Health Equity Audit Research Articles

Disparities in access to breast, colorectal, and cervical cancer screening programmes have intensified during the pandemic period. Findings of a health equity audit conducted by the Pavia Healthcare Protection Agency (Lombardy Region, Northern Italy)

to evaluate the disparities in access to cancer screening programmes in the Province of Pavia (Lombardy Region, Northern Italy), along with identifying the factors influencing these disparities; to assess the impact of the pandemic emergency on invitation and screening coverage in the three organized screening programmes, which are provided free of charge to the target population. observational retrospective study covering both the pre-pandemic and the pandemic periods. for breast cancer screening, the eligible population comprises women aged 45 to 74; colorectal cancer screening is offered to men and women aged 50 to 74; cervical cancer screening is tailored based on women age. The management of all three screening programmes is overseen by the Health Protection Agency of Pavia, which proactively invites the eligible population through invitation letters. for each screening programme, the examination coverage (the number of screened individuals out of the total eligible population) was analysed considering its influencing factors, with a specific emphasis on equity-related factors such as demographics (sex, age), geographic factors (country and continent of birth, residential district), comorbidities. the SARS-CoV-2 pandemic has led to a reorganization of healthcare services and to a reduction of the offer, resulting in an overall reduction in test coverage for all three programmes (-16.3% for breast and colorectal cancer screening, -8.5% for cervical cancer screening). The disparities in coverage among various population groups, reflecting inequalities in access, further escalated from the pre-pandemic to the pandemic period. Noteworthy, equity-related predictors of reduced screening access were non-Italian nationality and residency in rural or mountainous districts. during periods of healthcare system strain, such as the pandemic, disparities in access can become more pronounced. It is crucial to implement measures for enhancing access to screening in a more equitable manner.

Application of health equity audit to emergency care for acute myocardial infarction

Application of health equity audit to emergency care for acute myocardial infarction

Participation in cancer research in BNSSG, England: A Health Equity Audit 2021.

1565 Background: Cancer is a cause of health inequalities, and nationally, patients from deprived communities have lower participation rates in cancer research. Equitable access to research benefits patients, healthcare organisations and improves applicability of research. Methods: We undertook a health equity audit of participation in cancer research (trials and non-trials based) in Bristol, North Somerset and South Gloucestershire (BNSSG), England from 1.4.2019-30.3.2020 using data from the Acute Trust patient datasets. Comparison cohorts were extracted from a regional primary care dataset (the system wide dataset). Firstly, an incident cancer cohort: diagnosed from 1.11.2019-1.10.2020. Secondly a “living with cancer” cohort: cancer flag in the 5 years prior to 1.7.2021. Deprivation is measured by IMD of home postcode small area (LSOA). Results: Results are presented for the audit in the table below, with 95% confidence intervals where appropriate. Compared to people newly diagnosed with cancer, adults aged 70 or older were 56% less likely to take part in research (OR 0.44, 95% CI 0.39-0.51), and adults aged 80 or older were 77% less likely to take part in research (OR 0.23, 95% CI 0.18-0.29). Compared to people newly diagnosed with cancer, people from the most deprived 20% of the population were 27% less likely to take part in research (OR 0.73, 95% CI 0.88-0.92). The most deprived research participants were more likely to be younger, have one or more comorbidities and a recent emergency admission. Patients from outside BNSSG (18%) appear similar in profile to those from within BNSSG, including for deprivation. Better data are needed for other factors relevant to equity, including ethnicity and Inclusion Health. Conclusions: This health equity audit confirms and quantifies inequities in access to cancer research in our region. Under-representation of deprived and older patients appeared multifactorial in this audit, but further work to understand facilitators and barriers to recruitment is needed. These results are a call to action. [Table: see text]

Health equity audits: a systematic review of the effectiveness

ObjectivesThe purpose of this systematic review is to explore whether health equity audits (HEAs) are effective in improving the equity of service provision and reducing health inequalities.DesignThree databases (Ovid Medline,...

A Health Equity Audit of the Diabetic Eye Screening Programmes in Cumbria and the North East

We report key findings and lessons learned from a health equity audit (HEA) of six National Health Service Diabetic Eye Screening Programmes (NDESPs) in Cumbria and the North East of England. Uptake of diabetic eye screening was analysed in relation to demographic variables including age, sex, socioeconomic deprivation and geography and a combinationof these in each of the six NDESPs. A total of 196,275 records of patients with diabetes aged 12 years and over on the NDESP registers were analysed. The key finding was a lower than acceptable screening uptake (70%) in the last year among the working age population, especially those living in the most socioeconomically deprived areas. The HEA process also highlighted the need for improvements in collecting data on ethnicity and sex. It informed action plans which address inequities in uptake of screening in each of the six NDESPs, especially those targeting the working age populations and individuals who never attended screening or never responded to screening invitations. We established a method of extracting the patient data from the local systems, pseudonymising and linking to lower super outputarea. This will be important for HEAs to become embedded in routine practice.

