Is ethnicity an independent predictor of health need? Linked cohort logistic regression analysis to predict amenable mortality.

Mortality outcomes and inequities experienced by rural Māori in Aotearoa New Zealand

Amenable mortality is a composite measure of deaths from conditions that might be avoided by timely and effective healthcare. It was developed as an indicator to study health care quality. We calculated mortality rates for the population aged 0-74 years for the time-period 1996-2010 and the following groups of causes of death: amenable conditions, ischaemic heart diseases (IHD, defined as partly amenable) and remaining conditions. We compared the Swiss results with those published for 16 other high-income countries. To examine the association between amenable mortality and socioeconomic position, we calculated hazard ratios (HRs) by using Cox regression. Amenable mortality fell from 49.5 (95% confidence interval [CI] 48.2-51.0) to 35.7 (34.6-36.9) in males and from 55.0 (53.6-56.4) to 43.4 (42.2-44.6) per 100 000 person-years in females, when 1996-1998 was compared with 2008-2010. IHD mortality declined from 64.7 (95% CI 63.1-66.3) to 33.8 (32.8-34.8) in males and from 18.0 (17.2-18.7) to 8.5 (8.0-9.0) in females. However, between 1996-1998 and 2008-2010 the proportion of all-cause mortality attributed to amenable causes remained stable in both sexes (around 12% in males and 26% in females). Compared with 16 other high-income countries, Switzerland had the lowest rates of amenable mortality and ranked among the top five with the lowest ischaemic heart disease mortality. HRs of amenable causes in the lowest socioeconomic position quintile were 1.77 (95% CI 1.66-1.90) for males and 1.78 (1.47-2.16) for females compared with 1.62 (1.58-1.66) and 1.38 (1.33-1.43) for unamenable mortality. For ischaemic heart disease, HRs in the lowest socioeconomic position quintile were 1.76 (95% CI 1.66-1.87) for males and 2.33 (2.07-2.62) for females. Amenable mortality declined substantially in Switzerland with comparably low death rates for amenable causes. Similar to previous international studies, these Swiss results showed substantial socioeconomic inequalities in amenable mortality. Proportions of amenable mortality remained constant over time and patterns of inequalities observed for amenable causes in men did not substantially differ from those observed for non-amenable causes of death. Additional amenable mortality research is needed to better understand the factors contributing to mortality changes and social inequalities including information on disease characteristics and health care supply measures.

In Aotearoa New Zealand, being enrolled with a Primary Health Care (PHC) provider furnishes opportunities for lower cost access to PHC, preventative care and secondary health care services, and provides better continuity of care. We examine the characteristics of populations not enrolled, and whether enrolment is associated with amenable mortality. We retrieved records of all deaths registered 2008 to 2017 in Aotearoa New Zealand, which included demographic and primary cause of death information. Deaths were classified as premature (aged under 75 years) or not, and amenable to health care intervention or not. The Primary Health Organisation (PHO) Enrolment Collection dataset provided the PHC enrolment status. Logistic regression was used to estimate the risk of amenable deaths by PHO enrolment status, adjusted for the effects of age, sex, ethnicity and deprivation. A total of 308,628 mortality records were available. Of these, 38.2% were premature deaths, and among them 47.8% were amenable deaths. Cardiovascular diseases made up almost half of the amenable deaths. Males, youths aged 15-24 years, Pacific peoples, Māori and those living in the most socio-economically deprived areas demonstrated a higher risk of amenable mortality compared to their respective reference category. One in twenty (4.3%) people who had died had no active enrolment status in any of the calendar years in the study. The adjusted odds of amenable mortality among those not enrolled in a PHO was 39% higher than those enrolled [Odds Ratio = 1.39, 95% Confidence Interval 1.30-1.47]. Being enrolled in a PHC system is associated with a lower level of amenable mortality. Given demonstrated inequities in enrolment levels across age and ethnic groups, efforts to improve this could have significant benefits on health equity.

