Address Health Inequities Research Articles

The Experiences of Families of Hospitalized Children Who Use Languages Other Than English.

Patients who use a language other than English (LOE) for health care communication are at increased risk of experiencing adverse events and worse outcomes. The objectives of this research are (1) to understand the lived experience of families who speak LOEs around the hospitalization of their child and (2) to understand the perspectives of patients and families who speak LOEs on opportunities to improve their experiences during hospitalization. This study is grounded in patient- and family-informed research. We designed a qualitative study involving children hospitalized in the general pediatric inpatient unit at a Canadian children's hospital. We conducted semistructured individual interviews with children and families with a medical interpreter. We used thematic analysis, and all interviews were coded by 2 reviewers. A total 20 families of 16 different languages participated in the interviews. Themes important to understanding their lived experience were the following: (1) communication uncertainty-families experienced inconsistent interpreter use and availability, which affected in-the-moment communication and families' ability to understand the overall clinical context, leading to increased uncertainty; (2) lack of belonging-despite communicating that they had positive experiences in the hospital, families described a lack of belonging and felt that they were "other" during hospitalization; (3) altered trust-in addition to language, each patient/family's unique and complex social contexts contribute to developing an altered trust relationship with the health system that impacts their engagement in care processes. Families described opportunities for improvement such as supporting patient-initiated interpretation, increasing workforce diversity, and tailoring concepts such as shared decision making to their realities. Patients and families also revealed that they experience communication uncertainty, altered trust, and a lack of belonging within the hospital setting. Our research builds on the current literature and serves to advance our efforts to address health inequities experienced by this population.

Political economy analysis of health financing reforms in times of crisis: findings from three case studies in south-east Asia

BackgroundOver the last decades, universal health coverage (UHC) has been promoted in south-east Asia (SEA), where many countries still need to ensure adequate financial protection to their populations. However, successful health financing reforms involve complex interactions among a range of stakeholders, as well as with context factors, including shocks and crises of different nature. In this article, we examine recent health financing reforms in Nepal, Thailand and Indonesia, using a political economy lens. The objective is to understand whether and how crises can be utilised to progress UHC and to analyse the strategies used by reformers to benefit from potential windows of opportunity.MethodsThe study adopted a retrospective, comparative case study design, using a shared framework and tools. The case studies mapped the contexts, including economic, political, social trends and any shocks which had recently occurred. A focal health financing reform was chosen in each setting to examine, probing the role of crisis in relation to it, through the key elements of the reform process, content and actors. Data sources were largely qualitative and included literature and document review (144 documents included across the three cases) and key informant interviews (26 in total).ResultsThe findings, which bring out similarities and differences in the roles played by change teams across the settings, highlight the importance of working closely with political leaders and using a wide range of strategies to build coalitions and engage or block opponents. Changing decision rules to block veto points was significant in one case, and all three cases used participation and dialogue strategically to further reforms. More broadly, the links with context emerged as important, with prior conflicts and economic crises creating a sense of urgency about addressing health inequities, while in all countries appeal was made to underlying values to enhance the legitimacy of the reforms.ConclusionThe lessons from these case studies include that technical teams can and should engage in Political Economy Analysis (PEA) thinking and strategizing, including being aware of and adaptable to the changing PEA landscape and prepared to take advantage of windows of opportunity, including, but not limited to, those emerging from crisis. There is a need for more empirical studies in this area and sharing of lessons to support future reforms to increase health coverage and financial protection, including in the face of likely shocks.

