Equity Considerations Research Articles

Sidewalks, trees and shade matter: A visual landscape assessment approach to understanding people’s preferences for walking

IntroductionPublic health professionals and urban designers consider neighborhood sidewalks as a vehicle for promoting outdoor physical activity. The design of streetscape and available greenness may also influence walking behaviors and physical activity more generally. MethodData collection included a visual landscape assessment (VLA) survey, followed by focus groups to evaluate streetscape features that influence participants’ preferences for and choice of walking routes. With the considerations of equity in access to the environmental amenities, the study was conducted in marginalized communities. Sixty-nine people from low-income neighborhoods in Denver, CO participated in this study. Data were analyzed both qualitatively and quantitatively, using multilevel statistical models. ResultsMore shade and trees, higher levels of maintenance, and the presence of a buffer between the street and sidewalk increase the likelihood of intuitively choosing a street for walking. The availability of natural surveillance, the presence of an open view, and the presence of attractive buildings increase the likelihood of cognitively choosing a street for walking. ConclusionPeople‘s preferences for and choice of walking routes, which include desired shade and walkability, should be considered in neighborhood planning to promote walkable environments.

Early Mental Health Foundations: A Scoping Review of Reflective Functioning in Caregiver-Child Dyads.

International public health strategies indicate a need for equitable resources for wellness in younger children and their caregivers. Reflective functioning, a proxy for emotional regulation abilities, is a key area in this domain. As an emerging area, reflective functioning has not been mapped comprehensively and requires systematic investigation. This review examines "what qualitative and quantitative evidence is there for the value of reflective functioning assessment and intervention studies in caregiver-child dyads?" This scoping review focused on data published to September 2021, focusing on caregivers of children ≤36 months of age (including Medline, PsycINFO, CINAHL, ERIC, Scopus, Web of Science, and Embase). Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines were followed. From 5162 initial articles, 608 papers were screened for full text yielding a final 181 papers. Only 69 studies included multiple ethnicities. Seven of the 69 studies included at least 1 Indigenous person. No studies were conducted in low- to middle-income countries, and no studies reported data on gender identity. This review comprises a novel and comprehensive mapping of the reflective functioning literature in terms of both assessment and intervention studies. The present mapping of the reflective functioning literature indicates the importance of health disparities in caregiver-child dyads (these include gaps and needs for future research). In relation to gaps, studies of adverse childhood experience, consideration of equity, diversity, and inclusion, and global mental health are underrepresented. Future research is needed to provide information on the relevance of gender identity and low- to middle-income countries in relation to the impact on reflective functioning in this context.

Best Practice Recommendations for Integrating Health Equity into Pragmatic Clinical Trials for Dementia Care.

Minoritized populations experience higher rates of dementia and worse health outcomes than non-Hispanic white people, but they are vastly underrepresented in pragmatic clinical trials embedded in health care systems (ePCTs). Little guidance is available to consider health equity-relevant issues in ePCTs. This report describes the development, structure, and content of a guidance document developed by the National Institute on Aging Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory to help investigators systematically assess the integration of health equity into all aspects of ePCT design. Led by a task force of IMPACT investigators, a literature review of existing frameworks for health equity considerations in clinical trials was conducted. Next, priority health equity-relevant recommendations in the domains of ePCT design were solicited from Collaboratory experts. The 50 submitted recommendations were reduced to 36 nonoverlapping best practices and categorized into 6 domains, as follows: Getting Started, Community Stakeholder Engagement, Design and Analysis, Intervention Design and Implementation, Health Care System and Participant Selection, and Selecting Outcomes. Each domain had 6 best practice recommendations consisting of a succinctly worded main sentence, with 1 to 2 explanatory sentences. The content was finalized through an iterative process of editing and revision. Although specifically focused on ePCTs involving dementia care, the best practices are applicable to any ePCT and can be useful to advance health equity in traditional clinical trials. This guidance document provides a first step toward promoting holistic, structured integration of health equity into the design and conduct of ePCTs as a matter of good science.

Centring equity in data‐driven public health: a call for guiding principles to support the equitable design and outcomes of Australia's data integration systems

Centring equity in data‐driven public health: a call for guiding principles to support the equitable design and outcomes of Australia's data integration systems

Inequalities in Immunization against Maternal and Neonatal Tetanus: A Cross-Sectional Analysis of Protection at Birth Coverage Using Household Health Survey Data from 76 Countries.

