Equity In Access To Health Care Research Articles

Racial and ethnic inequities in spatial access to pharmacies: A geographic information system analysis

BackgroundPharmacy accessibility is crucial for equity in health care access because community pharmacists may reach individuals who do not have access to other health care providers. ObjectiveThe objective of this study was to determine whether spatial access to pharmacies differs among racial/ethnic groups across the rural-urban continuum. MethodsWe obtained a 30% random sample of the Research Triangle Institute synthetic population, sampled at the census block level. For each individual, we defined optimal pharmacy access as having a driving distance ≤2 miles to the closest pharmacy in urban counties, ≤5 miles in suburban counties, and ≤10 miles in rural counties. We used a logistic regression model to measure the association between race/ethnicity and pharmacy access, while controlling for racial/ethnic composition of the census tract, area deprivation index, income, age, gender, and U.S. region. The model included an interaction between race/ethnicity and urbanicity to evaluate whether racial/ethnic inequities differed across the rural-urban continuum. ResultsThe sample included 90,749,446 individuals of whom 80.6% had optimal pharmacy access. Racial/ethnic inequities in pharmacy access differed across the rural-urban continuum (P value for interaction= <0.0001). In rural areas, Black (OR 0.87; 95% CI 0.86-0.87), Hispanic (OR 0.80; 95% CI 0.79-0.80), and indigenous (OR 0.47; 95% CI 0.47-0.48) individuals had lower odds of optimal pharmacy access, than White individuals. Hispanic (OR 0.96; 95% CI 0.96-0.97) and Indigenous individuals (OR 0.75; 95% CI 0.75-0.76) had lower odds of optimal pharmacy access compared to White individuals in suburban areas. In Western states, Asian had lower odds of optimal pharmacy access in suburban (OR 0.88; 95% CI 0.86-0.90) and rural areas (OR 0.91; 95% CI 0.87-0.95) compared to White individuals. ConclusionsRacial/ethnic inequities in spatial access to community pharmacies vary between urban and rural communities. Underrepresented racial/ethnic groups have significantly lower pharmacy access in rural and some suburban areas, but not in urban areas.

A cross-sectional survey of patient attitudes towards telemedicine in head and neck surgical oncology

ObjectiveTo investigate patient attitudes towards desire for and barriers to utilizing telemedicine visits for head and neck oncology care. MethodsThis is a retrospective analysis of data from cross-sectional survey responses collected via prospectively administered questionnaire to 616 adult patients during their clinical visit to a tertiary care head and neck surgical oncology clinic. Responses to questions investigating interest in telemedicine and potential barriers were collated with patient demographics, measures of rurality, and insurance status. Interest in telemedicine appointments was the assessed primary outcome. ResultsOf 616 survey respondents, 315 (51 %) indicated interest in telemedicine visits. Limitations in access to technology (17.5 %) and lack of reliable internet connection (13.14 %) were identified as key barriers to telemedicine use. Lack of interest in telemedicine was associated with older age (OR 0.97 [95%CI 0.96–0.98]), governmental insurance (0.43 [0.31–0.60]) and, retired work status (0.48 [0.33–0.69]). Women (1.43 [1.04–1.97]) and patients who reported access to compatible electronic devices (41.05 [14.88–113.20]) and reliable internet connection (20.94 [8.34–52.60]) were more likely to be interested in telemedicine appointments. Respondents also indicated preference for a “hands on” examination over telemedicine appointments. ConclusionNearly 1 in 2 patients evaluated in a tertiary care head and neck surgical oncology clinic expressed reticence regarding telemedicine for clinical visits. Limited access to technology platforms and unreliable internet remain key concerns for these patients. Understanding the needs and attitudes of specific patient populations may be important for organizations pivoting to telemedicine platforms to ensure equity in healthcare access. Level of evidenceRetrospective analysis of prospectively collected cross-sectional survey.