How much does health care contribute to health inequality in New Zealand?

IntroductionIn Aotearoa New Zealand, being enrolled with a Primary Health Care (PHC) provider furnishes opportunities for lower cost access to PHC, preventative care and secondary health care services, and provides better continuity of care. We examine the characteristics of populations not enrolled, and whether enrolment is associated with amenable mortality.MethodWe retrieved records of all deaths registered 2008 to 2017 in Aotearoa New Zealand, which included demographic and primary cause of death information. Deaths were classified as premature (aged under 75 years) or not, and amenable to health care intervention or not. The Primary Health Organisation (PHO) Enrolment Collection dataset provided the PHC enrolment status. Logistic regression was used to estimate the risk of amenable deaths by PHO enrolment status, adjusted for the effects of age, sex, ethnicity and deprivation.ResultsA total of 308,628 mortality records were available. Of these, 38.2% were premature deaths, and among them 47.8% were amenable deaths. Cardiovascular diseases made up almost half of the amenable deaths. Males, youths aged 15–24 years, Pacific peoples, Māori and those living in the most socio-economically deprived areas demonstrated a higher risk of amenable mortality compared to their respective reference category. One in twenty (4.3%) people who had died had no active enrolment status in any of the calendar years in the study. The adjusted odds of amenable mortality among those not enrolled in a PHO was 39% higher than those enrolled [Odds Ratio = 1.39, 95% Confidence Interval 1.30–1.47].ImplicationsBeing enrolled in a PHC system is associated with a lower level of amenable mortality. Given demonstrated inequities in enrolment levels across age and ethnic groups, efforts to improve this could have significant benefits on health equity.

BackgroundMortality amenable to healthcare interventions has increasingly been used as an indirect indicator of the effect of healthcare on health inequalities. Studies have consistently shown socioeconomic differences in amenable mortality,...

Spatial equity of physiotherapy accessibility in Aotearoa New Zealand in relation to Māori and Pacific ethnicity, socioeconomic deprivation, and rurality.

Census-based and personally reported income measures as long-term risk-adjusted mortality predictors

Socio-economic inequalities in amenable mortality rates are increasing across Europe, which is an affront to universal healthcare systems where the numbers of, and inequalities in, amenable deaths should be minimal and declining over time. However, the fundamental causes theory proposes that inequalities in health will be largest across preventable causes, where unequally distributed resources can be used to gain an advantage. Information on individual-level inequalities that may better reflect the fundamental causes remains limited. We used the Scottish Longitudinal Study, with follow-up to 2010 to examine trends in amenable mortality by a range of socioeconomic position measures. Large inequalities were found for all measures of socioeconomic position and were lowest for educational attainment, higher for social class and highest for social connection. To reduce inequalities, amenable mortality needs to be interpreted both as an indicator of healthcare quality and as a reflection of the unequal distribution of socio-economic resources.

Do Canada and the United States Differ in Prevalence of Depression and Utilization of Services?