Substantial progress in maternal and neonatal tetanus elimination has been made in the past 40 years, with dramatic reductions in neonatal tetanus incidence and mortality. However, twelve countries have still not achieved maternal and neonatal tetanus elimination, and many countries that have achieved elimination do not meet key sustainability thresholds to ensure long-lasting elimination. As maternal and neonatal tetanus is a vaccine-preventable disease (with coverage of the infant conferred by maternal immunization during and prior to pregnancy), maternal tetanus immunization coverage is a key metric for monitoring progress towards, equity in, and sustainability of tetanus elimination. In this study, we examine inequalities in tetanus protection at birth, a measure of maternal immunization coverage, across 76 countries and four dimensions of inequality via disaggregated data and summary measures of inequality. We find that substantial inequalities in coverage exist for wealth (with lower coverage among poorer wealth quintiles), maternal age (with lower coverage among younger mothers), maternal education (with lower coverage among less educated mothers), and place of residence (with lower coverage in rural areas). Inequalities existed for all dimensions across low- and lower-middle-income countries, and across maternal education and place of residence across upper-middle-income countries. Though global coverage changed little over the time period 2001-2020, this obscured substantial heterogeneity across countries. Notably, several countries had substantial increases in coverage accompanied by decreases in inequality, highlighting the need for equity considerations in maternal and neonatal tetanus elimination and sustainability efforts.

The Magic of Proteases: From a Procoagulant and Anticoagulant Factor V to an Equitable Treatment of Its Inherited Deficiency.

Proteostasis, i.e., the homeostasis of proteins, responsible for ensuring protein turnover, is regulated by proteases, which also participate in the etiopathogenesis of multiple conditions. The magic of proteases is such that, in blood coagulation, one same molecule, such as coagulation factor V, for example, can perform both a procoagulant and an anticoagulant function as a result of the activity of proteases. However, this magic has an insidious side to it, as it may also prevent the completion of the clinical value chain of factor V deficiency. This value chain encompasses the discovery of knowledge, the transfer of this knowledge, and its translation to clinical practice. In the case of rare and ultra-rare diseases like factor V deficiency, this value chain has not been completed as the knowledge acquisition phase has dragged out over time, holding up the transfer of knowledge to clinical practice. The reason for this is related to the small number of patients afflicted with these conditions. As a result, new indications must be found to make the therapies cost-effective. In the case of factor V, significant research efforts have been directed at developing a recombinant factor V capable of resisting the action of the proteases capable of inactivating this factor. This is where bioethics and health equity considerations come into the equation.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

Introduction: Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions. Methods: A systematic review of peer-reviewed original research published between 2010–2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10–24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status). Results: Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls). Discussion: Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified. Conclusion: This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

A systematic review of social equity in FEWS analyses

Integrating social equity considerations into analyses of the food-energy-water systems nexus (FEWS) could improve understanding of how to meet increasing resource demands without impacting social vulnerabilities. Effective integration requires a robust definition of equity and an enhanced understanding of reliable FEWS analysis methods. By exploring how equity has been incorporated into FEWS research in the United States and countries with similar national development, this systematic literature review builds a knowledge base to address a critical research need. Our objectives were to 1) catalog analysis methods and metrics relevant to assessing FEWS equity at varying scales; 2) characterize current studies and interpret shared themes; and 3) identify opportunities for future research and the advancement of equitable FEWS governance. FEWS equity definitions and metrics were categorized by respective system (food, energy, water, overall nexus) and common governance scales (local, regional, national, global). Two central issues were climate change, which increases FEWS risks for vulnerable populations, and sustainable development, which offers a promising framework for integrating equity and FEWS in policy-making contexts. Social equity in FEWS was integrated into studies through affordability, access, and sociocultural elements. This framework could support researchers and practitioners to include equity in FEWS analysis tools based on study scale, purpose, and resource availability. Research gaps identified during the review included a lack of studies effectively integrating all three systems, a need for publicly available datasets, omission of issues related to energy conversion facilities, and opportunities for integration of environmental justice modalities into FEWS research. This paper synthesized how social equity has previously been incorporated into FEWS and outlines pathways for further consideration of equity within nexus studies. Our findings suggested that continued exploration of connections between FEWS, equity, and policy development across scales could reduce social risks and vulnerabilities associated with these systems.

Culture, stigma, and inequities creating barriers in alcohol use disorder management in alcohol-associated liver disease.

Culture, stigma, and inequities creating barriers in alcohol use disorder management in alcohol-associated liver disease.

