Drivers Of Health Inequities Research Articles

The Association of Socio-Environmental Inequality and Outcomes Among Patients Undergoing Major Surgery

IntroductionEnvironmental hazards may influence health outcomes and be a driver of health inequalities. We sought to characterize the extent to which social–environmental inequalities were associated with surgical outcomes following a complex operation. MethodsIn this cross-sectional study, patients who underwent abdominal aortic aneurysm repair, coronary artery bypass grafting, colectomy, pneumonectomy, or pancreatectomy between 2016 and 2021 were identified from Medicare claims data. Patient data were linked with social–environmental data sourced from Centers for Disease Control and Agency for Toxic Substances and Disease Registry data based on county of residence. The Environmental Justice Index social–environmental ranking (SER) was used as a measure of environmental injustice. Multivariable regression analysis was performed to assess the relationship between SER and surgical outcomes. ResultsAmong 1,052,040 Medicare beneficiaries, 346,410 (32.9%) individuals lived in counties with low SER, while 357,564 (33.9%) lived in counties with high SER. Patients experiencing greater social–environmental injustice were less likely to achieve textbook outcome (odds ratio 0.95, 95% confidence interval 0.94-0.96, P < 0.001) and to be discharged to an intermediate care facility or home with a health agency (odds ratio 0.97, 95% confidence interval 0.96-0.98, P < 0.001). ConclusionsCumulative social and environmental inequalities, as captured by the Environmental Justice Index SER, were associated with postoperative outcomes among Medicare beneficiaries undergoing a range of surgical procedures. Policy makers should focus on environmental, as well as socioeconomic injustice to address preventable health disparities.

Racial Capitalism and Black-White Health Inequities in the United States: The Case of the 2008 Financial Crisis.

Scholars cite racist political-economic systems as drivers of health inequities in the United States (i.e., racial capitalism). But how does racial capitalism generate health inequities? I address this open question within the historical context of predatory lending during the 2008 financial crisis. Relevant hypotheses are tested with multiple waves of data from Black and White participants of the National Longitudinal Study of Adolescent to Adult Health (N = 8,877). Across socioeconomic strata, I find that Black participants report higher rates of foreclosure, eviction, repossession, delinquent bills, lost income, and new debts in the wake of the financial crisis. Using structural equation and quasi-experimental models, I then show that Black participants also self-report rapid health declines and increases in prescription drug abuse throughout this period, much of which is explained by chronic financial stress. I conclude that racial capitalism can generate health inequities by ensnaring Black Americans in a toxic web of financial exploitation and stress proliferation.

A longitudinal analysis of health inequalities from adolescence to young adulthood and their underlying causes

Research suggests that children of low-educated parents face greater health burdens during the passage from adolescence to young adulthood, as they are more likely to become low-educated themselves, establish behavioural and psychosocial disadvantages, or being exposed to unhealthy working conditions. However, studies examining the development and drivers of health inequalities during this particular life stage are limited in number and have produced varied results. This study investigates trajectories of self-rated health and overweight from 14 to 25 years of age, stratified by parental education, and explores the role of potential mediators (educational achievement, health behaviours, psychosocial factors, working conditions). We rely on prospective cohort data from the National Educational Panel Study (NEPS), a representative sample of 14,981 German ninth graders interviewed yearly from 2011 to 2021 (n = 90,096 person-years). First, we estimated random-effects growth curves for self-rated health and overweight over participants’ age and calculated the average marginal effect of high versus low parental education. Second, a series of simulation-based mediation analyses were performed to test how much of health inequalities were explained by children’s educational attainment (years of school education, years in university), health behaviours (smoking, alcohol, physical inactivity), psychosocial factors (number of grade repetitions, years in unemployment, chronic stress, self-esteem) and working conditions (physical and psychosocial job demands). We accounted for potential confounding by controlling for age, sex, migration background, residential area, household composition, and interview mode. Results show that higher parental education was related to higher self-rated health and lower probabilities of being overweight. Interaction between parental education and age indicated that, after some equalisation in late adolescence, health inequalities increased in young adulthood. Furthermore, educational attainment, health behaviours, psychosocial factors, and early-career working conditions played a significant role in mediating health inequalities. Of the variables examined, the level of school education and years spent in university were particular strong mediating factors. School education accounted for around one-third of the inequalities in self-rated health and one-fifth of the differences in overweight among individuals. Results support the idea that the transition to adulthood is a sensitive period in life and that early socio-economic adversity increases the likelihood to accumulate health disadvantages in multiple dimensions. In Germany, a country with comparatively low educational mobility, intergenerational continuities in class location seem to play a key role in the explanation of health inequalities in youth.

