Considerable Health Inequalities Research Articles

Peer Education as a Tool to Improve Health Knowledge for People Who Are Incarcerated: A Secondary Analysis of Data From the Indiana Peer Education Program ECHO.

Considerable health inequities occur among people who are incarcerated, with ripple effects into broader community health. The Indiana Peer Education Program uses the Extension for Community Health Outcomes (ECHO) model to train people who are incarcerated as peer health educators. This analysis sought to evaluate the effectiveness of this program and explore emergent themes not covered in survey instruments. Survey data for both peer educators and their students were assessed using multivariate regression. Qualitative data were used to triangulate survey findings and explore additional themes via thematic analysis. Students showed improvements in knowledge scores and postrelease behavior intentions; peer educators improved in knowledge, health attitudes, and self-efficacy. Qualitative data affirmed survey findings and pointed toward peer educators acquiring expertise in the content they teach, and how to teach it, and that positive results likely expand beyond participants to others in prison, their families, and the communities to which they return. Though preliminary, the results confirm an earlier analysis of the New Mexico Peer Education Program ECHO, adding to the evidence that training individuals who are incarcerated as peer educators on relevant public health topics increases health knowledge and behavior intentions and likely results in improvements in personal and public health outcomes.

Social rights in relation to digitalization, mobile phone, and internet use – experiences of women in homelessness: a qualitative study

ABSTRACT Given the fact that women in homelessness face considerable health inequities, the question of how digitalization can be understood in relation to social rights and right to health surfaces. The objective of this qualitative interview study was to explore the use of mobile phones and internet for women experiencing homelessness. Women (n = 26) shared experiences of healthcare access by using a mobile phone or internet. Data were analyzed using NVivo software. The results are presented in two themes: Conditions and circumstances of having a mobile phone; and Structural and intrapersonal challenges affecting social rights. The results show that digitalization actively influenced everyday life for women experiencing homelessness. Whether women wanted it to or not, digitalization presents a line of demarcation for participation and inclusion or exclusion, in health- and social-care services.

The status of health services in the 15 counties of Liberia

Aim: Liberia, situated at the West African coast, is composed of 15 counties with an economic gradient steeply decreasing from the Northwest to the Southeast. Health-related activities by government action in the 15 counties concentrate on the areas of family planning, antenatal and delivery care, as well as immunization, health workforce and infrastructure. The differences in this regard between the 15 Liberian counties will be reviewed. Methods: A narrative review is employed, making use of the recent international and national documents, relevant literature and available information from the following primary and secondary sources and databases. Results: The results point to gross differences between the 15 counties of Liberia in terms of health service provision. The overall readiness based on defined indicators for all 701 facilities was 59% with a range between facilities at the level of counties of 50% to 65%; for family planning services 88% (range 65% – 100%); for antenatal care 62% (range 55% – 100%); for immunization coverage 76% (range 66% – 86%). The health workforce of Liberia comprises 11.8 health workers per 10.000 population, WHO target is 23, the counties range from 8.0 to 15.7. Similarly, according to WHO standards, there should be 2 health facilities per 10.000 inhabitants, Liberia comes up to 1.9 however the counties range from 1.1 – 3.0 per 10.000. Conclusions: It is obvious that across almost all areas of women and child health and health services in general there exist large differences between counties, which points to considerable health inequities in this country. The government of Liberia should consider reallocating the available resources per number of population instead of accepting historical developments, however with a correction factor in favou of disadvantaged regions and population groups.

A survey study to determine health disparities among men who have sex with men in Eastern Ontario: looking beyond sexual risk and the gay, urban core

To create health promotion programs and clinical guidelines inclusive of gay, bisexual and other men who have sex with men (gbMSM), a better understanding of the health and social determinants that influence health outcomes for these men is required. Health research on gbMSM, however, has focused primarily on sexual health and HIV (human immunodeficiency virus) with most information coming from men living in large urban centers. To address this limitation and better characterize the overall health of this population, we conducted a survey of gbMSM living in Eastern Ontario, Canada. The survey, completed anonymously, was available from June to October 2015. A total of 674 gbMSM completed the survey; 61% were urban, 23% suburban and 16% lived in small towns or rural settings. The average age was 44.2 years, ranging from 18 to 83 years. Healthcare engagement was high for all groups of gbMSM, though disclosure of sexual orientation to healthcare providers varied based on the gender of sexual partners. Urban men tended to be younger, sexually active only with men, open about their sexual orientation, and more likely to use recreational drugs while men living in small towns and rural settings tended to be older, bisexual and more likely to conceal their sexual orientation. While the physical health of respondents was on par with national averages for men, we found younger men were more likely to suffer from anxiety and use recreational drugs while older men were more likely to develop problem alcohol use. Depressive symptoms were high across all demographic groups. Our data demonstrate that while gbMSM in Eastern Ontario have a high degree of contact with the healthcare system, considerable health inequities remain unaddressed. We also find significant health differences among gbMSM depending on age, area of residence, and degree of disclosure of sexual orientation.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study