Sustainability analysis of overhead cable line powered freight trucks: a life cycle impact and techno-economic assessment toward transport electrification

We must move toward electrification of the transportation sector to help mitigate the adverse impacts of climate change. Carbon emission reduction in long-haul freight transport should be developed and administered given it accounts for 22% of transportation related emissions worldwide. Although electrified transport can make tail-pipe vehicle carbon emissions negligible, it does not mean that the entire system that supports electrified transport is carbon-neutral. We address this latter point in the present study by conducting a cradle-to-grave life cycle assessment of long-haul electric trucks that are powered by overhead cable lines (OCL). The environmental impacts were compared with those of battery electric vehicle trucks (BEV), and conventional diesel-powered trucks. The techno-economic analysis of long-haul freight OCL technology was conducted based on data from pilot-scale studies in Germany. The feasibility of implementing this technology in other countries was examined by comparing environmental impacts across respective electricity mixes. Results show that the environmental and economic impacts of OCL technology depends on the adoption percent. After analyzing different adoption rate scenarios, OCL adoption was found to be economically and environmentally beneficial at the 10% adoption rate or higher. We also found that use phase electricity accounts for over 83% of the net greenhouse gas emissions, thereby making the electricity mix powering this technology a determining factor for implementation around the world. Across their life cycles, the carbon footprint of both OCL and BEV was 2.5 times lesser than that of the conventional truck. Other findings reveal adaptable methods, a unique environmental-to-economic ratio measure, and equity considerations that can be leveraged for immediate decision-making activities and future studies alike.

Multi‐objective optimization models for the renewal planning of multiple asset classes

AbstractManaging the aging infrastructure of water distribution systems presents a challenge for many utilities. With various asset types competing for limited dollars, designing an effective asset management program is a resource allocation problem. Mobilization of equipment and crew is a significant cost (typically 2%–10%) within any capital improvement program. Therefore, selecting projects that target multiple asset classes together can reduce mobilization and help utilities stretch their budgets further. This research presents a process for modeling the joint renewal planning of multiple asset classes. The problem is framed as a dual‐objective optimization, where the selection of project areas aims to maximize lead service line removal and water meter changeout together. A case study from a Midwest utility is presented, and empirical data suggests the dual‐objective approach effectively reduces duplicate interventions in the same regions. Equity considerations are also examined, where constraints are added to enforce system‐wide project selection. Results show that the sensitivity of the objective toward equity is dependent on the underlying spatial distribution of the target asset itself, where uneven spread of the target asset leads to greater negative impact on model performance.

Unchaining Workers

Abstract An influential report on protecting the medical supply chain in the next pandemic fails to include a commitment to protecting the workers who protect the supply chain. The securing strategy outlined by Richard Locke, Ben Armstrong, Samantha Schaab-Rozbicki, and Geordie Young offers examples of such an approach, and the analytical framework for protecting the chain-awareness, mitigation, preparedness, and response-can be applied equally well to the workforce. Considerations of equity and fairness should lead us to unchain the workers strung along the chain of medical and consumer supplies.

Health workforce perceptions on telehealth augmentation opportunities

BackgroundThe availability and use of telehealth to support health care access from a distance has expanded in response to the COVID-19 pandemic. Telehealth services have supported regional and remote health care access for many years and could be augmented to improve health care accessibility, acceptability and overall experiences for both consumers and clinicians. This study aimed to explore health workforce representatives’ needs and expectations to move beyond existing telehealth models and plan for the future of virtual care.MethodsTo inform recommendations for augmentation, semi-structured focus group discussions were held (November–December 2021). Health workforce representatives with experience in health care delivery via telehealth across country Western Australia were approached and invited to join a discussion.ResultsFocus group participants included 53 health workforce representatives, with between two and eight participants per discussion. In total, 12 focus groups were conducted: seven were specific to regions, three with staff in centralised roles, and two with a mixture of participants from regional and central roles. Findings identified four key areas for telehealth augmentation: improvements required to existing service practice and processes; equity and access considerations; health workforce-focussed opportunities; and consumer-focussed opportunities.ConclusionsFollowing the onset of the COVID-19 pandemic and the rapid increase in health services delivered via telehealth modalities, it is timely to explore opportunities to augment pre-existing models of care. Workforce representatives consulted in this study suggested modifications to existing process and practice that would improve the current models of care, and recommendations on ways to improve clinician and consumer experiences with telehealth. Improving experiences with virtual delivery of health care is likely to support continued use and acceptance of this modality in health care delivery.

