Evidence Of Health Inequalities Research Articles

Evaluating local primary health care actions to address health inequities: analysis of Australia’s Primary Health Networks

BackgroundMeso-level, regional primary health care organisations such as Australia’s Primary Health Networks (PHNs) are well placed to address health inequities through comprehensive primary health care approaches. This study aimed to examine the equity actions of PHNs and identify factors that hinder or enable the equity-orientation of PHNs’ activities.MethodsAnalysis of all 31 PHNs’ public planning documents. Case studies with a sample of five PHNs, drawing on 29 original interviews with key stakeholders, secondary analysis of 38 prior interviews, and analysis of 30 internal planning guidance documents. This study employed an existing framework to examine equity actions.ResultsPHNs displayed clear intentions and goals for health equity and collected considerable evidence of health inequities. However, their planned activities were largely restricted to individualistic clinical and behavioural approaches, with little to facilitate access to other health and social services, or act on the broader social determinants of health. PHNs’ equity-oriented planning was enabled by organisational values for equity, evidence of local health inequities, and engagement with local stakeholders. Equity-oriented planning was hindered by federal government constraints and lack of equity-oriented prompts in the planning process.ConclusionsPHNs’ equity actions were limited. To optimise regional planning for health equity, primary health care organisations need autonomy and scope to act on the ‘upstream’ factors that contribute to local health issues. They also need sufficient time and resources for robust, systematic planning processes that incorporate mechanisms such as procedure guides and tools/templates, to capitalise on their local evidence to address health inequities. Organisations should engage meaningfully with local communities and service providers, to ensure approaches are equity sensitive and appropriately targeted.

Abstract MP39: Association Of Race And Ethnicity On The Management Of Acute Non-st Elevation Myocardial Infarction

Background: Whether differences in acute coronary syndrome (ACS) management are explained or attenuated by social risk factors has important implications for the development of interventions to address health inequities. We examined the associations between (1) race and ethnicity and (2) annual household income with the management of non-ST elevation Myocardial Infarction (NSTEMI). Hypothesis: We hypothesized we would identify racial and ethnic differences in the acute management of NSTEMI and that annual household income would attenuate such differences. Methods: We employed administrative claims of commercially insured and Medicare Advantage beneficiaries (Optum’s de-identified Clinformatics® Data Mart Database) to examine the rates of coronary angiography and percutaneous coronary intervention (PCI) by race and ethnicity as well as the contributions of social risk factors, particularly annual household income, toward racial and ethnic differences. Race and ethnicity were categorized as Asian, Black, Hispanic, or White. Covariates included demographics (age, sex); conditions compromising the Elixhauser Comorbidity Index; and social risk factors (annual household income, educational attainment). Results: We identified 87,094 individuals (age 73.8±11.6 years; 55.6% male; 2.6% Asian, 13.4% Black, 11.2% Hispanic, 72.7% White) with NSTEMI events from 2017 to 2019. The overall incidence rate for coronary angiography was 555 per 1,000 individuals (95% Confidence Interval [CI] 550-560) and for PCI was 297 per 1,000 (95% CI 293-300). Individuals of Black race were 7% less likely to undergo coronary angiography (95% CI 1.02-1.12) and 17% less likely to undergo PCI (95% CI 1.11-1.23) than those of White race. Hispanic individuals were 13% less likely (95% CI 1.08-1.19) to undergo coronary angiography and 18% less likely to undergo PCI (95% CI 1.12-1.24) than White individuals. Higher annual household income attenuated differences in the receipt of PCI for Asian and Black individuals but not those of Hispanic ethnicity. Conclusion: We identified significant racial and ethnic differences in the management of individuals presenting with NSTEMI that were marginally attenuated by higher household income. Our findings demonstrate continued evidence of health inequities in contemporary ACS treatment.