BackgroundPeople who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. MethodsWe linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results90,195 individuals (13% women, 49% Māori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. ConclusionExperience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

Developing undergraduate autism education for medical students: a qualitative study

BackgroundAutistic adults and children experience considerable health inequalities and have high rates of premature mortality, hospital admissions and emergency department visits. This is in part due to a lack of...

Barriers to older Pacific peoples’ participation in the health-care system in Aotearoa New Zealand.

Introduction Participation in the health-care system is a key component of healthy ageing strategies. The number of Pacific people aged ≥65 years in Aotearoa New Zealand will increase significantly over the next decade. Addressing the considerable health inequities and unmet need for care Pacific Island people experience when compared to other ethnicities in Aotearoa New Zealand should be a priority. Aim To identify barriers to older Pacific people's participation in the health-care system in Aotearoa New Zealand. Methods A participatory action research design was utilised. In total, 104 Pacific co-researchers contributed to focus groups using Talanoa , a traditional method of conversational dialogue deeply rooted in Pacific Island culture. Data were collected in Pacific Island languages from storytelling and conversations shared within the focus groups. Data were translated into English and analysed using a collaborative approach. Results Three main themes captured older Pacific peoples' barriers to participation in the health-care system: accessing health care; relationships with health-care providers; and understanding the health-care system. Discussion Older Pacific people have the capacity to influence locally driven programmes to be more responsive to their needs and aspirations. Improving older Pacific peoples' participation in health care will require a commitment to partnership and inter-sectoral collaboration identified in recent ageing strategies. The findings will inform local communities, and policy and practice aimed at improving the health and wellbeing of Pacific peoples who are ageing in Aotearoa New Zealand.

New directions in global environmental health

BACKGROUND AND AIM: The COVID-19 pandemic is challenging the world’s economic and health systems and exemplifies the degree of global interdependencies, the problems in the governance of global crises and the need of preparedness for global health threats. The outbreak of COVID-19 highlighted the links between the occurrence of new infections, the environment and climate at a global scale and the need for a planetary health perspective and trans-disciplinary approaches. The pandemic brought forward considerable health inequities globally METHODS: The new post-pandemic global settings bring forward overarching topics that have not been efficiently addressed: research needs for policy development, locally and globally; development of transdisciplinary research; implementation science for long-standing global problems; global ethics; new approaches in global public health governance. RESULTS:The pandemic has profoundly affected global society in multiple ways, introducing entirely new challenges and accelerating ongoing trends. The pandemic has highlighted the deep interconnections between problems typically studied in isolation or that previously were situated at the periphery of environmental epidemiology. There is a need to develop research and action on multiple levels. For example, air pollution, chemical pollution, or nature-based solutions must be addressed locally in cities. We should also address them at a global level: global air-pollution in relation to decarbonisation, the effects of global pollution and loss of biodiversity on ecosystems and human health. LMICs are disproportionately impacted by environmental pollution because of the lack of environmental policies and export of contaminants from high-income countries. The urgency of responding to the pandemic brought into prominence the need for international collaboration to develop actionable knowledge to emergencies that will require research in understudied populations and understudied thematic areas. CONCLUSIONS:The dramatic changes occurring in a short time will affect research in environmental epidemiology in the long term and the role of environmental epidemiology on a global scale. KEYWORDS: global epidemiology, covid-19, international collaboration

Developing a National Set of Health Equity Indicators Using a Consensus Building Process.