National policy and local practice: a trainee public health registrar’s view

The first six weeks of my training as a public health registrar has been an eyeopening time. The dedication of the workforce, the depth of knowledge and the experience that many registrars bring to the scheme from previous careers, as well as the breadth of opportunities available, has contributed to an exciting - if occasionally intimidating - start to the programme.But with a previous career as a policy analyst behind me, what has really struck me are the ways in which national and local policy play out and my assumptions about this have shifted quite significantly. Indeed, part of my reason for applying to the public health training programme had been a growing disillusionment with the impact of the policy that I was crafting on front-line practice. A typical exchange with a medical director would involve me enquiring as to whether they had read such-and-such a report, and them politely nodding and pointing to a pristine and evidently un-thumbed copy sitting on their shelf.This viewpoint had been reinforced by the rhetoric of politicians of all stripes. Clanging bedpans and recalcitrant councils that refuse to empty the bins have provided me with a caricature of a perpetual tug-of-war between 'local services for local people' and Whitehall command and control. Thankfully, my experience so far is that this relationship doesn't have to be as oppositional as all that.With a background in child health and obesity policy, my first pleasant surprise was an induction meeting with a senior public health manager. He had read a report that I had co-written for the Academy of Medical Royal Colleges called Measuring up: the medical profession's prescription for the nation's obesity crisis.1 Not only that, he had taken the trouble to tabulate its recommendations in a spreadsheet of evidence for comparison with National Institute for Health and Care Excellence (NICE) guidance, academic papers and other grey literature. Here was an example of national policy carefully considered, its implications for practice at a local level methodically teased out.One of the recommendations had concerned what we perceived as a 'postcode lottery' in terms of weight management service provision. My new local authority, Medway, already has good coverage in this area for children and young people through the delivery of its MEND (Mind, Exercise, Nutrition, Do it!) programmes.2 On reading Measuring up, my new colleague could have given himself a pat on the back as a recommendation met, but instead has been benchmarking its local outcomes to those reported by MEND nationally and conducting a health equity audit, both activities helping to ensure that they are addressing local people's needs equitably. …

Addressing the inverse care law: the role of community paediatric services

Children's health suffers disproportionately from the effects of poverty. The inverse care law states that those who need care the most are the least likely to receive it. Community paediatricians are well placed to address health inequalities in children. To explore, using routinely collected data, whether we address health inequalities and the inverse care law, particularly for certain conditions targeted by our specialty. Five years of data were analysed, during which health equity audits have led to service changes in order to tackle inequities. The data include postcodes, allowing each child to be assigned to a deprivation quintile, and a range of diagnoses, including five sentinel conditions: attention deficit hyperactivity disorder (ADHD) on medication, autistic spectrum disorder (ASD), epilepsy, cerebral palsy and Down's syndrome. This allowed analysis of the caseload by deprivation index for these conditions, comparison with the background population and exploration of time trends. The number of children on the caseload and their distribution across the quintiles remained stable. The proportion of deprived children (i.e. in the lowest two quintiles) on the caseload over the last five years taken together is 56%, compared to 44% in the background population. The numbers of children with ADHD on medication has almost quadrupled in deprived quintiles and doubled in the least deprived quintile, while the numbers of children with this diagnosis in the most deprived is four times that in the least deprived. Numbers of children with ASD have also increased in each quintile. In contrast, the number of children with epilepsy and cerebral palsy did not show much variation, but those from deprived quintiles made up a greater proportion of the caseload. Routine data collection demonstrates that inequalities are addressed using all four quality domains of service provision and sentinel conditions more likely to affect deprived children are targeted. We believe it is possible for all services to collect and analyse data thus with minimal effort, thereby providing a foundation from which to address the inverse care law.