Relative contributions of pre-pandemic factors and intra-pandemic activities to differential COVID-19 risk among migrant and non-migrant populations in the Netherlands: lessons for future pandemic preparedness

BackgroundAlthough risk factors for differences in SARS-CoV-2 infections between migrant and non-migrant populations in high income countries have been identified, their relative contributions to these SARS-CoV-2 infections, which could aid in the preparation for future viral pandemics, remain unknown. We investigated the relative contributions of pre-pandemic factors and intra-pandemic activities to differential SARS-CoV-2 infections in the Netherlands by migration background (Dutch, African Surinamese, South-Asian Surinamese, Ghanaians, Turkish, and Moroccan origin).MethodsWe utilized pre-pandemic (2011–2015) and intra-pandemic (2020–2021) data from the HELIUS cohort, linked to SARS-CoV-2 PCR test results from Public Health Service of Amsterdam (GGD Amsterdam). Pre-pandemic factors included socio-demographic, medical, and lifestyle factors. Intra-pandemic activities included COVID-19 risk aggravating and mitigating activities such as physical distancing, use of face masks, and other similar activities. We calculated prevalence ratios (PRs) in the HELIUS population that was merged with GGD Amsterdam PCR test data using robust Poisson regression (SARS-CoV-2 PCR test result as outcome, migration background as predictor). We then obtained the distribution of migrant and non-migrant populations in Amsterdam as of January 2021 from Statistics Netherlands. The migrant populations included people who have migrated themselves as well as their offspring. We used PRs and the population distributions to calculate population attributable fractions (PAFs) using the standard formula. We used age and sex adjusted models to introduce pre-pandemic factors and intra-pandemic activities, noting the relative changes in PAFs.ResultsFrom 20,359 eligible HELIUS participants, 8,595 were linked to GGD Amsterdam PCR test data and included in the study. Pre-pandemic socio-demographic factors (especially education, occupation, and household size) resulted in the largest changes in PAFs when introduced in age and sex adjusted models (up to 45%), followed by pre-pandemic lifestyle factors (up to 23%, especially alcohol consumption). Intra-pandemic activities resulted in the least changes in PAFs when introduced in age and sex adjusted models (up to 16%).ConclusionInterventions that target pre-pandemic socio-economic status and other drivers of health inequalities between migrant and non-migrant populations are urgently needed at present to better prevent infection disparities in future viral pandemics.

Mistreatment in health care among women in Appalachia

Good quality patient care requires health care providers to respect the humanity and autonomy of their patients. However, this is not achieved in all settings. This study used cross-sectional survey data including open-ended text responses to explore negative experiences with health care providers among women in Appalachia. We used the Heath Stigma & Discrimination Framework (HSDF) to identify how stigma is created and perpetuated through interactions with health care providers. Survey data from 628 women collected through purposive sampling identified that two out of three participants had had a bad encounter with a provider that made them not want to return for care. One in six participants had a negative experience specifically while seeking contraception. Using the domains of the HSDF framework, qualitative answers to open-ended questions illuminated how health care providers, influenced by social and cultural norms related to religiosity, patriarchal views, poverty, poor health infrastructure, and the opioid crisis, created and perpetuated stigma through dehumanising treatment, low-quality care, and health care misogyny. Because stigma is a driver of health inequity, these findings highlight the important and sometimes problematic role that health care providers can play when they create a barrier to future care through poor treatment of patients.

Promoting Cessation and a Tobacco Free Future: Knowledge and Attitude of Pharmacy Students Regarding Smoking Cessation in a Nigerian University

Tobacco smoking is a global public health threat and the largest single driver of health inequalities. Currently, there are over a billion smokers worldwide with approximately 80% of the smokers living in low-and-middle-income countries like Nigeria. Knowledge gaps on smoking cessation among pharmacy students might impact the quality of service these future pharmacists would provide in practice. Therefore, this study aimed to evaluate the knowledge and attitude of pharmacy students regarding smoking cessation in a Nigerian university. A University-based cross-sectional study was conducted among 277 pharmacy students of a Nigerian university using a pretested self-administered questionnaire between August and December 2019. Data were summarised descriptively using IBM SPSS (version 23). Most of the pharmacy students 203 (73.2%) agreed it is the pharmacists’ responsibility to support patients with smoking cessation. The majority of our respondents 226 (81.6%) reported pharmacy students need more training on smoking cessation. Thirty-three (11.9%) pharmacy students knew nicotine does not cause cancer. Less than one-tenth 27 (9.7%) of the pharmacy students were aware of smoking cessation products. Overall, 203 (73.2%) respondents had poor knowledge (score &lt; 60%) and an average positive attitude about smoking cessation. Pharmacy students have suboptimal knowledge about smoking cessation. However, they revealed a positive attitude towards smoking cessation. Therefore, there is a need for educational interventions to address the deficit in smoking cessation knowledge, as well as equip future healthcare providers. Thus, improving the quality of public health especially among smokers in Nigeria.