Considerable health inequities documented in Israel between communities, populations and regions, undermine the rights of all citizens to optimal health. The first step towards health equity is agreement on a set of national indicators, reflecting equity in healthcare provision and health outcomes, and allowing monitoring of the impact of interventions on the reduction of disparities. We describe the process of reaching a consensus on a defined set of national equity indicators. The study was conducted between January 2019 and June 2020, in a multistage design: (A) Identifying appropriate and available inequity measures via interviews with stakeholders. (B) Agreement on the screening criteria (public health importance; gap characteristics; potential for change; public interest) and relative weighting. (C) Constructing the consultation framework as an online, 3-round Delphi technique, with a range of experts recruited from the health, welfare and education sectors. Participants were of diverse age, gender, geographic location, religion and ethnicity, and came from academia, healthcare provision, government ministries and patient representative groups. Thirty measures of inequity, presented to participants, represented the following domains: Health promotion (11 indicators), acute and chronic morbidity (11), life expectancy and mortality (2), health infrastructures and affordability of care (4), education and employment (2). Of the 77 individuals contacted, 75 (97%) expressed willingness to participate, and 55 (73%) completed all three scoring rounds. The leading ten indicators were: Diabetes care, childhood obesity, adult obesity, distribution of healthcare personnel, fatal childhood injuries, cigarette smoking, infant mortality, ability to afford care, access to psychotherapy and distribution of hospital beds. Agreement among raters, measured as intra-class correlation coefficient (ICC), was 0.75. A diverse range of consultants reached a consensus on the most important national equity indicators, including both clinical and system indicators. Results should be used to guide governmental decision-making and inter-sectoral strategies, furthering the pursuit of a more equitable healthcare system.

Perspectives on expertise in teaching about transgender healthcare: A focus group study with health professional programme teaching staff and transgender community members

Background It is well established that transgender people experience considerable health inequities, which are sustained in part by limited teaching about transgender healthcare for trainee health professionals. Aims The aim of this study was to explore the perspectives of both teaching staff from health professional education programmes and transgender community members on the best ways to teach about transgender healthcare, with a focus on ways of: 1) overcoming barriers to this teaching; and 2) involving community members in this teaching. Methods A research advisory committee was convened to guide the project and included transgender community members, teaching staff from health professional programmes, and trainee health professionals in Aotearoa/New Zealand. Three preliminary focus groups were held with 10 transgender community members. These community members were then invited to act as transgender community ‘ambassadors’ in focus groups with teaching staff based on suggestions from the advisory committee. Six focus groups were conducted with 22 teaching staff from a range of health professional education programmes along with at least two transgender community ambassadors. Results Teaching staff positioned themselves as lacking the expertise to teach about transgender healthcare but also as expert teachers when applying methods such as small group teaching. Transgender participants also positioned themselves as having expertise arising primarily from their own experiences and acknowledged that effective teaching about transgender healthcare would need to cover a diversity of transgender identities and healthcare outside their own experiences. Teaching staff and transgender community members were keen to pool expertise and thus overcome the shared sense of lacking the expertise to teach about transgender healthcare. Discussion These findings provide insights into the current barriers to teaching about transgender healthcare and provide future directions for staff development on teaching about transgender healthcare and ways of safely involving transgender community members in teaching.

Predictors Linking Obesity and the Gut Microbiome (the PROMISE Study): Protocol and Recruitment Strategy for a Cross-Sectional Study on Pathways That Affect the Gut Microbiome and Its Impact on Obesity.

BackgroundThe prevalence of obesity has increased substantially over recent decades and is associated with considerable health inequalities. Although the causes of obesity are complex, key drivers include overconsumption of highly palatable, energy-dense, and nutrient-poor foods, which have a profound impact on the composition and function of the gut microbiome. Alterations to the microbiome may play a critical role in obesity by affecting energy extraction from food and subsequent energy metabolism and fat storage.ObjectiveWe report the study protocol and recruitment strategy of the PRedictors linking Obesity and the gut MIcrobiomE (PROMISE) study, which characterizes the gut microbiome in 2 populations with different metabolic disease risk (Pacific and European women) and different body fat profiles (normal and obese). It investigates (1) the role of gut microbiome composition and functionality in obesity and (2) the interactions between dietary intake; eating behavior; sweet, fat, and bitter taste perception; and sleep and physical activity; and their impact on the gut microbiome, metabolic and endocrine regulation, and body fat profiles.MethodsHealthy Pacific and New Zealand (NZ) European women aged between 18 and 45 years from the Auckland region were recruited for this cross-sectional study. Participants were recruited such that half in each group had either a normal weight (body mass index [BMI] 18.5-24.9 kg/m2) or were obese (BMI ≥30.0 kg/m2). In addition to anthropometric measurements and assessment of the body fat content using dual-energy x-ray absorptiometry, participants completed sweet, fat, and bitter taste perception tests; food records; and sleep diaries; and they wore accelerometers to assess physical activity and sleep. Fasting blood samples were analyzed for metabolic and endocrine biomarkers and DNA extracted from fecal samples was analyzed by shotgun sequencing. Participants completed questionnaires on dietary intake, eating behavior, sleep, and physical activity. Data were analyzed using descriptive and multivariate regression methods to assess the associations between dietary intake, taste perception, sleep, physical activity, gut microbiome complexity and functionality, and host metabolic and body fat profiles.ResultsOf the initial 351 women enrolled, 142 Pacific women and 162 NZ European women completed the study protocol. A partnership with a Pacific primary health and social services provider facilitated the recruitment of Pacific women, involving direct contact methods and networking within the Pacific communities. NZ European women were primarily recruited through Web-based methods and special interest Facebook pages.ConclusionsThis cross-sectional study will provide a wealth of data enabling the identification of distinct roles for diet, taste perception, sleep, and physical activity in women with different body fat profiles in modifying the gut microbiome and its impact on obesity and metabolic health. It will advance our understanding of the etiology of obesity and guide future intervention studies involving specific dietary approaches and microbiota-based therapies.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12618000432213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370874International Registered Report Identifier (IRRID)RR1-10.2196/14529