NEUROVASCULAR DYSREGULATION IN PREECLAMPSIA- PATHOPHYSIOLOGY AND CLINICAL IMPLICATIONS

After 20 weeks of pregnancy, proteinuria and new-onset hypertension are hallmarks of preeclampsia, a complex hypertensive pregnancy disease that frequently coexists with systemic organ failure. It continues to be a major cause of maternal and newborn morbidity and mortality, affecting 5–8% of pregnancies worldwide, especially in environments with low resources. Although it has historically been associated with placental malfunction, mounting data indicates a substantial neurovascular involvement, including disruption of the blood-brain barrier (BBB), neuroinflammation, and oxidative stress, which results in cerebral edema, ischemia, and bleeding. Headaches, seizures, visual abnormalities, and posterior reversible encephalopathy syndrome (PRES) are examples of neurological symptoms. The characteristics of preeclampsia, a complicated hypertensive pregnancy syndrome that often coexists with systemic organ failure, are proteinuria and new-onset hypertension after 20 weeks of pregnancy. It still accounts for 5–8% of pregnancies globally, particularly in low-resource settings, and is a leading cause of maternal and neonatal morbidity and mortality. Growing evidence suggests a significant neurovascular involvement, including disruption of the BBB, neuroinflammation, and oxidative stress, which leads to cerebral edema, ischemia, and bleeding, despite its historical association with placental dysfunction. Neurological symptoms include visual problems, headaches, seizures, and PRES. Long-term monitoring, supportive care, and neuroprotective techniques are crucial, especially for cardiovascular risks and postpartum problems. The burden of preeclampsia can be lessened by addressing health inequities and including preventive care. Its neurovascular and systemic interactions warrant more investigation in order to develop novel therapeutic strategies that will eventually enhance the results for mothers and newborns. KEYWORDS: Neurovascular dysregulation, preeclampsia, brain-blood barrier, Angiogenic dysregulation, Oxidative stress.

P-1639. Assessing Disparities in Inappropriate Outpatient Antibiotic Prescriptions in Tennessee

Abstract Background The Centers for Disease Control and Prevention (CDC) estimates almost 47 million antibiotics are prescribed each year for indications that do not warrant antibiotic use. Identifying populations that are inappropriately prescribed antibiotics is imperative to address health inequities and prevent antimicrobial resistance. Tennessee Department of Health (TDH) evaluated disparities in outpatient antibiotic prescriptions in patients of different age groups, gender, geographical location, and insurance type. Methods The IQVIA Medical Claims and Longitudinal Prescription Claims databases were used to perform a cross-sectional study to evaluate the appropriateness of all outpatient antibiotics dispensed from retail pharmacies in TN from January 1–December 31, 2022. Data were categorized using a tiered system utilizing ICD-10 codes. Logistic regression was performed to predict whether age, gender, insurance type, and residence were associated with receiving an antibiotic in encounters for which antibiotics are rarely indicated (tier 3). Results In 2022, 2,017,863 prescribed antibiotics were linked to the medical claims database. Over half of these antibiotics were classified as a tier 3 encounter. Females were prescribed more antibiotics (62.0%). For tier 3 encounters specifically: 41.0% of antibiotics were prescribed to patients 65 and older. Residence in low and high socially vulnerable index (SVI) counties accounted for 27.9% and 24.9% of antibiotics, respectively. 37.2%, 16.5%, and 44.5% of antibiotics prescribed were billed to third-party payers (e.g., private health insurance), Medicaid, and Medicare Part D, respectively. Logistic regression showed female gender, younger age, and residence in low SVI had significantly higher odds of receiving an antibiotic for a tier 3 encounter; whereas prescriptions filled with Medicaid and Medicare were less likely to be associated with tier 3 encounters. Conclusion Previously TDH had not explored outpatient antibiotic use through a health equity lens. While the study provided basic demographic information about patients, there is a need to continue exploring disparities within various populations to aid in targeting inventions that drive appropriate antimicrobial use in ambulatory clinical settings. Disclosures All Authors: No reported disclosures

The effects of unified pooling arrangement on health inequity in China: a DID-RIF approach

BackgroundTo address the health inequity caused by decentralized management, China has introduced a provincial pooling system for urban employees’ basic medical insurance. This paper proposes a research framework to evaluate similar policies in different contexts. This paper adopts a mixed-methods approach to more comprehensively and precisely capture the causal effects of the policy. Ultimately, this paper aims to assess the impact of the UPA policy on health inequity.MethodsThis study takes the provincial unified reform of basic medical insurance for urban employees in China as an example, uses the China Family Panel Studies (CFPS) data and related policy documents, and adopts the DID-RIF hybrid method to test the impact of the equalization of the medical insurance system on health inequity, by using the interaction term in the DID (Difference-in-Differences) model as the independent variable in the RIF (Recentered Influence Function) to exclude the influence of other interfering variables. In addition, the DID method explores the effects of UPA on medical expenditures, which can guide the improvement of the policy.ResultsThe empirical results show that the UPA policy increases the likelihood of patients developing chronic diseases within six months. Although factors such as age, gender, and marital status influence the probability of chronic disease, health inequity between income groups after the policy’s implementation primarily stems from the rise in outpatient and reimbursement expenses.ConclusionsAlthough the gap in medical reimbursement expenses between participants of different socioeconomic statuses narrowed after the provincial medical insurance pooling reform, health inequity among the insured population increased. The equalized health insurance reform failed to address health inequities based on socioeconomic status. Additionally, the reverse reallocation of medical resources and outpatient arbitrage driven by moral hazard warrant close attention. This paper recommends that, in advancing the provincial pooling of UEBMI, greater focus should be placed on strengthening digital oversight and improving the hierarchical diagnosis and treatment system to promote social equity.