The Intellectual Roots Of Current Knowledge On Racism And Health: Relevance To Policy And The National Equity Discourse.

Research related to racism and health has evolved in recent decades, with a growing appreciation of the centrality of the social determinants of health, life-course approaches and structural racism, and other upstream factors as drivers of health inequities. Examining how race, class, and structural racism relate to each other and combine over the life course to affect health can facilitate a clearer understanding of the determinants of health. Yet there is ongoing discomfort in many public health and medical circles about research on racism, including opposition to the use of racial terminology. Similarly, most major national reports on racial and ethnic inequities in health have given limited attention to the role of racism. We conclude that there is a need to acknowledge the central role of racism in the national discourse on racial inequities in health, and paradigmatic shifts are needed to inform equity-driven policy and practice innovations that would tackle the roots of the problem of racism and dismantle health inequities.

Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy.

The COVID-19 pandemic precipitated catastrophic job loss, unprecedented unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g., social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends, and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic Whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of pandemic control strategies to mitigate COVID-19 spread and death.

Pandemic Housing Policy: Examining the Relationship Among Eviction, Housing Instability, Health Inequity, and COVID-19 Transmission

The COVID-19 pandemic precipitated catastrophic job loss, high unemployment rates, and severe economic hardship in renter households. As a result, housing precarity and the risk of eviction increased and worsened during the pandemic, especially among people of color and low-income populations. This paper considers the implications of this eviction crisis for health and health inequity, and the need for eviction prevention policies during the pandemic. Eviction and housing displacement are particularly threatening to individual and public health during a pandemic. Eviction is likely to increase COVID-19 infection rates because it results in overcrowded living environments, doubling up, transiency, limited access to healthcare, and a decreased ability to comply with pandemic mitigation strategies (e.g. social distancing, self-quarantine, and hygiene practices). Indeed, recent studies suggest that eviction may increase the spread of COVID-19 and that the absence or lifting of eviction moratoria may be associated with an increased rate of COVID-19 infection and death. Eviction is also a driver of health inequity as historic trends and recent data demonstrate that people of color are more likely to face eviction and associated comorbidities. Black people have had less confidence in their ability to pay rent and are dying at 2.1 times the rate of non-Hispanic whites. Indigenous Americans and Hispanic/Latinx people face an infection rate almost 3 times the rate of non-Hispanic whites. Disproportionate rates of both COVID-19 and eviction in communities of color compound negative health effects and make eviction prevention a critical intervention to address racial health inequity. In light of the undisputed connection between eviction and health outcomes, eviction prevention, through moratoria and other supportive measures, is a key component of a pandemic control strategies to mitigate COVID-19 spread and death.

The use of strategies from the social sciences to inform pipeline development programs for under-represented minority faculty and students in the health sciences.

Representation of under-represented minority (URM) faculty in the health sciences disciplines is persistently low relative to both national and student population demographics. Although some progress has been made through nationally funded pipeline development programs, demographic disparities in the various health sciences disciplines remain. As such the development of innovative interventions to help URM faculty and students overcome barriers to advancement remains a national priority. To date, the majority of pipeline development programs have focused on academic readiness, mentorship, and professional development. However, insights from the social sciences literature related to "extra-academic" (e.g., racism) barriers to URM persistence in higher education suggest the limitations of efforts exclusively focused on cognitively mediated endpoints. The purpose of this article is to synthesize findings from the social sciences literature that can inform the enhancement of URM pipeline development programs. Specifically, we highlight research related to the social, emotional, and contextual correlates of URM success in higher education including reducing social isolation, increasing engagement with research, bolstering persistence, enhancing mentoring models, and creating institutional change. Supporting URM's success in the health sciences has implications for the development of a workforce with the capacity to understand and intervene on the drivers of health inequalities.

Politics as an Explanation to the Health Divide in Different Settings: A Comparative Study of England and Ghana.

