Decrease Health Inequalities Research Articles

Does high-speed rail relieve income-related health inequalities? A quasi-natural experiment from China

IntroductionThe rapid increases in income and high-speed rail (HSR) construction in China raise the prospect of reshaping the space economy, the exploration of which, from the perspective of optimised transportation networks, can provide insights into alleviating the increasing health inequalities. MethodsBased on matched data of prefecture-level cities and Chinese Labor Dynamic Survey packages from 2014 to 2018, we used the ordered probit model and ordinary least squares (OLS) with time- and city-fixed effects to estimate the effects of HSR on personal health status. We calculated the degree of income-related health inequalities and decomposed the contributive degree of HSR to health inequalities by decomposing the concentration index (CI) and Blinder-Oaxaca, respectively. ResultsPersonal health status showed significant differences under different income levels and in areas with and without HSR. The estimated coefficients regarding HSR on personal health status were 0.112 in the ordered probit model and 0.167 in the OLS model. The CI of health inequalities showed a positive coefficient of 0.059, with a pro-rich phenomenon. Contribution decomposition of CI showed that HSR accounted for an important contribution of 1.919% to health inequalities. Blinder-Oaxaca decomposition revealed that the contribution of HSR to overall CI was 0.075% from 2014 to 2018. CI decomposition also demonstrated a decreasing trend over time in the HSR's contribution to increasing health inequalities. Further, mechanism analysis showed that HSR improved health more significantly among high-income groups in ways that included improved high quality of healthcare services, socioeconomic status, and social capital. ConclusionsThere is a pro-rich distribution of health in China, and HSR exacerbates health inequalities more significantly among high-income groups in several ways, including high-quality healthcare services, socioeconomic status, and social capital. Furthermore, HSR has the potential to decrease health inequalities in the future.

Increasing Uptake of COVID-19 Vaccination and Reducing Health Inequalities in Patients on Renal Replacement Therapy-Experience from a Single Tertiary Centre.

Background: COVID-19 vaccination has changed the landscape of the COVID-19 pandemic; however, decreased uptake due to vaccine hesitancy has been observed, particularly in patients from minority ethnic backgrounds and socially deprived areas. These patient characteristics are common in patients on Renal Replacement Therapy (RRT), a population at extremely high risk of developing serious illness from COVID-19 and who would thus benefit the most from the vaccination programme. We designed a bespoke COVID-19 vaccination programme for our RRT population with the aim of decreasing health inequalities and increasing vaccination uptake. Methods: Key interventions included addressing vaccine hesitancy by deploying the respective clinical teams as trusted messengers, prompt eligible patient identification and notification, the deployment of resources to optimise vaccine administration in a manner convenient to patients, and the timely collection and analysis of local safety and efficacy data. First, COVID-19 vaccination data in relation to ethnicity and social deprivation in our RRT population, measured by the multiple deprivation index, were analysed and compared to uptake data in the total regional adult clinically extremely vulnerable (CEV) population in Greater Manchester (GM). Univariate logistic regression analysis was used to explore the factors associated with not receiving a vaccine. Results: Out of 1156 RRT patients included in this analysis, 96.7% received the first dose of the vaccination compared to 93% in the cohort of CEV patients in the GM. Age, gender, ethnicity, and a lower index of multiple deprivation were not identified as significant risk factors for poor first dose vaccine uptake in our cohort. Vaccine uptake in Asian and Black RRT patients was 94.9% and 92.3%, respectively, compared to 93% and 76.2% for the same ethnic groups in the reference CEV GM. Vaccine uptake was 96.1% for RRT patients in the lowest quartile of the multiple deprivation index, compared to 90.5% in the GM reference population. Conclusion: Bespoke COVID-19 vaccination programmes based on local clinical teams as trusted messengers can improve negative attitudes towards vaccination and reduce health inequalities.

Increasing Health Literacy Among Residents at a Juvenile Temporary Detention Center.