Survival Disparities By Frontline Clinical Trial Enrollment Status for Treatment of Pediatric Acute Myeloid Leukemia

Introduction: Studies have suggested superior outcomes for patients enrolled on clinical trials for their cancer treatment. While sociodemographic disparities in trial enrollment are well established in adults, the literature in children is mixed and limited. A deeper understanding of disparities in pediatric clinical trial enrollment and potential survival differences is critical to ensure the generalizability of trial results and equitable outcomes. In a cohort of children with AML, we sought to examine (1) differences in sociodemographic and clinical characteristics by trial enrollment status, (2) the impact of trial enrollment on survival, and (3) the potential drivers of survival differences. Methods: A retrospective cohort including all pediatric (age &amp;lt;19 years) patients with AML treated at 10 institutions in the United States from 2011-2018 was established and is being actively expanded to include diagnoses through 2023. Chart abstraction by trained study personnel collected detailed demographic and clinical information. Resource utilization data from the Pediatric Health Information System was merged to ascertain patient acuity. Higher acuity was defined as requiring ICU-level resources for 2 or more organ systems within 72 hours of diagnosis. Only patients who had a frontline therapeutic trial option available at their treating institution were included. This was operationalized as a center-level restriction to patients initiating therapy while any frontline trial was enrolling at the center. We additionally included only patients with complete data for all covariates in this analysis. Statistical Analysis: Demographic and clinical characteristics by trial enrollment status were compared using t-test or Fisher's exact test as appropriate. Cox proportional hazards regression estimated hazard ratios (HR) with a doubly robust estimator (adjusted models only) of 4-year OS and EFS by trial enrollment status. A stepwise propensity score (PS) approach assessed the impact of potential drivers of the associations between trial enrollment and overall survival (OS) and event-free survival (EFS). PS were computed by logistic regression and generated stabilized inverse probability weights used for adjustment. First, a Base PS model including a predefined set of potential confounders (age, sex, weight category, preferred language, risk classification, mean annual hospital AML volume) was created. Additional variables of interest were then sequentially added to the PS. The change in adjusted HR relative to the unadjusted comparison was used to quantify the proportion of the association explained at each step. Results: 342 pediatric patients diagnosed with AML with representation from three distinct frontline clinical trials (AAML1031, AML08, and AML16) were included. Patients who were Black (11% vs. 24%), Hispanic (24% vs. 28%), publicly insured (44% vs. 55%), higher acuity (3% vs. 8%), and high-risk classification (29% vs. 34%) were underrepresented in the trial enrollment group compared to non-trial enrolled (Table 1). In unadjusted analyses, trial enrollment was significantly associated with superior OS (HR=0.69, 95% CI 0.47-0.99, p=0.04); there was no significant difference in EFS (HR=0.95, 95% CI 0.69-1.31, p=0.75). Adjustment for the Base PS accounted for 23% of the observed association between trial enrollment and OS (Figure 1). Acuity explained an additional 7% of the association. Inclusion of race/ethnicity and insurance did not result in further adjustment. In fully adjusted analysis, the association was substantially attenuated (HR=0.93, 95% CI 0.59-1.46, p=0.76). Conclusions: Significant sociodemographic and clinical differences exist in frontline trial enrollment for pediatric AML, which may contribute to worse overall survival outcomes for patients not enrolled on trials. Acuity at diagnosis may be a potential modifiable driver of survival differences. These findings support the need to evaluate enrollment patterns across pediatric clinical trials, including how enrollment disparities impact generalizability of clinical trial results, as well as a critical need for interventions designed to improve equity in healthcare access.

States' racial resentment correlates with administrative distancing and lower rates of health plan selection in affordable care act marketplaces: a cross sectional analysis.