Socioeconomic inequalities in health behaviors in children and adolescents: evidence from an Australian cohort

BackgroundUnderstanding the association between socioeconomic inequalities and health behaviors is imperative for elucidating and effectively addressing health inequities among children and adolescents. Despite the wealth of literature on social gradients in health behaviors, longitudinal analyses of socioeconomic inequalities in the health behaviors of children and adolescents are relatively limited, particularly in the Australian literature. Therefore, this study aimed to investigate the association between socioeconomic inequalities and health behaviors among Australian children and adolescents.MethodsThis study utilized the secondary data from the Longitudinal Study of Australian Children (Waves 2–8), which included participants aged 2 to 15 years. Relative index inequality (RII) methods were used to investigate the associations between socioeconomic inequalities and the health behaviors of children and adolescents.ResultsCompared with their counterparts, children and adolescents with high socioeconomic status (SES) are 84% more likely to consume fruits and vegetables (RII = 1.84, 95% CI = 1.63–2.09) and 19% less likely to consume sugary beverages (RII = 0.81, 95% CI = 0.77–0.86), but more likely to consume sweet and savory foods (RII = 1.09, 95% CI = 1.01–1.19). Children and adolescents with high SES were less likely to spend their free time on screens (RII = 0.86, 95% CI = 0.81–0.91) and more inclined toward outdoor activities (RII = 1.75, 95% CI = 1.53–1.98).ConclusionThis study provides useful insight into socioeconomic inequalities and health behavior outcomes in children and adolescents. These findings stress the need for tailored interventions designed to improve the health behaviors of families from lower socioeconomic backgrounds. Additionally, addressing unhealthy dietary behaviors, such as the higher consumption of sweet and savory foods among children from higher SES backgrounds, is equally critical. Such comprehensive interventions have the potential to reduce socioeconomic disparities in health behaviors and improve the well-being of the broader population.

Collaborating With and Enabling Diverse Communities to Address Health Inequities: The Experiences of a Community Engagement and Outreach Team

Collaborating With and Enabling Diverse Communities to Address Health Inequities: The Experiences of a Community Engagement and Outreach Team

Cultural humility strategies for recruitment and retention of minoritised participants: a scoping review protocol

IntroductionCultural humility practices are shown to be effective when working with diverse populations in healthcare settings. Research recruitment and retention among minoritised groups are essential to address health inequities. Given...

Global impact of PM2.5 on cardiovascular disease: Causal evidence and health inequities across region from 1990 to 2021.

PM2.5 is an important environmental risk factor for cardiovascular disease (CVD) and poses a threat to global health. This study combines bibliometric analysis, Mendelian randomization (MR), and Global Burden of Disease (GBD) data to comprehensively explore the relationship between PM2.5 exposure and CVD. MR analyses provided strong evidence for causality, reinforcing findings from traditional observational studies. The estimated global burden of PM2.5-related CVD indicated, that there exist significant impacts on the elderly, men, and populations in low and medium socio-demographic index (SDI) areas. This study further found that population growth and aging are the main drivers of this burden with large inequities, although medical advances have mitigated some of the effects. Overall, the opportunity to reduce the burden of CVD remains significant, particularly in medium SDI countries. Projections to 2045 suggested that the absolute burden will increase, while age-standardized rates will decline due to improvements in air quality and health care. These findings emphasized the urgent need for targeted interventions to mitigate the deleterious effects of PM2.5 on global cardiovascular health and to address health inequalities between regions.

A realist review of how, why, for whom and in which contexts quality improvement in healthcare impacts inequalities

IntroductionQuality improvement (QI) is aimed at improving care. Equity is one of the six domains of healthcare quality, as defined by the Institute of Medicine. If this domain is ignored,...