Health literacy is a nationwide public health concern. Low health literacy in adolescents is related to increased adolescent high-risk behaviors, which can negatively affect their overall health. A quality improvement health literacy project was developed, implemented, and evaluated in a juvenile temporary detention center. Stakeholders identified pertinent health-related topics for discussion, including female body anatomy, sexual health, consent, pornography, sex trafficking, smoking, and anger management. Toolkits and pretest/posttest questionnaires guided weekly group sessions. Youth engaged in content during each session. Group health literacy scores were examined to evaluate the program. Group comments were debriefed by facilitators after each session; 119 youth residents participated. Positive increases in health literacy and health knowledge were observed in all sessions for all groups. Interactive health education programs for incarcerated youth can improve their health literacy and health knowledge and begin a path to decrease health inequities in this vulnerable population.

Improving Access to Behavioral Strategies to Improve Mental Well-being With an Entertaining Breakfast Show App: Feasibility Evaluation Study.

BackgroundAlthough mental ill-health is more prevalent among people from lower socioeconomic groups, digital mental well-being innovations are often developed for people from higher socioeconomic groups, who already have resources to maintain good mental and physical health. To decrease health inequalities and ensure that available solutions are appealing and accessible to people with fewer resources, new approaches should be explored. We developed the app Wakey!, which focused on creating engaging mental health content that is accessible, particularly among lower socioeconomic groups in the United Kingdom.ObjectiveThe aim of this study is to assess engagement with the app, investigate initial effectiveness data for 6 well-being outcomes, and explore participants’ subjective experiences of using Wakey!MethodsThe app Wakey! was publicly launched on January 20, 2020, and was free to download from Apple Store and Google Play. The app provided its users with entertaining and educational content related to mental well-being. Concurrently, a single-arm mixed methods feasibility trial was carried out from January to April 2020 among people who had downloaded the app and created an account. The primary outcome was engagement, which was collected passively from data logs. Secondary outcome measures were 6 well-being outcomes collected from self-report questionnaires. Individual interviews with 19 app users were carried out in April 2020.ResultsIn total, 5413 people fit the inclusion criteria and were included in the final sample—65.62% (3520/5364) women, 61.07% (3286/5381) aged between 25 and 44 years, 61.61% (2902/4710) in employment, 8.92% (420/4710) belonging to the lower socioeconomic group, and 8.09% (438/5413) were engaged users. There was no evidence of a difference in engagement regarding sociodemographic and socioeconomic characteristics. There was evidence that users with a higher average daily sleep score, who joined the study more recently, who had higher baseline self-report of sleep quality, and who found episodes more entertaining were more likely to be engaged users. Among 230 users who provided follow-up data, there was evidence of improvements on four of the six well-being outcomes: life satisfaction (P<.001), feeling that life is worthwhile (P=.01), ease of getting up in the morning (P<.001), and self-efficacy (P=.04). The app and its content were well received by those who were interviewed, and several people perceived a positive change in their mental well-being.ConclusionsThis study shows that the app Wakey! could potentially be engaging across different socioeconomic groups, and there is an indication that it could positively impact the mental well-being of those engaged with the app. However, this study was a pragmatic trial with a limited sample, and the selection bias was present in the qualitative and quantitative study. Further work is needed to make any generalizable conclusions.Trial RegistrationClinicalTrials.gov NCT04287296; https://clinicaltrials.gov/ct2/show/NCT04287296

Latent Tuberculosis Infection Treatment Outcomes in an At-Risk Underserved Population in Rhode Island.

Objectives:Within the United States (US), significant racial and ethnic disparities exist in the rates of latent TB infection (LTBI) and active TB disease. A disproportionate number of TB disease cases result from untreated LTBI among individuals born outside the US. This study evaluates LTBI treatment outcomes among an underserved, at-risk population in Rhode Island.Methods:A quantitative retrospective chart review of adult patients with a positive screening test assessed LTBI care cascade outcomes including referral, treatment initiation, and completion.Results:Seventy-four percent of patients found to have positive screening TB tests were born outside of the US; 80% identified as Hispanic or Black and 45% spoke a preferred language other than English. Twenty-one percent of potential candidates for LTBI treatment initiated treatment.Conclusions:Major gaps were identified in referral success and treatment initiation. Expanding LTBI treatment access into primary care settings could be a solution to improve outcomes and decrease health inequities among at-risk communities.