In the United States, the Affordable Care Act (ACA) pursued equity in healthcare access and treatment, but ACA implementation varied, especially limiting African Americans' gains. Marketplaces for subsidized purchase of coverage were sometimes implemented with limited outreach and enrollment assistance efforts. Reflecting state's ACA receptivity or reluctance, state's implementation may rest on sociopolitical stances and racial sentiments. Some states were unwilling to provide publicly supported healthcare to nonelderly, non-disabled adults- "the undeserving poor" -who evoke anti-black stereotypes. The present study assessed whether some states shunned Affordable Care Act (ACA) marketplaces and implemented them less vigorously than other states, leading to fewer eligible persons selecting insurance plans. It assessed if states' actions were motivated by racial resentment, because states connote marketplaces to be government assistance for unworthy African Americans. Using marketplace and plan selection data from 2015, we rated states' marketplace structures along a four-level continuum indicating greater acceptance of marketplaces, ranging from states assuming sole responsibility to minimal responsibility. Using national data from a four-question modern racism scale, state-wide racial resentment estimates were estimated at the state level. Analysis assessed associations between state levels of racial resentment with states' marketplace structure. Further analysis assessed relationships between both state levels of racial resentment and states' marketplace structure with states' consumer plan selection rates-representing the proportion of persons eligible to enroll in insurance plans who selected a plan. Racial resentment was greater in states with less responsibility for the administration of the marketplaces than actively participating states. States higher in racial resentment also showed lower rates of plan selection, pointing to less commitment to implementing marketplace provisions and fulfilling the ACA's coverage-improvement mission. Differences persisted after controlling for differences in conservatism, uninsurance, poor health, and rejection of Medicaid expansion. Resentment of African Americans' purported irresponsibility and entitlement to government assistance may interfere with states structuring and operating marketplaces to maximize health insurance opportunities for everyone available under the ACA. N/A.

Access to health care among internal migrants in Chhattisgarh, India: critical perspectives on the question of health equity and urban development

PurposeMigrants face some unique health-care challenges, which often remain unaddressed by the health system. The purpose of this study is to determine health-care access among migrants in Chhattisgarh, from a lens of health equity.Design/methodology/approachThis study was conducted in a government-built tenement under the Integrated Housing and Slum Development program in Bilaspur district of Chhattisgarh state of India. It is a mixed-methods study which used a survey method, focus group discussion, in depth-interviews, semi-structured interviews and non-participant observations of health facilities in the area. Respondents included residents (migrants) and other local stakeholders like the Chief Medical Officer of the district, elected representatives of the local government and frontline health workers. This paper focuses on the findings from the qualitative component of the study.FindingsThe move to resettle the people living in the slums to the periphery of the city had a negative impact on their health-care access. They find it difficult to access public health services, given the services are concentrated in the city. Women, elderly people and disabled people grapple with additional challenges in being able to access basic reproductive health services and care for chronic illnesses. Equity in health-care access is linked to various social determinants of health including access to housing and social security. However, the authors found that the migrant community is being deprived of appropriate housing facilities and social security.Originality/valueThis paper explores the health-care access of internal migrants in Chhattisgarh state of India in the larger context of urban development with a focus on health equity.

Financial Sustainability of Hospitals and Equity in Healthcare Access: Using the Social Resource-Based View

Ensuring financial sustainability is crucial for the long-term success of any organization, as it determines whether it can continue to operate and achieve its mission. While previous studies explored how organizational resources and capabilities affect financial performance, there is limited research on how social and environmental factors impact financial sustainability. This study employs the social resource-based view (SRBV) framework to investigate whether healthcare service providers situated in low-income and minority communities with higher health risks are more financially unsustainable. Our findings reveal that hospitals’ community outreach is a crucial capability for financial sustainability, supporting the assumptions of the social resource-based view. However, the positive effects of community outreach do not hold for hospitals located within minority communities.

Navigating the challenges of neuro-oncology in Africa: addressing diagnostic and treatment barriers in the region: a correspondence

Navigating the challenges of neuro-oncology in Africa: addressing diagnostic and treatment barriers in the region: a correspondence

Out-of-pocket fees for health care in Australia: implications for equity.

Out-of-pocket fees for health care in Australia: implications for equity.

Inequitable access to general and behavioral healthcare in the US during the COVID-19 pandemic: A role for telehealth?