Guardians of the Living Water: Using a Health Literacy Framework to Evaluate a Child as Change Agent Intervention.

American Indian communities in the United States experience considerable health inequities, including increased exposure to environmental contaminants. Consequently, community members of the Apsáalooke (Crow) Nation identified the lack of water-related environmental knowledge among children as an area of concern. The purpose of this study was to provide a feasibility evaluation of an increasingly sophisticated environmental health literacy program for children. A community-academic partnership developed and piloted the Guardians of the Living Water program to increase environmental health literacy among children and their families on the Crow reservation. Nutbeam's framework for health literacy, a schema based on functional, interactive, and critical literacy, shaped the program evaluation. We used a within-subjects, quasi-experimental design without a control group. Interviews with children and parents were used to assess the feasibility of the program, while pre-/posttests assessed changes in knowledge, skills, and behavior. Compared with preintervention responses, those from postintervention indicated significant increases for selected knowledge and attitude components. Based on qualitative interviews with children and caregivers, the camp was a valuable experience and increased knowledge of water quality science and reinforced cultural knowledge. This success of our program stems from the trust initially built between partners and then expanded throughout the community. The program and the evaluation benefited from both the health literacy framework and from our integration of Apsáalooke values. Our findings suggest that a community-based intervention designed to increase environmental health literacy among youth and their social networks is feasible and acceptable to this American Indian community.

A Culturally Responsive Approach to Improving Replication of a Youth Sexual Health Program.

Youth-serving agencies continually turn to evidence-based interventions that have been empirically assessed for effectiveness in influencing young people's lives, particularly those living in communities with considerable health inequities. Replicating promising evidence-based interventions requires thoughtful adaptation and modification to better fit participants' sociocultural context and to enhance their learning experiences. Due to the restrictive nature of a replication model, adaptations to the intervention curriculum must be minimized during full implementation. Implementers must find innovative ways to ensure content is relevant and engaging to participants without altering core elements of the curriculum. This article describes practical best practice strategies used in implementing a sexual health education program among socioculturally diverse youth in a northeastern city in the United States. The implementing agency applied Richard, Brown and Forde's framework for culturally responsive pedagogy as a heuristic approach to describe the application of implementation practices across three dimensions: institutional, personal, and instructional. The results not only highlight successful culturally responsive practices that enhanced the implementation process but also acknowledge areas in which such practices proved daunting to implement.

Connecting the dots on health inequalities--a systematic review on the social determinants of health in Portugal.

IntroductionHealth inequalities are recognised as a public health issue worldwide, but only a few countries have developed national strategies to monitor and reduce them. Despite its considerable health inequalities, Portugal seems to lack a systematic strategy to tackle them, possibly due to the absence of organised evidence on the issue. We performed a systematic review that aimed to describe the available evidence on social inequalities in health in Portugal, in order to contribute towards a comprehensive and focused strategy to tackle them.MethodsWe followed the PRISMA guidelines and searched Scopus, Web of Science and PubMed for studies that looked at the association between a measure of socioeconomic status and a health outcome in the Portuguese resident population since the year 2000. We excluded health behaviours and healthcare use from our search. We performed a qualitative description of the results.ResultsSeventy-one publications were selected, all reporting observational analyses, most of them using cross-sectional data. These publications showed strong evidence for health inequalities related to education and gender, chiefly for obesity, self-rated health and mental health.ConclusionsAnalysis of the eligible publications showed that current research does not seem to have consistently covered the link between health and key Portuguese social problems. A strategy focusing on the monitoring of most prevalent diseases, most determining socioeconomic factors and vulnerable populations would be crucial to guide academic research in a country in which health inequalities are so ubiquitous and deeply rooted.RegistrationThis systematic review is not registered.Electronic supplementary materialThe online version of this article (doi:10.1186/s12939-016-0314-z) contains supplementary material, which is available to authorized users.