Health equity audits in general practice: a strategy to reduce health inequalities

This quality improvement project was set in Tower Hamlets, east London, with the aim of reducing health inequalities by ethnicity, age and gender in the management of three common chronic diseases. Routinely collected clinical data were extracted from practice computer systems using Morbidity Information Query and Export Syntax (MIQUEST) and Egton Medical Information Systems (EMIS) Web, between 2007 and 2010. Health equity audits for 38 practices in Tower Hamlets primary care trust (PCT) were constructed to cover key process and outcome measures for each of the three major chronic diseases: coronary heart disease (CHD), type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). The equity audit was disseminated to practices along with facilitation sessions. We show evidence of baseline inequalities in each condition across the three east London PCTs. The intervention tracked four key indicators (cholesterol levels in CHD, blood pressure and haemoglobin A1c levels in diabetes and % smoking in COPD). Performance for physician-driven interventions improved, but smoking rates remained static. All ethnic groups showed improvement, but there was no evidence of a reduction in differences between ethnic groups. Reductions in gender and age group differences were noted in diabetes and CHD. Using routine clinical data, it is possible to develop practice-level health equity reports. These can unmask previously hidden inequalities between groups, and promote discussion with practice teams to stimulate strategies for improvements in performance. Steady improvements in chronic disease management were observed, however, systematic differences between ethnic groups remain. We are not able to attribute observed changes to the audits. These reports illustrate the importance of collecting ethnicity data at practice level. Tools such as this audit can be adapted to monitor inequalities in primary care settings.

Tackling child health inequalities due to deprivation: using health equity audit to improve and monitor access to a community paediatric service

Deprived children constitute a large population with high levels of ill health, and difficulty with access to healthcare contributes to their poor health outcomes. There is debate on how best to engage deprived families and the literature on differential access to paediatric care based on deprivation is limited. To demonstrate that community paediatrics can contribute to reduction of health inequalities by providing services that are accessible to and preferentially used by children whose health is likely to be affected by deprivation. To provide a template for others to improve and monitor equity in their services. Long-term service reconfiguration and health equity audit. We used routinely collected activity data and the Indices of Multiple Deprivation to construct equity profiles of the children using our service, and compared these with the profile of the population aged 0-16 years in the geographical area covered by the service. The new patient contact rate for the most deprived children in the population was more than three times that of the least deprived [odds ratio (OR) 3.29, 95% confidence interval (CI) 2.76-3.93]. Deprived children were more than twice as likely to require multi-agency meetings as part of their medical care (OR 2.28, 95% CI 1.94-2.69). Seventy per cent (3693/5312) of our total contacts were with children in the two most deprived quintiles. There was a marked socio-economic gradient in all types of contact. The model of care used by our community paediatric service successfully engages deprived families, thereby reducing health inequalities due to poor access. Key features are multi-agency working, removing barriers to access, raising staff awareness and use of health equity audit. Our findings provide support for tackling health inequalities via health services that are available to all, but capable of responding proportionately according to level of need, a model recently described as proportionate universalism.

Sociodemographic differences in diabetic retinopathy screening; using patient-level primary care data for health equity audit

Sociodemographic differences in diabetic retinopathy screening; using patient-level primary care data for health equity audit Simon DS Fraser1, GE Watkinson2, CA Rennie3, D King2, H Sanderson2, L Edwards4, P Roderick1 1Public Health Sciences and Medical Statistics, University of Southampton, Southampton General Hospital, Southampton, 2NHS Southampton City, Southampton, 3Southampton Eye Unit, Southampton General Hospital, Southampton, 4NHS Hampshire, Eastleigh, Hampshire, UK Background: The prevalence of diabetes is increasing worldwide and there is inequality in the distribution of diabetic complications. Diabetic retinopathy is the leading cause of blindness in adults of working age in the UK, and certain risk factors are recognized. Retinopathy screening in the UK involves annual digital retinal photography and image grading. Auditing equity in retinopathy screening poses unique challenges, and screening program data are often incomplete for variables relevant to equity. Using two sources of patient-level primary care data, we conducted a health equity audit comparing the access and uptake of screening between groups of people with diabetes in each of three screening programs covering this area of southern England. Methods: A patient-level dataset using data from general practices and a combined health record was used to compare dimensions of equity (gender, age, length of time since diabetes diagnosis, type of diabetes, presence of hypertension, socioeconomic deprivation, ethnicity, and screening program) between people with and without a record of retinopathy screening within three years in Hampshire and the Isle of Wight, UK. Results: Anonymized data for 70,004 people with diabetes were obtained from 205 (88%) general practices. In total, 62,836 people (89.8%) had a record of screening within three years and 7168 (10.2%) did not. Lower uptake of screening was independently associated with the youngest and oldest age groups (compared with 50–79-year-olds), recent diabetes diagnosis, and deprived areas. Diagnosed hypertension was positively associated with screening. Conclusion: Evaluating equity in screening programs is important to help reduce inequalities. We found evidence of inequity in access and uptake of retinopathy screening. Primary care data contained more information than screening program data. Using a combined health record was more efficient than obtaining data directly from general practices, but data were incomplete for deprivation measures at the time of this audit. Our audit informed subsequent efforts to improve equity in local diabetic retinopathy screening services. Keywords: inequality, diabetes, eye, complications, screening