Wide-ranging effects of the COVID-19 pandemic have led to increased psychological distress and alcohol consumption, and disproportionate hardship for disadvantaged groups. Early in the pandemic, telehealth services were expanded to maintain healthcare access amidst lockdowns, medical office closures, and fear of infection. This study examines general and behavioral healthcare access and disparities during the first year of the pandemic. Data are from the 2019–2020 US National Alcohol Survey (collected February 2019 to April 2020) and its COVID follow-up survey conducted January 30 to March 28, 2021 (N = 1819). General and behavioral healthcare-related outcomes were assessed at follow-up, and included perceived need for and receipt of care, delayed care, and use of telehealth since April 1, 2020. Results indicate that the majority of respondents with perceived need for healthcare received some behavioral healthcare (reported by 63%) and particularly general healthcare (88%), but nearly half (48%) delayed needed care. Delays were mostly due to COVID-related reasons, but cost barriers also were common and significantly impeded care-seeking by uninsured persons, young adults, rural residents, and persons whose employment was reduced by the pandemic. Disparities in the receipt of healthcare were pronounced for Hispanic/Latinx (vs. White) and lower-income (vs. higher-income) groups (AORs <0.37, p's < 0.05). Notably, telehealth was commonly used by Hispanic/Latinx and lower-income groups for general and particularly behavioral healthcare. Results suggest that telehealth has provided an important bridge to healthcare for certain medically underserved groups during the pandemic, and may be vital to future efforts to increase equity in healthcare access.

Health Equity, History, and a New Presidential Bioethics Commission: Lessons from the "Lost" Reports.

Convening a national bioethics commission has historically been one of the most powerful bioethical legacies a US presidential administration can undertake. The Biden Administration has not yet created such a commission; here we argue that centering health equity and healthcare access would provide a vital framework for a new commission’s legacy. Moreover, we demonstrate two crucial historical episodes when American presidents appointed commissions to examine the practical and ethical implications of these very issues. We turn first to the 1952 President’s Commission report on “Building America’s Health,” a lofty vision of universal healthcare access stymied by both political conflict and unaddressed problems of racism in the era’s legislation. Its rich yet incomplete account of American health inequities serves as a valuable forerunner to questions of justice in bioethics. We then explore the President’s Commission’s 1983 report “Securing Access to Healthcare: A Report on the Ethical Implications of Differences in the Availability of Health Services.” This report took up the mantle of equity in healthcare access, again with mixed results. Only by understanding the checkered history of these overlooked, practically “lost” reports can a new era in American bioethics successfully re-center the goal of equitable health for all.

Starting with us: Imagining relational, co-designed policy approaches to improve healthcare access for rural people with disability.

Access to healthcare for rural Australians is a wicked problem, particularly for rural people with disability. Contemporary healthcare access frameworks in Australia tend to overlook geography, use a 'one-size-fits-all approach', and disregard the valuable relationships between key rural healthcare stakeholders, including rural people with disability, rural health services and health professionals. The United Nation's Convention on the Rights of Persons with Disabilities requires the Australian Government to engage people with disability in the design of policies that will shape their day-to-day lives, including their access to healthcare. However, the nature and extent to which rural people with disability, rural health professionals and other key rural stakeholders are involved in the design of Australian policies impacting the health of rural people with disability are unknown. This paper examines approaches taken to engage rural people with disability and health professionals in the design of Australian disability policy impacting healthcare access, and reimagines future processes which can improve healthcare access for rural people with disability. Co-design and ethics of care lenses are applied to policy design approaches in this paper. We approach this work as rural disability and health academics, rural health professionals, and as rural people with disability, neurodivergence and family members of people with disability. We argue future co-designed policy approaches could focus on driving change towards equity in healthcare access for rural people with disability by harnessing the relational nature of rural healthcare.