Informed by the theoretical perspective of the political economy of health and in the context of the recommendations of World Health Organization’s Commission on Social Determinants of Health, this article examines the political explanations of geographical health inequities in 2 extremely different settings: Ghana and England. Based on the “north-south health divide” in the 2 countries, the article finds that, while the drivers of health inequities in both countries are policy driven, historically situated contextual factors (colonialism in the case of Ghana and deindustrialization in the case of England) offer explanations for health inequities in both countries. We conclude by discussing the importance of paying attention to structural factors such as colonialism for understanding contemporary health inequities in formerly colonized countries such as Ghana.

Globalization and health equity: The impact of structural adjustment programs on developing countries.

Among the many drivers of health inequities, this article focuses on important, yet insufficiently understood, international-level determinants: economic globalization and the organizations that spread market-oriented policies to the developing world. One such organization is the International Monetary Fund (IMF), which provides financial assistance to countries in economic trouble in exchange for policy reforms. Through its 'structural adjustment programs,' countries around the world have liberalized and deregulated their economies. We examine how policy reforms prescribed in structural adjustment programs explain variation in health equity between nations-approximated by health system access and neonatal mortality. Our empirical analysis uses an original dataset of IMF-mandated policy reforms for a panel of up to 137 developing countries between 1980 and 2014. We employ regression analysis to evaluate the relationship between these reforms and health equity, taking into account the non-random selection and design of IMF programs. We find that structural adjustment reforms lower health system access and increase neonatal mortality. Additional analyses show that labor market reforms drive these deleterious effects. Overall, our evidence suggests that structural adjustment programs endanger the attainment of Sustainable Development Goals in developing countries.

The effect of personalised weight feedback on weight loss and health behaviours: Evidence from a regression discontinuity design.

Using a regression-discontinuity approach on a U.K. longitudinal dataset, this research analyses whether personalised weight feedback resulted in individuals losing weight over a period of between 2 and 7years. The analysis presented here finds that being told one was "overweight" had, on average, no effect on subsequent weight loss; however, being told one was "very overweight" resulted in individuals losing, on average, approximately 1% of their bodyweight. The effect of feedback was found to be strongly moderated by household income, with those in higher income households accounting for seemingly all of the estimated effect due, in part, to increased physical activity. These findings suggest that the provision of weight feedback may be a cost-effective way to reduce obesity in adults. They do however also highlight that the differential response to the provision of health information may be a driver of health inequalities and that the provision of feedback may bias longitudinal health studies.

Health sector employment: a tracer indicator for universal health coverage in national Social Protection Floors.

BackgroundHealth sector employment is a prerequisite for availability, accessibility, acceptability and quality (AAAQ) of health services. Thus, in this article health worker shortages are used as a tracer indicator estimating the proportion of the population lacking access to such services: The SAD (ILO Staff Access Deficit Indicator) estimates gaps towards UHC in the context of Social Protection Floors (SPFs). Further, it highlights the impact of investments in health sector employment equity and sustainable development.MethodsThe SAD is used to estimate the share of the population lacking access to health services due to gaps in the number of skilled health workers. It is based on the difference of the density of the skilled health workforce per population in a given country and a threshold indicating UHC staffing requirements. It identifies deficits, differences and developments in access at global, regional and national levels and between rural and urban areas.ResultsIn 2014, the global UHC deficit in numbers of health workers is estimated at 10.3 million, with most important gaps in Asia (7.1 million) and Africa (2.8 million). Globally, 97 countries are understaffed with significantly higher gaps in rural than in urban areas. Most affected are low-income countries, where 84 per cent of the population remains excluded from access due to the lack of skilled health workers. A positive correlation of health worker employment and population health outcomes could be identified. Legislation is found to be a prerequisite for closing access as gaps.ConclusionsHealth worker shortages hamper the achievement of UHC and aggravate weaknesses of health systems. They have major impacts on socio-economic development, particularly in the world’s poorest countries where they act as drivers of health inequities. Closing the gaps by establishing inclusive multi-sectoral policy approaches based on the right to health would significantly increase equity, reduce poverty due to ill health and ultimately contribute to sustainable development and social justice.

New approaches for moving upstream: how state and local health departments can transform practice to reduce health inequalities.