Ischemic Heart Disease in Nigeria: Exploring the Challenges, Current Status, and Impact of Lifestyle Interventions on Its Primary Healthcare System.

The burden of ischemic heart disease in Nigeria calls for an evidence-based, innovative, and interdisciplinary approach towards decreasing health inequalities resulting from individual lifestyle and poor socioeconomic status in order to uphold the holistic health of individuals to achieve global sustainability and health equity. The poor diagnosis and management of ischemic heart disease in Nigeria contributes to the inadequate knowledge of its prognosis among individuals, which often results in a decreased ability to seek help and self-care. Hence, current policies aimed at altering lifestyle behaviour to minimize exposure to cardiovascular risk factors may be less suitable for Nigeria’s diverse culture. Mitigating the burden of ischemic heart disease through the equitable access to health services and respect for the autonomy and beliefs of individuals in view of achieving Universal Health Coverage (UHC) requires comprehensive measures to accommodate, as much as possible, every individual, notwithstanding their values and socioeconomic status.

Clinician perspectives on the need for training on caring for pregnant women with intellectual and developmental disabilities

BackgroundWomen with intellectual and developmental disabilities (IDDs) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDDs. ObjectiveThe study was conducted to describe obstetric clinicians’ training experiences related to providing obstetric care to women with IDDs, to assess the perceived need for formalized training, and to identify recommendations for training content. MethodsThis study involved qualitative individual interviews (n = 9) and one focus group (n = 8) with obstetric clinicians who self-reported experience caring for women with IDDs during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. ResultsAnalysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDDs. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff members should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDDs. ConclusionResults indicate a need for systematic training efforts regarding obstetric care for women with IDDs. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDDs. Level of evidenceVI.

Stage at diagnosis and survival among adolescents and young adults with lymphomas following the Affordable Care Act implementation in California.

Adolescents and young adults (AYAs, 15-39 years) are the largest uninsured population in the Unites States, increasing the likelihood of late-stage cancer diagnosis and poor survival. We evaluated the associations between the Affordable Care Act (ACA), insurance coverage, stage at diagnosis and survival among AYAs with lymphoma. We used data from the California Cancer Registry linked to Medicaid enrollment files on AYAs diagnosed with a primary non-Hodgkin (NHL; n=5959) or Hodgkin (n=5378) lymphoma pre-ACA and in the early and full ACA eras. Health insurance was categorized as continuous Medicaid, discontinuous Medicaid, Medicaid enrollment at diagnosis/uninsurance, other public and private. We used multivariable regression models for statistical analyses. The proportion of AYAs uninsured/Medicaid enrolled at diagnosis decreased from 13.4% pre-ACA to 9.7% with full ACA implementation, while continuous Medicaid increased from 9.3% to 29.6% during this time (P < .001). After full ACA, AYAs with NHL were less likely to be diagnosed with Stage IV disease (adjusted odds ratio [aOR]=0.84, 95% confidence interval [CI]=0.73-0.97). AYAs with lymphoma were more likely to receive care at National Cancer Institute-Designated Cancer Centers (aOR=1.42, 95%CI=1.28-1.57) and had lower likelihood of death (adjusted hazard ratio=0.54, 95%CI=0.46-0.63) after full ACA. However, AYAs from the lowest socioeconomic neighborhoods, racial/ethnic minority groups and those with Medicaid continued to experience worse survival. In summary, AYAs with lymphomas experienced increased access to healthcare and better clinical outcomes following Medicaid expansion under the ACA. Yet, socioeconomic and racial/ethnic disparities remain, calling for additional efforts to decrease health inequities among underserved AYAs with lymphoma.

Is Buying and Drinking Zero and Low Alcohol Beer a Higher Socio-Economic Phenomenon? Analysis of British Survey Data, 2015-2018 and Household Purchase Data 2015-2020.