MO491: Low Income is Associated With Late Nephrology Referral in Portugal: A Retrospective Study

Abstract BACKGROUND AND AIMS Social disparities in chronic kidney disease (CKD) are a reality. Low socioeconomic status is associated with an increased incidence of CKD and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System (NHS) was established to provide equity in healthcare access, but its impact in specialized CKD care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese centre. METHOD Retrospective cohort study evaluating maintenance haemodialysis patients of a Public Portuguese Nephrology Centre from 2017 through 2021. Medical records were compared for the presence of Low-Income status (LIs), with primary outcome as baseline estimated glomerular filtration rate (eGFR) at nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment (KRTOa), timely vascular access assessment and time to dialysis from referral. RESULTS A total of 212 participants were evaluated, 96 with LIs. This group presented higher sCr and lower eGFR at referral (2.35 versus 3.29 mg/dL, P &amp;lt; .001; 27.63 versus 18.47 mL/min/1.73 m2 P &amp;lt;.001, respectively). LIs associated with absence of KRTOa {OR: 2.7, [95% confidence interval (95% CI): 1.44–5.08]; P = .003} and late vascular access evaluation (OR: 2.77, 95% CI: 1.55–4.98; P = .001). Dialysis-free survival analysis revealed shorter time to dialysis in the LIs group (15.77 versus 20.71 months; P &amp;lt; .001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39–3.21; P &amp;lt; .001), a difference that was not verified after adjusting for eGFR at referral (HR: 1.16, 95% CI: 0.74–1.80; P = .53). CONCLUSION Low-Income CKD Portuguese patients are at risk of late nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for CKD.

Low income is associated with late nephrology referral in Portugal: A retrospective study

Introduction: Social disparities in chronic kidney disease are a reality. Low socioeconomic status is associated with increased incidence of chronic kidney disease and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System was established to provide equity in healthcare access, but its impact in specialized chronic kidney disease care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese center. Subjects and Methods: Retrospective cohort study evaluating maintenance hemodialysis patients of a Public Portuguese Nephrology Center from 2017 through 2021. Medical records were compared for presence of low-income status, with primary outcome as baseline estimated glomerular filtration rate at Nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment, timely vascular access assessment and time to dialysis from referral. Results: A total of 212 participants were evaluated, 96 with low-income status. This group presented higher serum creatinine and lower estimated glomerular filtration rate at referral (2.35 vs. 3.29 mg/dl, p&lt;0.001; 27.63 vs. 18.47 ml/min/1.73 m2, p&lt;0.001; respectively). Low-income status associated with absence of kidney replacement therapy options appointment (OR 2.7, 95% CI: 1.44-5.08; p=0.003) and late vascular access evaluation (OR 2.77, 95% CI: 1.55-4.98, p=0.001). Dialysis-free survival analysis revealed shorter time to dialysis in the low-income status group (15.77 vs. 20.71 months, p&lt;0.001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39-3.21, p &lt; 0.001), a difference that was not verified after adjusting for estimated glomerular filtration rate at referral (HR: 1.16, 95 % CI: 0.74 – 1.80, p = 0.53). Conclusion: Low-Income chronic kidney disease Portuguese patients are at risk for late Nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for chronic kidney disease.

Health Inequalities amongst Refugees and Migrant Workers in the Midst of the COVID-19 Pandemic: a Report of Two Cases

Malaysia hosts a significant number of refugees, asylum-seekers and migrant workers. Healthcare access for these individuals has always proved a challenge: language barriers, financial constraints and mobility restrictions are some of the frequently cited hurdles. The COVID-19 pandemic has exacerbated these existing inequalities, with migrants and refugees bearing the brunt of chronic systemic injustices. Providing equitable healthcare access for all, regardless of their citizenship and social status remains an ethical challenge for healthcare providers, particularly within the framework of a resource-limited healthcare system. Inclusive healthcare and socio-economic policies are necessary to ensure every individual’s equal opportunity to attain good health. The collective experiences of refugees and migrants in the pursuit of healthcare, as highlighted by the two cases described, showcases the importance of equity in healthcare access and the detrimental implications of non-inclusive healthcare and socio-economic policies.