Growing evidence shows that unequal distribution of wealth and power across race, class, and gender produces the differences in living conditions that are "upstream" drivers of health inequalities. Health educators and other public health professionals, however, still develop interventions that focus mainly on "downstream" behavioral risks. Three factors explain the difficulty in translating this knowledge into practice. First, in their allegiance to the status quo, powerful elites often resist upstream policies and programs that redistribute wealth and power. Second, public health practice is often grounded in dominant biomedical and behavioral paradigms, and health departments also face legal and political limits on expanding their scope of activities. Finally, the evidence for the impact of upstream interventions is limited, in part because methodologies for evaluating upstream interventions are less developed. To illustrate strategies to overcome these obstacles, we profile recent campaigns in the United States to enact living wages, prevent mortgage foreclosures, and reduce exposure to air pollution. We then examine how health educators working in state and local health departments can transform their practice to contribute to campaigns that reallocate the wealth and power that shape the living conditions that determine health and health inequalities. We also consider health educators' role in producing the evidence that can guide transformative expansion of upstream interventions to reduce health inequalities.

A qualitative study exploring the determinants of maternal health service uptake in post-conflict Burundi and Northern Uganda.

BackgroundArmed conflict has been described as an important contributor to the social determinants of health and a driver of health inequity, including maternal health. These conflicts may severely reduce access to maternal health services and, as a consequence, lead to poor maternal health outcomes for a period extending beyond the conflict itself. As such, understanding how maternal health-seeking behaviour and utilisation of maternal health services can be improved in post-conflict societies is of crucial importance. This study aims to explore the determinants (barriers and facilitators) of women’s uptake of maternal, sexual and reproductive health services (MSRHS) in two post-conflict settings in sub-Saharan Africa; Burundi and Northern Uganda, and how uptake is affected by exposure to armed conflict.MethodsThis is a qualitative study that utilised in-depth interviews and focus group discussions (FGDs) for data collection. One hundred and fifteen participants took part in the interviews and FGDs across the two study settings. Participants were women of reproductive age, local health providers and staff of non-governmental organizations. Issues explored included the factors affecting women’s utilisation of a range of MSRHS vis-à-vis conflict exposure. The framework method, making use of both inductive and deductive approaches, was used for analyzing the data.ResultsA complex and inter-related set of factors affect women’s utilisation of MSRHS in post-conflict settings. Exposure to armed conflict affects women’s utilisation of these services mainly through impeding women’s health seeking behaviour and community perception of health services. The factors identified cut across the individual, socio-cultural, and political and health system spheres, and the main determinants include women’s fear of developing pregnancy-related complications, status of women empowerment and support at the household and community levels, removal of user-fees, proximity to the health facility, and attitude of health providers.ConclusionsImproving women’s uptake of MSRHS in post-conflict settings requires health system strengthening initiatives that address the barriers across the individual, socio-cultural, and political and health system spheres. While addressing financial barriers to access is crucial, attention should be paid to non-financial barriers as well. The goal should be to develop an equitable and sustainable health system.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0449-8) contains supplementary material, which is available to authorized users.

Major drivers of health inequalities in later life and future research needs.

Europe is the oldest region in the world and its life expectancy is currently increasing at around about 12 months every 5 years. When added to population re-structuring as a result of demographic change, this means that by 2060 30% of the European population will be aged 65 years and over and with those aged 80 and over being the fastest growing age group. The European Union is placing a high priority on healthy ageing and its key indicator is Healthy Life Years (HLY). It is already obvious from the variation in HLY that not all European populations are ageing healthily. For example in France, life expectancy at age 50 for women is 22.9 years, with 9.9 years of healthy life. In comparison women’s life expectancy at age 50 in Latvia is 17.2 years, with only 4.3 years of healthy life. In 2009 the European Commission funded the FUTURAGE project, whose aim was to develop a definitive road map for ageing research for Europe for the next 10-15 years. Seven major research priority themes were identified by FUTURAGE according to a standard format covering: the significance of the theme; the fundamental insights necessary for future research; an overview of current research knowledge; and the main priority topics within the general theme (full report available at http://futurage.group.shef.ac.uk/road-map-launch-conference.html). Here we focus on one of these seven themes, that of ‘Unequal Ageing’. Six challenges related to future European ageing research were identified in the area of unequal ageing: Monitoring inequalities; Health in work and retirement; Inequalities and discrimination on health; Ageing and migration; Focus on the very old; and Inequalities and discrimination in the labour market. These challenges, as well as examples of specific research questions, can be described in the context of a life course perspective and the World Health Organisation model of health transitions. FUTURAGE represented the most extensive consultation ever conducted in this research area, and it included all major stakeholders and active users of ageing research. ‘Unequal Ageing’ was identified as one of the main research priorities for the road map and within this the challenge to monitor inequalities across Europe. To be able to address this challenge demands not only a concerted collection of truly harmonised measures across Europe, but also that they are appropriate at a country or regional level.