Study question Is ethnic background among 18-45-year-old women associated with initiating ART-treatment in Denmark? Summary answer Results indicate ethnic disparity in the use of ART-treatment, with immigrants and descendants having lower odds of initiating ART-treatment compared to women with Danish origin. What is known already The use of fertility treatment has increased over the past decades. Ethnic disparity exists in the use of health care, but there is limited knowledge about the association between ethnicity and use of fertility treatment. Previous studies have shown that women with lower socioeconomic position (SEP) have lower odds of initiating ART-treatment compared to women with higher SEP. Immigrants and descendants often have lower SEP compared to the general population, but specific mechanisms might be at play when residing and navigating in a new country and healthcare system. Study design, size, duration This is a national, register-based study based on the DANAC II cohort. Women initiating ART-treatment (IVF or ICSI) aged 18–45 were identified in the Danish IVF Register from 1994-2017. According to the time of ART-treatment women were included in the study and randomly age-matched with 10 untreated women in the background population. The study population consisted of 676.355 women. Participants/materials, setting, methods The probability of initiating ART-treatment was compared across ethnic groups and examined in logistic regression analysis. Migration status and country of origin were used as proxies for ethnic group in separate analysis. Age was accounted for by matching, and additional factors of interest such as SEP measures were classified as potential mediators and thus not included in the main analyses. The effect of duration of residence in Denmark was analysed separately among immigrants. Main results and the role of chance The study population consisted of 526.507 (78 %) women of Danish origin, 142.656 (21 %) were immigrants and 7.192 (1 %) descendants of immigrants. Among women of Danish origin 11 % had initiated ART-treatment compared to 5 % of immigrants and 9 % of descendants. Immigrants had 56 % lower odds of receiving first ART-treatment compared to women of Danish origin (OR 0,44, CI 95 % 0,43-0,45), while descendants had 22 % lower odds compared to women of Danish origin (OR 0,78, CI 95 % 0,72-0,84). Regarding the analysis looking at country of origin results showed that 3-4 % of women originating from western countries had received first ART-treatment, compared to 6-8 % of women originating from non-western countries. Women originating from western countries had between 65-78% lower odds for receiving first ART-treatment compared to women of Danish origin. Odds of receiving ART-treatment among women of non-western origin was between 34-47 % lower compared to women of Danish origin. This indicates that disparity in first ART-treatment is particularly distinctive among women of western origin, possibly explained by differences in reasons for migrating. Limitations, reasons for caution Information on the reason for infertility and desire to have children could have provided more insight into the disparity. Data about basis for residence could have provided information on reasons for immigration and duration of residence. Wider implications of the findings Infertility and childlessness can have severe consequences for individuals and society, and equal access to fertility treatment is important, not least in a universal welfare society. The results of this study indicate ethnic disparity in ART-treatment, and we encourage further research regarding the possible causes and barriers to initiate treatment. Trial registration number not applicable

Background：Health inequalities have attracted much attention in recent years. Reducing or avoiding health inequalities are important policy goals. However, there could be significant changes in the patterns of health inequalities across different development stages and during the epidemiological transition. The implementation of universal health coverage, e.g. Taiwan’s National Health Insurance (NHI) may also play a role in the changes. Past research is limited in this area and mostly from Western countries. In this study we analyzed temporal changes in socioeconomic inequalities of all-cause and cause-specific mortality as well as causes of death considered amenable to health care in Taiwan during the period from 1971 to 2012. Methods：We conducted an ecological analysis using townships (n=354) as the area unit. Cause-of-death mortality data in five periods (1971-1975, 1978-1982, 1988-1992, 1998-2002, 2008-2012) were extracted from the Taiwan national mortality data files. Township-level socio-economic variables were derived from five censuses in 1965, 1980, 1990, 2000, and 2010 and National Taxes Statistics in 2000 and 2010. We use the proportion of people with below college education as the main indicator of township-level socioeconomic status across all periods as it showed the strongest association with household income from tax data. In sensitivity analyses we used the proportion of agricultural workers in the working population and the first component derived from principle component analysis based on 13 socioeconomic variables. We calculated township-level period expected years of life lost (PEYLL) for all-cause, cause-specific and amenable mortality. We ranked the townships based on the socioeconomic indicator and then plotted the concentration curve and calculated the concentration index to investigate trend in health inequalities in Taiwan in 1971-2012. Results：The concentration indices for all-cause mortality were -0.100 (95% Confidence Interval (CI) -0.120, -0.080) in 1971-1975 and declined to -0.123 (-0.142, -0.104) in 1998-2002, and then slightly increased to -0.120 (-0.141, -0.100) in 2008-2012, indicating that the PEYLL tended to concentrate in areas with low socioeconomic position and the level of inequalities increased in 1978-2002 and became stable afterwards. There were marked differences in the patterns of different causes of death. For example, there was no evidence for inequalities for cancer mortality in 1971-1975 but the level of inequalities increased over the study period; for cardiovascular diseases the level of inequalities expended during 1971-2002 and became stable toward the end of the study period. The PEYLL of respiratory diseases and infectious and parasitic diseases also tended to concentrate in areas of low socioeconomic position, whilst their inequalities levels decreased over the study period. The level of inequalities for injuries and poisonings rose during 1971-2002 and then slightly decreased; within this category of deaths, socioeconomic inequalities for suicide decreased and disappeared gradually, whilst those for motor vehicle accident and other injuries and poisonings increased in 1971-2012. The concentration indices of amenable mortality were -0.126 (95% CI: -0.151, -0.100) in 1971-1975 and rose to -0.087 (-0.107，-0.066) in 1988-1992, and, after the implementation of Taiwan’s NHI in 1995, the concentration index was -0.090 (-0.111, -0.070), similar to the pre-NHI level, although it later increased to -0.081 (-0.102, -0.059) in 2008-2012. The finding indicated that the level of inequalities for amenable mortality reduced over the study period but the reduction was greater in the periods before than after the NHI. Conclusion：Over the last four decades, mortality tended to concentrate in deprived areas for most causes of deaths, and the inequalities level for all-cause mortality showed a rise in Taiwan. However, the inequalities level of amenable mortality had reduced, but there was no strong evidence for an effect of universal health coverage.