A language-matching model to improve equity and efficiency of COVID-19 contact tracing

Contact tracing is a pillar of COVID-19 response, but language access and equity have posed major obstacles. COVID-19 has disproportionately affected minority communities with many non-English-speaking members. Language discordance can increase processing times and hamper the trust building necessary for effective contact tracing. We demonstrate how matching predicted patient language with contact tracer language can enhance contact tracing. First, we show how to use machine learning to combine information from sparse laboratory reports with richer census data to predict the language of an incoming case. Second, we embed this method in the highly demanding environment of actual contact tracing with high volumes of cases in Santa Clara County, CA. Third, we evaluate this language-matching intervention in a randomized controlled trial. We show that this low-touch intervention results in 1) significant time savings, shortening the time from opening of cases to completion of the initial interview by nearly 14 h and increasing same-day completion by 12%, and 2) improved engagement, reducing the refusal to interview by 4%. These findings have important implications for reducing social disparities in COVID-19; improving equity in healthcare access; and, more broadly, leveling language differences in public services.

Developing and validating regression models for predicting household consumption to introduce an equitable and sustainable health insurance system in Cambodia.

Financial protection is a challenge for low- and middle-income countries, where the fiscal space is limited, and majority of the population is engaged in the informal economy. This study developed and validated household consumption predictive models for Cambodia to collect contributions according to one's ability to pay. This study used nationally representative survey data collected annually between 2010 and 2017, involving 38,472 households. We developed four alternative models: the manually selected linear model, the linear model with stepwise technique, the mixed effects linear model, and the model with regularisation technique. Subsequently, we performed out-of-sample cross-validation for each model, and evaluated the model prediction performance. Overall, observed and predicted household consumptions were linearly related in all four models. While the prediction performance of the models did not substantially differ, the stepwise linear model showed the best performance. The regularisation and the mixed effects were not particularly effective in these regressions. The household consumption was better predicted for those with lower consumption, and the predictivity declined as the consumption level increased. This study suggests the possibility of predicting household consumption at a reasonable level. This would maximise the contribution revenue, optimise the government subsidy, and ensure equity in healthcare access.

Unmet Health Care Need and Income-Related Horizontal Equity in Access During the COVID-19 Pandemic

Using monthly data from the Understanding Society (UKHLS) COVID-19 Survey we analyse the evolution of unmet need and assess how the UK health care system performed against the norm of horizontal equity in health care access during the first wave of COVID-19 wave. Unmet need was most evident for hospital care, and less pronounced for primary health services (medical helplines, GP consultations, local pharmacist advice, over the counter medications and prescriptions). Despite this, there is no evidence that horizontal equity, with respect to income, was violated for NHS hospital outpatient and inpatient care during the first wave of the pandemic. There is evidence of pro-rich inequities in access to GP consultations, prescriptions and medical helplines at the peak of the first wave, but these were eliminated as the pandemic progressed. There are persistent pro-rich inequities for services that relate to individuals’ ability to pay (over the counter medications and advice from the local pharmacist).

Social policies and change in education-related disparities in mortality in Japan, 2000-2010.

Persistent socioeconomic disparity in mortality is a widely observed phenomenon despite improvements in the economic standard of living and the prevailing universal healthcare coverage policy. In this study, we selected Japan as a case in which public universal coverage has maintained horizontal equity in healthcare access while demographic and economic challenges have affected the life chances of vulnerable subpopulations over the past decade. We assessed the changing trends in the education-related disparity in mortality over a decade across demographic subpopulations for different causes of death, with the goal of generating social policy lessons to contribute to closing the mortality gap. Using a deterministic data merge between nationwide census and death records, we estimated age- and sex-specific mortality rates for 14 causes and their education-related gradients with absolute and relative indices of inequality in 2000 and 2010 via Poisson regression. Estimation parameters were standardized to the age structure of the sub-population of high school graduates in 2000 as the reference. The results demonstrated that the relative gaps in all-cause mortality persisted despite a decrease in the average mortality rate over the study period. The absolute gaps in mortality increased for preventable causes of death associated with lifestyle behavior choices. The average mortality worsened among socioeconomically vulnerable populations such as youth and women, who were left behind in the existing social/economic policy. External causes of death such as suicide and traffic accidents showed decreasing absolute gaps in a subpopulation targeted by universal social and labor policy measures. These change patterns indicate that, compared with a high-risk approach, a universal policy approach to dealing with societal and fundamental causes of health inequality seems more effective in reducing the education-related mortality gap in both absolute and relative terms.