The Relationship between Noise Pollution and Depression and Implications for Healthy Aging: A Spatial Analysis Using Routinely Collected Primary Care Data.

Environmental noise is a significant public health concern, ranking among the top environmental risks to citizens' health and quality of life. Despite extensive research on atmospheric pollution's impact on mental health, spatial studies on noise pollution effects are lacking. This study fills this gap by exploring the association between noise pollution and depression in England, with a focus on localised patterns based on area deprivation. Depression prevalence, defined as the percentage of patients with a recorded depression diagnosis, was calculated for small areas within Cheshire and Merseyside ICS using the Quality and Outcomes Framework Indicators dataset for 2019. Strategic noise mapping for rail and road noise (Lden) was used to measure 24-h annual average noise levels, with adjustments for evening and night periods. The English Index of Multiple Deprivation (IMD) was employed to represent neighborhood deprivation. Geographically weighted regression and generalised structural equation spatial modeling (GSESM) assessed the relationships between transportation noise, depression prevalence, and IMD at the Lower Super Output Area level. The study found that while transportation noise had a low direct effect on depression levels, it significantly mediated other factors associated with depression. Notably, GSESM showed that health deprivation and disability were strongly linked (0.62) to depression through the indirect effect of noise, especially where transportation noise exceeds 55dB on a 24-h basis. Understanding these variations is crucial for developing noise mitigation strategies. This research offers new insights into noise, deprivation, and mental health, supporting targeted interventions to improve quality of life and address health inequalities.

The potential of a population register for addressing health inequities: an observational study using data linkage to improve breast cancer screening enrolment and participation in Indigenous Māori women in Aotearoa New Zealand

BackgroundBreast cancer screening in Aotearoa New Zealand (NZ) still has persistent inequitable coverage by ethnicity, especially for Indigenous Māori women. This project aimed to undertake systematic data linkage to identify and invite eligible Māori women to participate in breast screening.MethodsThis is a cross-sectional observational study conducted in Northern New Zealand between 1/01/2020 and 30/06/2021. The BreastScreen Aotearoa (BSA) register was linked with the primary care data to identify and invite eligible Māori women (aged 45–69 years) to breast screening, who were not currently enrolled in BSA, and who were enrolled in BSA but had not been screened or overdue for breast screening. Invitations were sent through invitation letters, text messages and phone calls. Enrolment to BSA and screening participation at 15 and 18 months from the project’s start date were reported.ResultsThrough the data linkage, 2295 women who were not enrolled in BSA were identified eligible for breast screening. Approximately half (n = 1086) of the women were contactable within 5 contact attempts. Of these contactable, 345 (32%) women were enrolled in BSA, 421 (39%) were screened at 15 months, increasing to 441 (41%) at 18 months from the project start. Among women who were previously enrolled but never screened or overdue for screening, 1470 women were eligible. Their contact details were updated through the data linkage, which facilitated BSA to contact them successfully for breast screening. Consequently, 305 (21%) of these eligible were screened at 15 months, and increased to 332 (23%) at 18 months.ConclusionsThe data linkage approach has evidenced the benefit of a population register to facilitate equitable access to breast screening services. Further work is needed on choices of combined approaches for optimising screening uptake equitably.

Trends and cross-country inequalities in global burns burden among children and adolescents: A population-based study from 1990 to 2021.

Burns among children and adolescents represent a significant global health burden, leading to substantial morbidity and disability. This study aimed to analyze the trends in burn incidence, prevalence, and years lived with disability (YLDs) from 1990 to 2021, and to project future trends to 2035, highlighting global and regional disparities. We utilized data from the Global Burden of Disease (GBD) database covering 204 countries and territories. Burn data were extracted from multiple sources including hospital records, health surveys, and national health databases. Trend analysis was projected using the Bayesian age-period-cohort (BAPC) model. Health inequality was assessed using the slope index of inequality (SII) and the concentration index (CI). In 2021, the global incidence of burns among children and adolescents was 8,484,254 cases, with an age-standardized incidence rate (ASIR) of 1315.94 per 100,000 population, showing an annual reduction of 1.33 % from 1990. The prevalence and YLDs also showed significant annual declines. Males had higher incidence rates than females. Younger children (0-4 years) experienced the highest incidence rates, while adolescents (15-19 years) had the highest prevalence. Regional disparities were evident, with Central Asia and Central Europe having the highest ASIRs. The SII and CI indicated persistent socio-economic health disparities, with lower socio-demographic index (SDI) countries bearing a disproportionate burden. Predictive analysis suggests a continued decline in burn incidence, prevalence, and YLDs through 2035. Additionally, burns among adolescents and young adults result in significant loss of labor force, exacerbating socio-economic challenges in affected regions. The global burden of burns in children and adolescents has decreased significantly, yet substantial disparities persist across different regions and socio-economic strata. Continued efforts in improving burn prevention, treatment, and rehabilitation are essential to further reduce the burden and address health inequalities.