Income-related inequality in quality-adjusted life expectancy in Korea at the national and district levels

BackgroundThe aim of this study was to measure differences in quality-adjusted life expectancy (QALE) by income in Korea at the national and district levels.MethodsMortality rates and EuroQol-5D (EQ-5D) scores were obtained from the National Health Information Database of the National Health Insurance Service and the Korea Community Health Survey, respectively. QALE and differences in QALE among income quintiles were calculated using combined 2008–2014 data for 245 districts in Korea. Correlation analyses were conducted to investigate the associations of neighborhood characteristics with QALE and income gaps therein.ResultsQALE showed a graded pattern of inequality according to income, and increased over time for all levels of income and in both sexes, except for low-income quintiles among women, resulting in a widened inequality in QALE among women. In all 245 districts, pro-rich inequalities in QALE were found in both men and women. Districts with higher QALE and smaller income gaps in QALE were concentrated in metropolitan areas, while districts with lower QALE and larger income gaps in QALE were found in rural areas. QALE and differences in QALE by income showed relatively close correlations with socioeconomic characteristics, but relatively weak correlations with health behaviors, except for smoking and indicators related to medical resources.ConclusionsThis study provides evidence of income-based inequalities in health measured by QALE in all subnational areas in Korea. Furthermore, QALE and differences in QALE by income were closely associated with neighborhood-level socioeconomic characteristics.

Poly-substance use and sexual risk behaviours: a cross-sectional comparison of adolescents in mainstream and alternative education settings

BackgroundSurveys of young people under-represent those in alternative education settings (AES), potentially disguising health inequalities. We present the first quantitative UK evidence of health inequalities between AES and mainstream education school (MES) pupils, assessing whether observed inequalities are attributable to socioeconomic, familial, educational and peer factors.MethodsCross-sectional, self-reported data on individual- and poly-substance use (PSU: combined tobacco, alcohol and cannabis use) and sexual risk-taking from 219 pupils in AES (mean age 15.9 years) were compared with data from 4024 pupils in MES (mean age 15.5 years). Data were collected from 2008 to 2009 as part of the quasi-experimental evaluation of Healthy Respect 2 (HR2).ResultsAES pupils reported higher levels of substance use, including tobacco use, weekly drunkenness, using cannabis at least once a week and engaging in PSU at least once a week. AES pupils also reported higher levels of sexual health risk behaviours than their MES counterparts, including: earlier sexual activity; less protection against sexually transmitted infections (STIs); and having 3+ lifetime sexual partners. In multivariate analyses, inequalities in sexual risk-taking were fully explained after adjusting for higher deprivation, lower parental monitoring, lower parent-child connectedness, school disengagement and heightened intentions towards early parenthood among AES vs MES pupils. However, an increased risk (OR = 1.73, 95% CI 1.15, 2.60) of weekly PSU was found for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours.ConclusionAES pupils are more likely to engage in health risk behaviours, including PSU and sexual risk-taking, compared with MES pupils. AES pupils are a vulnerable group who may not be easily targeted by conventional population-level public health programmes. Health promotion interventions need to be tailored and contextualised for AES pupils, in particular for sexual health and PSU. These could be included within interventions designed to promote broader outcomes such as mental wellbeing, educational engagement, raise future aspirations and promote resilience.

Measuring Humanity: hip-hop as evidence for health inequalities

Measuring Humanity: hip-hop as evidence for health inequalities

Health inequalities and the impact on the prevalence of cardiovascular risk factors and chronic complications in Argentina: a study on national risk factors surveys.