Sustainable aquatic food systems: Multisectoral analysis of determinants of child nutrition in coastal Kenya

Marine foods produced by small-scale fishers can make vital contributions to sustainable, healthy food systems with multisectoral considerations of public health nutrition, gender equity, economics, and marine ecology. This pilot study aimed to map the multidimensional determinants of fish food security and young child nutrition in four coastal communities of Kenya with a view toward designing a large intervention trial. We compared anthropometric and dietary diversity indicators of children under 5 years in fishing vs. non-fishing households. Mixed methods included household surveys, 24-h recalls for dietary intake, and anthropometric measures of children. Child dietary diversity score (CDDS) and height-for-age Z (HAZ) were primary outcomes tested in ordinary least square regression modeling. Stunting was widely prevalent (20.2%), as were morbidities for acute diarrhea (29.0%) and fever (46.5%), with no statistically significant differences in fishing compared to non-fishing households. High proportions of children showed nutrient intake inadequacies for vitamins A, C, and E, iron and zinc; <50% met requirements for all nutrients except protein, which was derived primarily from plant-based foods. Regression modeling showed children living in fishing households were associated with lower CDDS. Maternal education, maternal body mass index (BMI), and household livelihood diversity were positively associated with both CDDS and HAZ, while child morbidities and north coast (of Mombasa) residence showed negative associations. Our findings highlight nutritional vulnerabilities within a coastal food system of Kenya and the need to involve multiple sectors—education, environment, health, finance, communications, and governance and policy—in deriving solutions.

How to do (or not to do)…how to embed equity in the conduct of health research: lessons from piloting the 8Quity tool.

Global health research reflects and can either perpetuate or challenge the complex power hierarchies and inequities that characterize our health systems and the societies in which they are situated. The imperative to embed equity in health research aligns with broader efforts globally to promote equitable partnerships among researchers, and between researchers and the communities potentially impacted by their research, or with whom knowledge is co-produced. We describe lessons learnt from piloting a heuristic and diagnostic tool for researchers to assess integration of equity considerations into their research practices. The '8Quity' tool comprises eight domains of equity we developed which roughly correspond to the typical stages in the research process-from team formation to capacity strengthening, research ethics and governance to relationships with research partners, participants and stakeholders beyond the project period. Resources that detail how this can be done on a practical level are also shared, corresponding to each of the eight domains. We acknowledge that tools like 8Quity may be helpful, even necessary, but are insufficient for the broader societal changes required to ensure equity in the research enterprise. However, by firmly setting intentions and accountabilities within our research practices, we (as researchers) can play a role, however modest, in turning the tide of the injustices that leave some communities behind.

Rural Internal Medicine Residencies: Models, Facilitators, Barriers, and Equity Considerations.

Rural communities in the USA on average experience higher mortality rates and greater physician shortages than urban communities, especially rural communities that are historically Black, American Indian, and Alaska Native. Graduate medical education resources in the USA are concentrated within teaching hospitals in non-rural settings. The federal government has recently established several pathways to expand rural graduate medical education. In the 2010s, most of the expansion and innovation in rural graduate medical education occurred in family medicine. In the 2020s, internal medicine has also begun to increase its rural graduate medical education footprint. Rural internal medicine residency training models include Rural Track Programs (RTPs), in which training is split between urban and rural training sites. RTPs, though the cornerstone of rural residency expansion in family medicine, raise complex issues in internal medicine. We review the structure of RTPs, alternate rural residency training pathways, and the facilitators and challenges of each pathway with respect to internal medicine training.

Assessment of health equity consideration in Cochrane systematic reviews and primary studies on urolithiasis.

Health injustice is defined as "unnecessary, preventable, unjustified and unfair health differences." One of the most important scientific sources on the prevention and management of urolithiasis are Cochrane reviews in this field. Given that the first step in eliminating health injustice is to identify the causes, the aim of the present study was to evaluate equity considerations in Cochrane reviews and the included primary studies on urinary stones. Cochrane reviews on kidney stones and ureteral stones were searched through the Cochrane Library. The included clinical trials in each of the reviews published after 2000 were also collected. Two different researchers reviewed all the included Cochrane reviews and primary studies. The researchers reviewed each PROGRESS criteria independently (P: place of residence, R: race/ethnicity/culture, O: occupation, G: gender, R: religion, E: education, S: socioeconomic status, S: social capital and networks). The geographical location of the included studies was categorized as low-income, middle-income and high-income countries, based on the World Bank income criteria. Each PROGRESS dimension was reported for both the Cochrane reviews and the primary studies. In total, 12 Cochrane reviews and 140 primary studies were included in this study. None of the included Cochrane reviews had specifically mentioned the PROGRESS framework in the Method section whereas gender distribution and place of residence were reported in two and one reviews, respectively. In 134 primary studies at least one item of PROGRESS was reported. The most frequent item was gender distribution, followed by place of residence. According to the results of this study, the authors of Cochrane systematic reviews on urolithiasis, and researchers who have conducted such trials, have rarely considered health equity dimensions when designing and performing their studies. Therefore, researchers worldwide should be motivated to study populations from low-income countries with low socioeconomic status in addition to different cultures, ethnicities, and so forth. Furthermore, RCT reporting guidelines such as CONSORT should include health equity dimensions and the editors and reviewers of scientific journals should encourage researchers to further emphasize on health equity in their studies.