Socioeconomic Determinants and Health Outcomes of Financial Resilience Patterns: A Latent Profile Analysis.

Financial resilience describes an actionable financial capability to cope with emergencies and adversities. However, little is known about whether financial resilience patterns impact holistic health outcomes. This study conducted a 3-step latent profile analysis using an urban community sample (n=3710) from a nationally representative database in China. A multinomial logistic regression model and multiple linear regression models were estimated to examine the proposed argument guided by social determinants of health and resilience theory. Three latent subgroups were identified to differentiate population heterogeneity with high, moderate, and low financial resilience. Younger generations with lower employment participation, education, income, and assets were significantly less likely to be in moderate and high financial resilience subgroups. After controlling demographics and conventional socioeconomic covariates, financial resilience patterns were significantly negatively associated with mental illness, while positively associated with physical health, subjective happiness, and life satisfaction. Financial resilience could be a strength-based and actionable socioeconomic determinant of health. Research and practical implications are provided for addressing health inequalities. A new target in community health and social welfare is to enhance financial resilience among marginalized populations through family asset-building, financial inclusion policy, financial literacy education, and social capital investment.

Inequalities in utilization of maternal health services in Ethiopia: evidence from the PMA Ethiopia longitudinal survey.

Previous studies documented the existence of substantial inequalities in the utilization of maternal health services across different population subgroups in Ethiopia. Regularly monitoring the state of inequality could enhance efforts to address health inequality in the utilization of maternal health services. Therefore, this study aimed to measure the level of inequalities in the utilization of maternal health services in Ethiopia. The study used data from the Performance Monitoring for Action Ethiopia (PMA Ethiopia) dataset. Longitudinal data was collected from a weighted sample of 1966 postpartum women using multistage stratified cluster sampling techniques between November 2021 to October 2022. We assessed inequality in maternal health services using three indicators: antenatal care four (ANC), skilled birth attendants (SBA), and postnatal care (PNC). Age, economic status, education level, place of residence, and subnational regions were used as dimensions for measuring inequality. The analysis was conducted using Health Equity Assessment Toolkit Plus (HEAT Plus) software. We computed the summary measure of health inequality: Difference (D), Ratio (R), Population Attributable Risk (PAR), and Population Attributable Fraction (PAF). The simple summary measures of inequality difference (D) reported a high level of inequality in the utilization of maternal health services in ANC four, SBA, and PNC across economic, education, residence, and subnational regions. The difference (D) in maternal health service utilization between advantaged and disadvantaged population groups exceeded 20 percentage points in all four dimensions of inequality for the three maternal health indicators. Similarly, the complex summary measures of inequality (PAR and PAF) also showed high levels of inequality in the utilization of ANC four, SBA, and PNC across all four dimensions of inequality. However, there was no age-related inequality in the use of maternal health services. A high level of socioeconomic and geographic area related inequality was observed in the utilization of ANC four, SBA, and PNC services in Ethiopia. Women from socioeconomically disadvantaged subgroups and women from disadvantaged geographic areas significantly lagged behind in the utilization of maternal health services. Therefore, implementing targeted interventions for the most disadvantaged groups can help to reduce inequality in accessing maternal health services.

Public policies for vulnerable populations: addressing health inequalities

Public policies for vulnerable populations: addressing health inequalities

Addressing Health Inequities: Understanding the Relationship Between Social Determinants of Health and Necrotizing Enterocolitis.