Zero and low alcohol products, particularly beer, are gaining consideration as a method to reduce consumption of ethanol. We do not know if this approach is likely to increase or decrease health inequalities. The aim of the study was to determine if the purchase and consumption of zero and low alcohol beers differs by demographic and socio-economic characteristics of consumers. Based on British household purchase data from 79,411 households and on British survey data of more than 104,635 adult (18+) respondents, we estimated the likelihood of buying and drinking zero (ABV = 0.0%) and low alcohol (ABV > 0.0% and ≤ 3.5%) beer by a range of socio-demographic characteristics. We found that buying and consuming zero alcohol beer is much more likely to occur in younger age groups, in more affluent households, and in those with higher social grades, with gaps in buying zero alcohol beer between households in higher and lower social grades widening between 2015 and 2020. Buying and drinking low alcohol beer had less consistent relationships with socio-demographic characteristics, but was strongly driven by households that normally buy and drink the most alcohol. Common to many health-related behaviours, it seems that it is the more affluent that lead the way in choosing zero or low alcohol products. Whilst the increased availability of zero and low alcohol products might be a useful tool to reduce overall ethanol consumption in the more socially advantageous part of society, it may be less beneficial for the rest of the population. Other evidence-based alcohol policy measures that lessen health inequalities, need to go hand-in-hand with those promoting the uptake of zero and low alcohol beer.

Socioeconomic differences in healthcare expenditure and utilization in The Netherlands

BackgroundWorldwide, socioeconomic differences in health and use of healthcare resources have been reported, even in countries providing universal healthcare coverage. However, it is unclear how large these socioeconomic differences are for different types of care and to what extent health status plays a role. Therefore, our aim was to examine to what extent healthcare expenditure and utilization differ according to educational level and income, and whether these differences can be explained by health inequalities.MethodsData from 18,936 participants aged 25–79 years of the Dutch Health Interview Survey were linked at the individual level to nationwide claims data that included healthcare expenditure covered in 2017. For healthcare utilization, participants reported use of different types of healthcare in the past 12 months. The association of education/income with healthcare expenditure/utilization was studied separately for different types of healthcare such as GP and hospital care. Subsequently, analyses were adjusted for general health, physical limitations, and mental health.ResultsFor most types of healthcare, participants with lower educational and income levels had higher healthcare expenditure and used more healthcare compared to participants with the highest educational and income levels. Total healthcare expenditure was approximately between 50 and 150 % higher (depending on age group) among people in the lowest educational and income levels. These differences generally disappeared or decreased after including health covariates in the analyses. After adjustment for health, socioeconomic differences in total healthcare expenditure were reduced by 74–91 %.ConclusionsIn this study among Dutch adults, lower socioeconomic status was associated with increased healthcare expenditure and utilization. These socioeconomic differences largely disappeared after taking into account health status, which implies that, within the universal Dutch healthcare system, resources are being spent where they are most needed. Improving health among lower socioeconomic groups may contribute to decreasing health inequalities and healthcare spending.

A Systematic Review and Meta-Analysis of Patient Decision Aids for Socially Disadvantaged Populations: Update from the International Patient Decision Aid Standards (IPDAS).

The effectiveness of patient decision aids (PtDAs) and other shared decision-making (SDM) interventions for socially disadvantaged populations has not been well studied. To assess whether PtDAs and other SDM interventions improve outcomes or decrease health inequalities among socially disadvantaged populations and determine the critical features of successful interventions. MEDLINE, CINAHL, Cochrane, PsycINFO, and Web of Science from inception to October 2019. Cochrane systematic reviews on PtDAs. Randomized controlled trials of PtDAs and SDM interventions that included socially disadvantaged populations. Independent double data extraction using a standardized form and the Template for Intervention Description and Replication checklist. Twenty-five PtDA and 13 other SDM intervention trials met our inclusion criteria. Compared with usual care, PtDAs improved knowledge (mean difference = 13.91, 95% confidence interval [CI] 9.01, 18.82 [I2 = 96%]) and patient-clinician communication (relative risk = 1.62, 95% CI 1.42, 1.84 [I2 = 0%]). PtDAs reduced decisional conflict (mean difference = -9.59; 95% CI -18.94, -0.24 [I2 = 84%]) and the proportion undecided (relative risk = 0.39; 95% CI 0.28, 0.53 [I2 = 75%]). PtDAs did not affect anxiety (standardized mean difference = 0.02, 95% CI -0.22, 0.26 [I2 = 70%]). Only 1 trial looked at clinical outcomes (hemoglobin A1C). Five of the 12 PtDA studies that compared outcomes by disadvantaged standing found that outcomes improved more for socially disadvantaged participants. No evidence indicated which intervention characteristics were most effective. Results were similar for SDM intervention trials. Sixteen PtDA studies had an overall unclear risk of bias. Heterogeneity was high for most outcomes. Most studies only had short-term follow-up. PtDAs led to better outcomes among socially disadvantaged populations but did not reduce health inequalities. We could not determine which intervention features were most effective.[Box: see text].