In Argentina, there is evidence of health inequalities, measured both at the general level and also using income as a parameter of social status. However, few studies address the issue of health equality in chronic diseases such as cardiovascular risk factors. To describe health inequalities, using cardiovascular risk factors as a tracer for chronic diseases in different areas of the country and over time. In addition, we aim to identify differences in the quality of care provided to people with cardiovascular risk factors, between 2005 and 2009. This is an observational study, which used descriptive and quantitative methods. Data from the National Risk Factors Survey from 2005 and 2009 in the cohorts who have chronic diseases (hypertension, diabetes, dyslipidemia and overweight/obesity) were analyzed to assess associations between health status and several demographic, epidemiological and socioeconomic variables. Additionally, clinical and metabolic characteristics of people with diabetes and other cardiovascular risks factors were analyzed in 2005 and 2009 using the database Quality of Diabetes Care (QUALIDIAB). Cardiovascular risk factors are more frequent in people with lower socioeconomic status, regardless of the indicator. The inequalities detected showed the worst indicators in strata with lower education and income, with the same results both nationwide and separated by region. This inequalities were more pronounced in 2009, and their magnitude changed by region and cardiovascular risk factor. From 2005 to 2009, body mass index, blood glucose and HbA1c value increased. In contrast, both systolic blood pressure and triglycerides decreased, with no significant changes in total cholesterol and diastolic blood pressure. Cardiovascular risk factors present inequalities attributed to social status manifesting at both national and regional levels.

Quality of HIV care in the United Kingdom: key indicators for the first 12 months from HIV diagnosis

Prompt HIV diagnosis and treatment are associated with increased longevity and reduced transmission. The aim of the study was to examine late diagnoses and to assess the quality of care following diagnosis. National surveillance and cohort data were used to examine late HIV diagnoses and to assess the quality of care received in the 12 months following HIV diagnosis. In 2011, 79% (4910/6219) of persons (15 years and over) diagnosed with HIV infection had CD4 counts reported within 3 months; of these, 49% were diagnosed late (CD4 count < 350 cells/μL). Adults aged 50 years and over were more likely to be diagnosed late (67%) compared with those aged 15-24 years (31%). Sixty-four per cent of heterosexual men were diagnosed late compared with 46% of women and 36% of men who have sex with men (MSM) (P < 0.01). The percentage of late diagnoses was highest among black African adults (66%) compared with other ethnicities; 96% of black African adults diagnosed late were born abroad. Overall, 88% and 97% of patients were linked to care within 1 and 3 months of diagnosis, respectively, with little variation by demographics and exposure category. The crude 1-year mortality rate was 31.6 per 1000 persons diagnosed in 2010. It was highest among adults diagnosed late (40.3/1000 versus 5.2/1000 for prompt diagnoses) and particularly among those aged 50 years and over. Excluding deaths, 85% of the 5833 diagnosed in 2010 were retained in care in 2011; 92% of the 2264 adults diagnosed late in 2010 received antiretroviral therapy by the end of 2011. The National Health Service provides high-quality care to persons newly diagnosed with HIV infection in the UK, with no evidence of health inequalities. Despite excellent care, half of adults are diagnosed late according to the threshold at which national guidelines recommend treatment should begin. Such patients have an 8-fold increased risk of 1-year mortality compared with those diagnosed promptly. Reducing late diagnosis of HIV infection remains a public health priority in the UK.

Socioeconomic differences in antidepressant use in the PATH through life study: Evidence of health inequalities, prescribing bias, or an effective social safety net?

BackgroundDepression is more common amongst those who are economically disadvantaged. However there is inconsistent evidence concerning the relationship between socioeconomic position and antidepressant use. Moreover, evidence of greater antidepressant use amongst those of lower socioeconomic position may reflect their greater psychiatric morbidity, a prescribing bias towards pharmacological treatments, or provide evidence of an effective social safety net. This study investigates these issues whilst addressing methodological limitations of earlier studies. MethodData were from a large, random community survey of Australian adults (N=4493) with linked administrative data for primary-care service use. Depression was measured using the Patient Health Questionnaire, with other measures of current mental health and history of depression included in analysis. Multiple personal indicators and a combined measure of social disadvantage were considered. A series of analyses systematically examined competing explanations for socioeconomic differences in depression and antidepressant treatment. ResultsMarkers of socioeconomic disadvantage were associated with a greater likelihood of antidepressant use. This finding was not attributable to the higher rates of depression amongst the disadvantaged. A similar pattern of results was evident for non-pharmaceutical treatments (primary care consultations). Socioeconomic position was not associated with use of complementary medications for depression, not covered by Australia's social safety net. LimitationsAnalysis did not consider specialist mental health services. ConclusionsSocially disadvantaged respondents reported greater antidepressant use and service use after controlling for current depression symptoms. This pattern of findings suggests Australia's universal health-care system and social safety net may help address potential inequalities in health care.