Necrotizing enterocolitis (NEC) is a severe illness with high mortality. Traditional risk factors are prematurity and neonatal stress. Maternal risk factors have also been postulated but are often overlooked. We aimed to define parental and patient factors associated with NEC and their impact on outcomes. Infants under 1 year old diagnosed with NEC were identified via the Pediatric Health Information System database between 2012 and 2022. The Childhood Opportunity Index (COI) was used to represent each family's household educational, environmental, and socioeconomic conditions. The COI was split into low, middle, and high levels and analyzed across demographics and mortality. Multivariable regression was used to determine the association between COI and in-hospital mortality, adjusting for gestational age, gender, race, primary payor, urban flag, and geographic region. Overall, 10,768 patients with a median gestational age of 29 weeks (IQR 25-34), and a median birthweight of 1,010g (IQR 660-1,880g) met inclusion criteria. The cohort was majority male (57%), and White (46%), and overall, had a mortality rate of 18%. Low COI was associated with longer length of stay (56 vs. 53 days) and increased mortality (19% vs. 15%) when compared to high COI. On adjusted analysis, high COI was associated with decreased odds of death by time of discharge (OR 0.75, 95% CI 0.65-0.86, p<0.001) when compared to low COI. NEC is a disease that disproportionately affects socially disadvantaged infants. The mortality rates of NEC are linked to parental social determinants of health, highlighting this unique population to target for risk assessment and additional prenatal resources. Cross Sectional Study. III.

Creating a Sustainable Native Hawaiian Pacific Islander Community Health Worker Workforce to Address Health Inequity in Hawai'i.

Creating a Sustainable Native Hawaiian Pacific Islander Community Health Worker Workforce to Address Health Inequity in Hawai'i.

Harnessing deliberative regulation to address inequities in accessing healthcare services in England.

System-level decisions around the commissioning and provision of healthcare services in England have contributed to barriers in accessing the National Health Service. In this article, we ask how to better regulate resource allocation to ensure greater equity in access to healthcare services. First, we focus on the Health and Care Act 2022, which, drawing on principles of deliberative regulation to address health inequalities, initiates a shift away from previous regulatory approaches towards a collaborative decision-making model. We then shed light on the systemic factors creating and maintaining access barriers by considering shortcomings in previous regulatory approaches. With these in mind, we consider whether deliberative regulation-providing communities with resources to create normative solutions to intrinsic issues-could help address these systemic challenges. To assess the potential of laws or policies to achieve greater equity in healthcare, we also introduce an evaluative framework based on deliberative principles. We apply this framework to a case study of an Integrated Care System to gauge the extent to which the Health and Care Act 2022 has indeed been effectively adopting a deliberative approach by intentionally engaging marginalized communities in decision-making and devising accountability mechanisms for the allocation of healthcare resources.

Integrating modern and herbal medicines in controlling malaria: experiences of orthodox healthcare providers in Ghana

BackgroundIn Ghana, the government has integrated herbal medicine into the formal healthcare system in response to widespread use of traditional remedies. However, empirical evidence supporting the contribution of integrated healthcare to malaria control remains limited. This study employed a phenomenological qualitative research design to explore the experiences of medical doctors and pharmacists from the coastal, forest and savannah regions of Ghana regarding the integration of modern and herbal medicine in the treatment and control of malaria. Donabedian’s framework for evaluating the quality of healthcare served as the foundational theoretical framework for this research.MethodsData were collected through individual in-depth interviews involving 26 participants and analysed using a framework analytical approach.ResultsThe findings revealed that inadequate political commitment to the practice of integration has led to several challenges, including the high cost of herbal anti-malaria medications, limited promotional activities surrounding integration, a shortage of qualified medical herbalists, inconsistent supply chains for herbal anti-malaria treatments, and a lack of standardisation in herbal medicine practices. Participants had divergent views regarding the impact of integration on malaria control; while medical doctors believed that the intervention has not significantly contributed to reducing malaria prevalence in Ghana, pharmacists viewed the presence of herbal clinics within government hospitals as an effective and sustainable alternative for treating malaria.ConclusionReflecting on these results, it is imperative for policymakers to explore strategies that could enhance the effectiveness of an integrated health system, thereby increasing the contribution of herbal medicine towards achieving a malaria free nation. Future research could benefit from including policymakers, heads of health directorates, and community members, regarding the role of public health interventions in addressing health inequities in Ghana.