Do educational reforms increase or decrease health inequalities: A matter of methods?

Evaluating whether social policies reduce health inequalities is complicated by the fact that these upstream determinants may also change the socioeconomic distribution. Failure to account for these compositional changes may severely bias the effect estimation procedure. In this article, we illustrate how a health inequality impact assessment of a policy that (also) changes the socioeconomic distribution may produce biased results. First, we show why analyses that do not account for compositional changes fail to estimate the correct counterfactual outcome. This problem most notably occurs when using repeated cross-sectional data, often the only available option to evaluate the health effect of large-scale policies. Second, we conducted a microsimulation study to estimate the magnitude of the bias under various conditions. The results showed that the actual impact of the policy on health inequalities is often underestimated and may even produce results that are in the opposite direction of the actual causal effect of the policy. Future studies should explore new strategies, such as simulation methods, to assess the impact of policies that (also) cause changes in the socioeconomic composition of the population, to enable researchers to accurately estimate their effect on health inequalities.

From Ebola to COVID-19: what explains institutionalized manias and the ultimate preference for non-optimal solutions in global health governance?

Purpose The purpose of this paper is to investigate how “manias” in global health governance lead to health inequalities even before, during and in the aftermath of acute health crises such as the COVID-19 pandemic. “Manias” as used here refer to obsessive ir/rational behaviors, misguided policy/strategic choices and the exercise of power that benefit the major global health actors at the expense of stakeholders. Design/methodology/approach From post-colonial and historical perspectives, this study delineates how the major global health actors influence outcomes in global health governance and international business when they interact at the national–global level using an illustration from an emerging economy. Findings Power asymmetry in global health governance is constructed around the centralization of economic influence, medico-techno-scientific innovation and the geopolitical hegemony of a conglomerate of super-rich/powerful actors. They cluster these powers and resources in the core region (industrialized economies) and use them to influence the periphery (developing economies) through international NGOs, hybrid organizations, MNCs and multilateral/bilateral agreements. The power of actors to maintain manias lies in not only how they influence the periphery but also the consequences of the periphery’s “passivity” and “voluntary” renunciation of sovereignty in medical innovations and global health policies/politics. Social implications As a quintessential feature of manias, power asymmetry makes it harder for weaker actors to actually change the institutional conditions that produce structural inequalities in global health. Originality/value This timely and multidisciplinary study calls for a novel architecture of global health governance. Thus, democratizing global health governance with sufficiently foresighted investments that prioritize equitable access by and the inclusiveness of vulnerable stakeholders will help dismantle institutionalized manias while decreasing health inequalities.

Public transport availability and healthcare use for Australian adults aged 18–60 years, with and without disabilities

IntroductionPublic transport (PT) availability may be more important for people with disabilities (PWD), as typically they have greater healthcare needs and mobility barriers compared with people without disabilities. This paper investigates how PT availability is associated with healthcare use for people aged 18–60 years, with and without disabilities in Australia. MethodWe used unique Australian healthcare use administrative data linked to the 2016 Census, where individuals report whether they have a disability (severe or profound core activity limitation). These data were merged with detailed information on local area PT availability for Australia's 21 largest cities. We estimated regression models to examine the association between PT availability and different types of healthcare use, while controlling for individual characteristics and larger area attributes. ResultsPT availability was positively associated with visits to general practitioners (GP), with a higher magnitude observed for people with disabilities (PWD). While people without disabilities had on average 0.1 more GP visits per year when PT availability was high compared with low, PWD on average visited their GP 0.5 more times per year if they lived in areas with high as opposed to low PT availability. Nervous system prescriptions (which includes antidepressants) were 0.27 per year fewer for PWD living in areas with high compared with low PT availability. Conversely, nervous system scripts were 0.06 higher for people without disability with high compared with low PT availability. ConclusionWe conclude that PT availability is likely to be a key factor of healthcare use. Increasing PT availability may help overcome some barriers to healthcare use for PWD. Our findings are also consistent with PT increasing access to preventive care, which may reduce the severity or better management of illnesses. PT can play an important role in improving health and decreasing health inequalities between those with and without disabilities.