Ensuring equity in healthcare delivery

AbstractOver the past 20 years, the development of health care services and the availability of health care coverage to the population have been accompanied by major gains in life expectancy. There remains, however, an issue in equity of access to health care services which may increase with the economic downturn. Evidence of health inequities can be found in health statistics all around Europe, where low income groups are less healthy and report more limitation to use of healthcare services than higher income groups. There is a strong commitment among researchers in health services to put health inequities on the political and research agendas. This is done by providing tools that assess the effect of new technologies on equity and by ensuring that dashboard indicators include measures of equity.

Health inequality: what does it mean and how can we measure it?

Reducing socioeconomic inequalities in health has become an important government objective. International organizations, such as the WHO, have played an important role providing the principles to encourage action in many countries. Evidence of socioeconomic inequalities in health is widespread. National and cross-national research has led to the development of a new set of methodological tools to address the challenges that the available data present. Several methods have been used in the literature to measure inequalities in health; the concentration index approach is becoming widely used. In the future, the research agenda will continue to shift away from documenting health inequalities toward efforts to support the development of policies to improve the health of the most deprived populations and to reduce inequalities in health.

Cancer care in Australia

Cancer has a significant impact on the Australian community. One in three men and one in four women will develop cancer by the age of 75. The estimated annual health expenditure due to cancer in 2000-1 in Australia was $2.7 billion, representing 5.5% of the country’s total healthcare expenditure. An historical overview of the national cancer control strategies in Australia is provided. In males, the five most common cancers in order of decreasing incidence are: prostate cancer, colorectal cancer, lung cancer, melanoma and lymphoma, while for Australian women, breast cancer is the most common cancer. Key epidemiologic information about these common cancers, current management issues and comprehensive national clinical practice guidelines (where available) are highlighted. Aspects of skin cancer, a particularly common cancer in the Australian environment – with a focus on melanoma – are also included.Cancer outcomes in Australia, measured by selected outcomes, are among the best in the world. However, there is still evidence of health inequalities, especially among patients residing in regional and remote areas, the indigenous population and people from lower socio-economic classes. Limitations of current cancer care practices in Australia, including provision of oncology services, resources and other access issues, as well as suggested improvements for future cancer care, are summarised. Ongoing implementation of national and state cancer control plans and evaluation of their effectiveness will be needed to pursue the goal of optimal cancer care in Australia.

Equity and efficiency in Italian health care.

Health care finance and provision in Italy is unusual by international standards: public financing relies heavily on both general taxation and social insurance, and although the vast majority of expenditure is publicly financed, the majority of care is provided by the private sector. The system suffers, however, from a chronic failure to control expenditures and its record on perinatal and infant mortality is poor. Hospitals in Italy have a low bed-occupancy rate by international standards and the per diem system of reimbursing private hospitals encourages unduly long stays. Costs per inpatient day are high by international standards, but costs per admission are close to the OECD average. Ambulatory care costs are extremely low, but this appears to be due to the fact that GPs see so many patients that their role is inevitably mainly administrative. Consumption of medicines is extremely high, but because the cost per item is low, expenditure per capita is not unduly high. Despite the emphasis on social insurance, the financing system appears to be progressive. There is evidence of inequalities in health in Italy, and some evidence that health care is not provided equally to those in the same degree of need.