Although most people would agree that lower socio-economic position (SEP) is associated with poorer health, there remain key debates over the measurement SEP, the mechanisms that explain this association with health, and the policy responses to such inequalities in health. The WHO Commission on the Social Determinants of Health addressed many of these issues. Measures of SEP should ideally reflect the mechanism generating social inequalities and not just simply describe stratification. Furthermore, different measures of SEP reflect different dimensions of SEP. So most epidemiological studies that claim to “adjust” for SEP by using a single crude measure of SEP are inaccurate. Explanations of the association of SEP with health are multi-factorial as they are about people’s living, working and growing conditions. Debates over the primacy of one factor over another ignore the reality that these risk factors accumulate in lower SEP individuals and groups across the life course. Policies to address social inequalities in health need to address the whole of the social gradient, not just target the extreme poor and disadvantaged. Targeted health sector interventions to the poorest groups alone will not reduce health inequalities. Coordinated inter-sectoral action that affects the living, working and growing conditions across all of society is needed.

Social and Physical Neighbourhood Environment and Risk of Depression in Adults With Diabetes

BackgroundSelf-rated health (SRH) and socioeconomic position (SEP) as important determinants of health differences are associated with health and economic changes in society.The objectives of this paper were (1) to describe trends in SRH and (2) to analyze associations between SRH and SEP among adults in Estonia in 1996–2014.MethodsThe study was based on a 25–64-year-old subsample (n = 18757) of postal cross-sectional surveys conducted every second year in Estonia during 1990–2014. SRH was measured using five-point scale and was dichotomized to good and less-than-good. Standardized prevalence of SRH was calculated for each study year. Poisson regression with likelihood ratio test was performed for testing trends of SRH over study years. Age, nationality, marital status, education, work status and income were used to determine SEP. Logistic regression analysis was used to assess association between SRH and SEP.ResultsThe prevalence of dichotomized good self-rated health increased significantly over the whole study period with slight decrease in 2008–2010. Until 2002, good SRH was slightly more prevalent among men, but after that, among women. Good SRH was significantly associated with younger age, higher education and income and also with employment status among both, men and women. Good SRH was more prevalent among Estonian women and less prevalent among single men.ConclusionsThere was a definite increase of good SRH over two decades in Estonia following economic downturn between 2008 and 2010. Good SRH was associated with higher SEP over the study period. Further research is required to study the possible reasons behind increase of good SRH, and it’s association with SEP among adults in Estonia.