A qualitative study on mental health and wellbeing of Syrian refugees in the UK

Abstract Background The Syrian conflict has resulted in an estimated 5.3 million registered Syrian refugees in various parts of the world. Evidence suggests that these individuals are at considerable risk of developing common mental disorders. This study aimed to explore the mental wellbeing of Syrian refugees, identify their coping mechanisms and pathways towards integration into new communities, and formulate recommendations for better access to mental healthcare services. Methods We conducted a qualitative study using in-depth semi-structured interviews with adult refugees (&amp;gt;18 years old) who are currently residing in Southeast of England. Interviews were conducted in Arabic, recorded, transcribed and translated verbatim. Translated transcripts were analysed using thematic analysis. Ethical Approval was obtained from the Brighton and Sussex Medical School Research Governance Ethics Committee (ER/BSMS9DAP/1). Results Twelve participants (3 females and 9 males) took part in the study; all were born in Syria and the majority (n = 9) were over 45 years of age. Participants described symptoms of reduced psychological wellbeing. Preliminary findings shows that almost all participants talked about psychological distress resulting from previous trauma, loss of and separation from family members and challenges adjusting to their host country. Barriers to accessing the healthcare system in the UK included fear of stigma, being misunderstood by healthcare staff and language issues. Communicating with loved ones, connecting with nature, practising faith and pursuing hobbies were reported as coping strategies. Conclusions For Syrian refugees in the UK, mental wellbeing embraces living with past traumatic experiences, achieving social integration and facing challenges accessing healthcare. Understanding differences between refugee and host communities is key to appropriately cater to the specific needs of each community and achieve equity in healthcare access. Key messages Syrian refugees in UK described symptoms of reduced psychological wellbeing. Understanding the needs of refugee communities is necessary to achieve equity in healthcare access.

Healthcare Access Inequity within a Social Health Insurance Setting: A Risk Faced by Indonesia’s Jaminan Kesehatan Nasional (JKN) Program

This paper is a literature review laying out empirical evidence of healthcare access inequity within an implementation of social health insurance (SHI) programs. The research question of this paper is: in what way, and how, inequity in healthcare access potentially happens, even if a type of SHI covers the whole, or most, of a society. This paper is mainly motivated by the implementation of Jaminan Kesehatan Nasional (JKN), an SHI program in Indonesia. Even though the program aims to create better equity in healthcare access, the existing health system and the program’s design may prevent the achievement of this goal. By laying out evidence on how healthcare access inequity in other countries remains within an SHI mechanism, this paper illuminates that JKN may face the same risk. In reviewing the papers, this study applied Goddard and Smith’s (2001) concept of healthcare access inequity in the area of availability, quality, cost, and information. The findings suggest that healthcare access inequity could happen despite the implementation of an SHI program. Four types of circumstances that might have led to healthcare access inequity include geographical disparities of health facilities; adequacy of insurance program’s reimbursement and healthcare providers’ financial motive; healthcare providers’ prejudices toward patients; and unequal personal advantages of health treatment seekers. When applied to the context of JKN implementation in Indonesia, the risks of healthcare access inequity are imminent, mostly due to the uneven concentration of health facilities, the program’s segmented tariff rates, and the socioeconomic diversity among JKN members. The findings imply that JKN members might be at risk of healthcare access inequity. While the risks are plausible, this study is limited to predicting the potential inequity within JKN, mirroring from the empirical evidence. This study signifies the need for further empirical research on this area, which will potentially inform policymakers to improve the program.