P32: a sex- and gender-sensitive model for evidence-based precision medicine: from knowledge generation to implementation in the field of kidney transplantation

Precision medicine emerged as a promising approach to identify suitable interventions for individual patients with a particular health concern and at various time points. Technology can enable the acquisition of increasing volumes of clinical and "omics" data at the individual and population levels and support advanced clinical decision making. However, to keep pace with evolving societal realities and developments, it is important to systematically include sex- and gender-specific considerations in the research process, from the acquisition of knowledge to implementation. Building on the foundations of evidence-based medicine and existing precision medicine frameworks, we propose a novel evidence-based precision medicine framework in the form of the P32model, which considers individual sex-related (predictive [P1], preventive [P2], and personalized [P3] medicine) and gender-related (participatory [P4], psychosocial [P5], and percipient [P6] medicine) domains and their intersection with ethnicity, geography, and other demographic and social variables, in addition to population, community, and public dimensions (population-informed [P7], partnered with community [P8], and public-engaging [P9] medicine, respectively). Through its ability to contextualize and reflect on societal realities and developments, our model is expected to promote consideration of diversity, equity, and inclusion principles and, thus, enrich science, increase reproducibility of research, and ensure its social impact.

Building back better children's surgical services toward universal health coverage: Perspectives from Bangladesh and Zimbabwe.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Children's surgical services are crucial, yet underappreciated, for children's health and must be sufficiently addressed to make and sustain progress toward universal health coverage (UHC). Despite their considerable burden and socioeconomic cost, surgical diseases have been relatively neglected in favor of communicable diseases living up to their inauspicious moniker: 'the neglected stepchild of global health'. This article aims to raise awareness around children's surgical diseases and offers perspectives from two prototypical LMICs on strengthening surgical services in the context of health systems recovery following the COVID-19 experience to make and sustain progress toward UHC. We used a focused literature review supplemented by the perspectives of local experts and the 6-components framework for surgical systems planning to present two case studies of Bangladesh and Zimbabwe. The lived experiences of the authors are used to describe the impact of COVID-19 on respective surgical systems and offer perspectives on building back the health system and recovering essential health services for sustainability and resilience. We found that limited high-level policy and planning instruments, an overburdened and under-resourced health and allied workforce, underdeveloped surgical infrastructure (from key utilities to essential medical products), lack of locally generated research, and the specter of prohibitively high out-of-pocket costs for children's surgery are common challenges in both countries that have been exacerbated by the COVID-19 pandemic. Continued chronic underinvestment and inattention to children's surgical diseases coupled with the devastating effect of the COVID-19 pandemic threaten progress toward key global health objectives. Urgent attention and investment in the context of health systems recovery is needed from policy to practice levels to improve infrastructure; attract, retain and train the surgical and allied health workforce; and improve service delivery access with equity considerations to meet the 2030 Lancet Commission goals, and make and sustain progress toward UHC and the SDGs.

A qualitative study of healthcare providers’ attitudes toward assisted partner notification for people with HIV in Indonesia

BackgroundAssisted partner notification (APN) is recommended as a public health strategy to increase HIV testing in people exposed to HIV. Yet its adoption in many countries remains at an early stage. This qualitative study sought the opinions of HIV health service providers regarding the appropriateness and feasibility of implementing APN in Indonesia where such services are on the cusp of adoption.MethodsFour focus group discussions totaling 40 health service providers were held in Jakarta, Indonesia to consider APN as an innovative concept and to share their reactions regarding its potential implementation in Indonesia. Voice-recorded discussions were conducted in Bahasa, transcribed verbatim, and analyzed.ResultsParticipants recognized APN’s potential in contacting and informing the partners of HIV-positive clients of possible viral exposure. They also perceived APN’s value as a client-driven service permitting clients to select which of three partner notification methods would work best for them across differing partner relationships and settings. Nonetheless, participants also identified personal and health system challenges that could impede successful APN adoption including medical and human resource limitations, the need for specialized APN training, ethical and equity considerations, and lack of sufficient clarity concerning laws and government policies regulating 3rd party disclosures. They also pointed to the job-overload, stress, personal discomfort, and the ethical uncertainty that providers might experience in delivering APN.ConclusionOverall, providers of HIV services embraced the concept of APN but forecast practical difficulties in key service areas where investments in resources and system change appeared necessary to ensure effective and equitable implementation.