Examining the Capacities of Municipal Governments to Reduce Health Inequities: A Survey of Municipal Actors’ Perceptions in Metro Vancouver

Canada is an increasingly urban nation, with considerable health inequities (HI) within its urban centres. While Canadian municipalities have a range of policy and planning levers that could reduce the burden of HI, little is known about how municipal employees perceive the capacities of municipal governments to address HI within their jurisdictions. This study sought to capture these perceptions through a survey of politicians and senior-level staff working in Metro Vancouver municipalities. The survey was administered by mail to 637 politicians and senior-level staff from 17 municipal governments in Metro Vancouver. The survey captured respondents' perceptions on the responsibilities of, opportunities for, and constraints on, municipal-level action to address HI, as well as respondents' input on existing municipal policies and programs that could reduce HI in their jurisdictions. Respondents perceived senior governments to bear greater responsibility for reducing HI than municipalities. Investing in "parks & recreation facilities" was considered the most promising policy lever for addressing HI, while "insufficient federal and provincial funding" was perceived to be the greatest constraint on municipal action. "Affordable housing" and "recreational programs" were the most commonly identified existing strategies to address HI in the municipalities sampled. Our findings revealed concerns about inter-governmental downloading of responsibilities, and behaviour-based assumptions of disease etiology. To advance an urban health equity agenda, more work is needed to engage and educate municipal actors from a range of departments on the social determinants of health inequities.

Boosting the public health agenda through collaboration

The Budget delivered on 21 March presented a number of surprises for us all and not least the imposition of VAT on a number of hot foods. It was Greggs’ pasties that took the lime light. My personal favourite (cheese and onion) will now be £1.09 instead of 90p but will that stop me having one as an occasional treat? Would it stop me if I bought one every day? Was it meant to stop me? After so much coverage in the press, I am sure you are all aware that this budget change was closing a loophole in legislation going back as far 1984; wouldn’t it have been so much better if it were part of a considered public health strategy to improve health through a variety of means including legislation and price fixing? ‘Not the Nanny State again!’ I hear you cry, however, a tax on high-fat foods sits right along minimal pricing on alcohol, increased prices on cigarettes and restrictions on smoking in public, as far as I am concerned. We need some national action to help nudge people into healthier lifestyles and we know legislation can help. Much was made in the media about this being a tax on the working man – that would be the working man who already suffers from considerable health inequalities than his more affluent neighbours? As nurses, we see the impact of obesity, alcohol and smoking every day. According to the Academy of Medical Royal Colleges, the UK now has the highest rate of obesity in Europe (2012). The impact on society is too great to note here but the extent of that impact on the NHS is, as you know, severe. This impact ranges from equipment requirements to research trials. A current trial to give obese pregnant women metformin to reduce the supply of insulin to the foetus and hopefully reduce the size of the baby at birth was noted in the media in early April. Alcohol consumption has doubled between 2000 and 2008. Deaths from alcohol-related causes have also doubled, though over a slightly longer time period. Alcohol misuse is estimated to cost the NHS £2.7 billion a year (National Audit Office, 2008) in England. The move towards legislation introducing minimum pricing is quickening across the UK, with Scotland taking the lead and likely to introduce it within the year. This move is strongly backed by evidence showing that increasing the price of alcohol decreases consumption and saves lives. Smoking has decreased dramatically over the last 40 years but approximately 10 million people still smoke in the UK and a quarter of cancer deaths are smoking related (Cancer Research UK, 2012). The Melanie Hornett Nurse Director NHS Lothian Health Board decline in smoking has been helped by legislation, including price control, with a further step due this month when large shops will need to keep tobacco products out of sight. However, the impact of smoking dominates our oncology units, medical wards and long-term conditions care in the community. All this makes me think about our role in public health as nurses and midwives. Many colleagues have specific roles to improve our public health but the rest of us also have opportunities, and not just related to obesity, smoking and alcohol. Sexual health, mental health, infectious diseases and drugs are just as important – and I am sure you can think of many others. The Nursing and Midwifery Council Code (NMC) obliges us to