more who answered for all the residents of the household. Poisson regression was used to assess the demand for health services according to geopolitical region, economic status, and type of municipality. The interaction of the health insurance was also evaluated in these associations. Of the total, 11.7% (95%CI: 11.1; 12.3) of the adolescents sought health services in the two weeks prior to the survey. Greater figures of demand were observed in the Southeast (PR = 1.32; 95%CI: 1.15; 1.52) and South regions (PR = 1.31; 95%CI: 1.13; 1.52) compared to the Northern Region of Brazil. Having a health insurance increased the demand for services by adolescents living in rural areas and in capitals and the municipalities of the Metropolitan Areas and/or Integrated Development Regions. The study showed a low prevalence of demand for health services among adolescents and contextual inequalities for the geopolitical region. Having a health insurance was an important marker to understand the disparities in the economic status and in the type of municipality.

Prepayment meters strongly associated with multiple types of deprivation and emergency respiratory hospital admissions: an observational, cross-sectional study

BACKGROUND

Prepayment meters (PPMs) require energy to be paid in advance. Action groups and media contend that PPMs are concentrated in the most vulnerable groups, prone to run out of credit and experience financial burden. This led to forced installation for those over age 85 being banned in April 2023 and a 'prepayment premium' scrapped in July 2023. Yet, we lack empirical evidence of which groups PPMs are concentrated. This ecological study examines the extent to which PPMs are associated with multiple measures of structural social, economic and health deprivation to establish evidence-based policy.

METHODS

Combining multiple regional data and census estimates at the Lower Layer Super Output Area and the Middle Layer Super Output Area level from England and Wales, we use Spearman's rank correlation, Pearson correlation and multivariate linear regression to empirically establish associations between PPMs and multiple types of deprivation.

RESULTS

Higher PPM prevalence is strongly associated with: lower income, receipt of employment benefits, ethnic minorities, lower education and higher health deprivation. Higher PPM prevalence is strongly associated with higher income deprivation affecting children, the elderly and social rental properties. PPMs are significantly associated with emergency hospital admissions for respiratory diseases in England, even after controlling for confounders (coefficient=1.81; 95% CI 1.51 to 2.11).

CONCLUSIONS

We found empirical evidence that PPM users are concentrated among the population who already experience multiple disadvantages. Furthermore, PPM concentrated areas are associated with higher emergency hospital admissions for respiratory diseases.

Are housing circumstances associated with faster epigenetic ageing?

BACKGROUND

Numerous aspects of housing are associated with health. However, the pathways between housing and health, particularly the psychosocial elements of housing, are less well understood. Epigenetic information alongside social survey data offers an opportunity to explore biological ageing, measured using DNA methylation, as a potential pathway through which housing affects health.

METHODS

We use data on housing and DNA methylation from the UK Household Longitudinal Study, linked with prior survey responses from the British Household Panel Survey, covering adults in Great Britain. We explore the association between epigenetic ageing and housing circumstances, both contemporary and historical, using hierarchical regression.

RESULTS

We find that living in a privately rented home is related to faster biological ageing. Importantly, the impact of private renting (coefficient (SE) 0.046 years (0.011) vs owned outright, p<0.001) is greater than the impact of experiencing unemployment (coefficient 0.027 years (0.012) vs employed, p<0.05) or being a former smoker (coefficient 0.021 years (0.005) vs never smoker, p<0.001). When we include historical housing circumstances in the analysis, we find that repeated housing arrears and exposure to pollution/environmental problems are also associated with faster biological ageing.

CONCLUSION

Our results suggest that challenging housing circumstances negatively affect health through faster biological ageing. However, biological ageing is reversible, highlighting the significant potential for housing policy changes to improve health.

Young people's perspectives on addressing UK health inequalities: utopian visions and preferences for action

INTRODUCTION

It is increasingly recognised by UK researchers and population health advocates that an important impetus to effective policy action to address health inequalities is activation of public dialogue about the social determinants of health and how inequalities might be addressed. The limited body of existing scholarship reaches varying conclusions on public preferences for responding to health inequalities but with consensus around the importance of tackling poverty. Young people's perspectives remain underexplored despite their increasingly visible role in activism across a range of policy issues and the potential impact of widening inequalities on their generation's health and wellbeing.

METHODS

Six groups of young people (39 in total) from two UK cities (Glasgow and Leeds) were engaged in online workshops to explore views on health inequalities and potential solutions. Inspired by calls to employ notions of utopia, artist-facilitators and researchers supported participants to explore the evidence, debating solutions and imagining a more desirable society, using visual and performance art. Drawing together data from discussions and creative outputs, we analysed participants' perspectives on addressing health inequalities across four domains: governance, environment, society/culture and economy.

FINDINGS

Proposals ranged from radical, whole-systems change to support for policies currently being considered by governments across the United Kingdom. The consensus was built around embracing more participatory, collaborative governance; prioritising sustainability and access to greenspace; promoting inclusivity and eliminating discrimination and improving the circumstances of those on the lowest incomes. Levels of acceptable income inequality, and how best to address income inequality were more contested. Individual-level interventions were rarely presented as viable options for addressing the social inequalities from which health differences emanate.

CONCLUSION

Young people contributed wide-ranging and visionary solutions to debates around addressing the enduring existence of health inequalities in the United Kingdom. Their reflections signal support for 'upstream' systemic change to achieve reductions in social inequalities and the health differences that flow from these.

PUBLIC CONTRIBUTION

An advisory group of young people informed the development of project plans. Participants shaped the direction of the project in terms of substantive focus and were responsible for the generation of creative project outputs aimed at influencing policymakers.

Development of a health promotion action with mothers aiming to support a healthy start in life for children using Participatory Action Research

Health inequalities arise already during the first thousand days of a child's life. Participatory action research (PAR) is a promising approach, addressing adverse contexts that impact health inequalities. This article describes the experience of mothers involved in a PAR process to develop a health promotion action that supports both children's and mothers' health. It also describes the experiences of mothers who attended the developed action and trainers who facilitated it. The PAR process resulted in the development of a sustained action called Mama's World Exercise Club aimed at promoting the health of mothers and their children. Results showed that the PAR process empowered the mothers and gave them a sense of pride at playing a useful role in their community. The developed action was highly valued by other mothers in the neighbourhood and widely implemented. These positive results can be ascribed to the strong collaboration between the researchers and the mothers, and the willingness of local stakeholders to support the action. Future studies should investigate if the results of this study sustain over a longer period of time and improve health outcomes of children and mothers in the long run.