Urban green infrastructure size, quality and proximity and health outcomes in older populations

Abstract Background A city's multi-functional network of green and blue spaces has an important role underpinning the health and wellbeing of its residents. Although evidence of positive links between nature and health is plentiful, little is known about which particular aspects of green and blue spaces are most influential, and how benefits might vary between social groups and age. Methods We used a green infrastructure (GI) approach combining a high-resolution spatial dataset of land-cover and function with area-level demographic and socio-economic data. A comprehensive characterisation of the Greater Manchester UK city region was generated. The GI attributes were used in step-wise multi-level regression analyses to test for associations between population chronic morbidity and the functional, physical and spatial components of GI across an urban socio-demographic gradient. Results Individual GI attributes were significantly associated with health in all socio-demographic contexts; even when associations between health and overall green cover were non-significant. For areas with having higher proportions of older people ('older neighbourhoods'), associations were found between health and land-cover diversity, informal greenery and patch size in high income areas. In lower income areas, health was predicted by proximity to public parks and recreation land. Conclusions A nuanced description of greenspace in terms of quality, cover type, diversity explains more variation in population health than a single metric such as percentage green cover. People in urban neighbourhoods that have older age populations and lower income are disproportionately healthy if their neighbourhoods contain accessible, good quality public greenspace. This has implications for strategies to decrease health inequalities and inform international initiatives, such as the World Health Organisation's Age-Friendly Cities programme. Key messages A nuanced description of green and blue space in terms of quality, cover type, diversity explains more variation in population health than a single metric such as percentage green cover. People in urban neighbourhoods that have older age populations and lower income are disproportionately healthy if their neighbourhoods contain accessible, good quality public greenspace.

Transformative co-mentoring: changing the healthcare profession by honoring roots and fostering wings

ABSTRACT The underrepresentation of minorities from rural communities in U.S. health professions has resulted in a lack of cultural understanding and inadequate healthcare for people of color and the poor. Described is the Roots to Wings (RTW) program, a partnership between higher education institutions and Native American tribes and schools. The heart of the program is Transformative Co-Mentoring (TCM), a relationship between individuals, with the goal of fostering cultural understanding and creating lasting changes for those involved and their environments. RTW focuses on the implementation of TCM, which is practiced in teams of university medical students, Native Americans, and Latino students living on Native American lands. RTW seeks to increase American Indian/Alaska Natives (AIAN) and Latinos in the health professions, decrease health inequities, reform medical student preparation, and enhance health care professionals’ understanding of AIAN and Latino communities. Presented are preliminary findings of program impact from participants’ perspective and lessons learned.

COVID-19 and Racial/Ethnic Disparities

This Viewpoint reviews possible reasons for reported excess mortality and poor outcomes in racial/ethnic minority populations with COVID-19 and proposes research, public health, and clinical interventions to decrease health inequities in and beyond the pandemic.

Relationships between health outcomes in older populations and urban green infrastructure size, quality and proximity

BackgroundThere is a growing body of literature supporting positive associations between natural environments and better health. The type, quality and quantity of green and blue space (‘green-space’) in proximity to the home might be particularly important for less mobile populations, such as for some older people. However, considerations of measurement and definition of green-space, beyond single aggregated metrics, are rare. This constitutes a major source of uncertainty in current understanding of public health benefits derived from natural environments. We aimed to improve our understanding of how such benefits are conferred to different demographic groups through a comprehensive evaluation of the physical and spatial characteristics of urban green infrastructure.MethodsWe employed a green infrastructure (GI) approach combining a high-resolution spatial dataset of land-cover and function with area-level demographic and socio-economic data. This allowed for a comprehensive characterization of a densely populated, polycentric city-region. We produced multiple GI attributes including, for example, urban vegetation health. We used a series of step-wise multi-level regression analyses to test associations between population chronic morbidity and the functional, physical and spatial components of GI across an urban socio-demographic gradient.ResultsGI attributes demonstrated associations with health in all socio-demographic contexts even where associations between health and overall green cover were non-significant. Associations varied by urban socio-demographic group. For areas characterised by having higher proportions of older people (‘older neighbourhoods’), associations with better health were exhibited by land-cover diversity, informal greenery and patch size in high income areas and by proximity to public parks and recreation land in low income areas. Quality of GI was a significant predictor of good health in areas of low income and low GI cover. Proximity of publicly accessible GI was also significant.ConclusionsThe influence of urban GI on population health is mediated by green-space form, quantity, accessibility, and vegetation health. People in urban neighbourhoods that are characterised by lower income and older age populations are disproportionately healthy if their neighbourhoods contain accessible, good quality public green-space. This has implications for strategies to decrease health inequalities and inform international initiatives, such as the World Health Organisation’s Age-Friendly Cities programme.

Advancing the evidence base for public policies impacting on dietary behaviour, physical activity and sedentary behaviour in Europe: The Policy Evaluation Network promoting a multidisciplinary approach

Non-communicable diseases (NCDs) are the leading cause of global mortality. As the social and economic costs of NCDs have escalated, action is needed to tackle important causes of many NCD’s: low physical activity levels and unhealthy dietary behaviours. As these behaviours are driven by upstream factors, successful policy interventions are required that encourage healthy dietary behaviours, improve physical activity levels and reduce sedentary behaviours of entire populations. However, to date, no systematic research on the implementation and evaluation of policy interventions related to these health behaviours has been conducted across Europe. Consequently, no information on the merit, gaps, worth or utility of cross-European policy interventions is available, and no guidance or recommendations on how to enhance this knowledge across European countries exists. As part of the Joint Programming Initiative “A Healthy Diet for a Healthy Life” (JPI HDHL), 28 research institutes from seven European countries and New Zealand have combined their expertise to form the Policy Evaluation Network (PEN). PEN’s aim is to advance tools to identify, evaluate, implement and benchmark policies designed to directly or indirectly target dietary behaviours, physical activity, and sedentary behaviour in Europe, as well as to understand how these policies increase or decrease health inequalities. Using well-defined evaluation principles and methods, PEN will examine the content, implementation and impact of policies addressing dietary behaviour, physical activity levels and sedentary behaviour across Europe. It will realise the first steps in a bespoke health policy monitoring and surveillance system for Europe, and refine our knowledge of appropriate research designs and methods for the quantification of policy impact. It will contribute to our understanding of how to achieve successful transnational policy implementation and monitoring of these policies in different cultural, demographic or socioeconomic settings. PEN will consider equity and diversity aspects to ensure that policy actions are inclusive and culturally sensitive. Finally, based on three policy cases, PEN will illustrate how best to evaluate the implementation and impact of such policies in order to yield healthy diets and activity patterns that result in healthier lives for all European citizens.

Worksite health promotion and social inequalities in health.

It is well-documented that higher educated employees have better health than the lower educated. The workplace has been put forward as a contributor to this inequality. We extend previous work on workplace characteristics that could influence employee health by asking to what extent workplace health promotion (WHP) can account for the relation between education and health. Two ways in which WHP may relate to health inequalities are addressed: higher educated employees may be more likely to use WHP than lower educated employees and the effect of WHP on health may be stronger for higher educated than for lower educated employees. Using data from the European Sustainable Workforce Survey which contains information on over 11000 employees in 259 organisations, we test whether three types of WHP mediate or moderate the relation between education and health: healthy menus, sports facilities and health checks. We find that higher educated employees are in better health and that use of WHP positively relates to health. Use of healthy menus and sports facilities in the workplace can contribute to increasing health inequalities, as lower educated employees are less likely to make use of these. Health checks could contribute to diminishing health inequalities, as lower educated employees are more likely to use them compared to higher educated employees. The effect of WHP is not contingent on education. We advise stimulating lower educated employees to make more use of WHP, which can contribute to decreasing health inequalities.