Targeting dental resources to reduce inequalities in oral health in the North East of England – a health equity audit methodology to evaluate the effects of practice location, practice population and deprivation

To use nationally available data sets to undertake an equity audit to support the targeting of resources to meet the needs of patients from deprived communities, in areas where levels of poor oral health remain higher than the rest of the population as a whole. Postcodes of 224,107 patients in County Durham were matched to Lower Super Output Areas (LSOA) for each practice. Deprivation scores were identified for each LSOA. The postcode of dental practices (59) was matched to the LSOA and the practice population divided into quintiles from the most to the least deprived areas. Results indicated that the more deprived the area in which a dental practice was located, the greater the proportion of the practice population accessing care from the most deprived quintile. The size of the practice alone was not directly related to meeting the needs of a more deprived population. The methodology used in this study can be used to identify inequalities and inequities in oral health in different areas. In the audit area improving access to dental services for those in most need, was best tackled by targeted investment into dental practices located in deprived communities. Audits are recommended to insure a fare distribution of resources to meet local population needs.

Summary of: Targeting dental resources to reduce inequalities in oral health in the North East of England – a health equity audit methodology to evaluate the effects of practice location, practice population and deprivation

To use nationally available data sets to undertake an equity audit to support the targeting of resources to meet the needs of patients from deprived communities, in areas where levels of poor oral health remain higher than the rest of the population as a whole. Postcodes of 224,107 patients in County Durham were matched to Lower Super Output Areas (LSOA) for each practice. Deprivation scores were identified for each LSOA. The postcode of dental practices (59) was matched to the LSOA and the practice population divided into quintiles from the most to the least deprived areas. Results indicated that the more deprived the area in which a dental practice was located, the greater the proportion of the practice population accessing care from the most deprived quintile. The size of the practice alone was not directly related to meeting the needs of a more deprived population. The methodology used in this study can be used to identify inequalities and inequities in oral health in different areas. In the audit area improving access to dental services for those in most need, was best tackled by targeted investment into dental practices located in deprived communities. Audits are recommended to insure a fare distribution of resources to meet local population needs.

Socioeconomic status and cardiovascular disease: risks and implications for care

Socioeconomic status (SES) refers to an individual's social position relative to other members of a society. Low SES is associated with large increases in cardiovascular disease (CVD) risk in men and women. The inverse association between SES and CVD risk in high-income countries is the result of the high prevalence and compounding effects of multiple behavioral and psychosocial risk factors in people of low SES. However, strong and consistent evidence shows that parental SES, childhood and early-life factors, and inequalities in health services also contribute to elevated CVD risk in people of low SES who live in high-income countries. In addition, place of residence can affect CVD risk, although the data on the influence of wealth distribution and work-related factors are inconsistent. Studies on the effects of SES on CVD risk in low-income and middle-income countries is scarce, but evidence is emerging that the increasing wealth of these countries is beginning to lead to replication of the patterns seen in high-income countries. Clinicians should address the association between SES and CVD by incorporating SES into CVD risk calculations and screening tools, reducing behavioral and psychosocial risk factors via effective and equitable primary and secondary prevention, undertaking health equity audits to assess inequalities in care provision and outcomes, and by use of multidisciplinary teams to address risk factors over the life course.

The RSPH Health Promotion and Community Well-Being Organization and Partnership Awards

The Royal Society for Public Health (RSPH) has launched the Health Promotion and Community Well-Being Organization and Partnership Awards, in collaboration with the Faculty of Public Health, the UK Public Health Register and the Institute of Health Promotion and Education. The Awards demonstrate the new Society's mission of "vision, voice and practice", and will raise the profile of health promotion in the UK and recognize good practice through public and professional acknowledgement. They are linked to a wider programme of advocacy and workforce development led by the RSPH through the Shaping the Future collaboration (see http://www.specialisedhealthpromotion.org.uk). The Awards have a powerful pedigree in the "settings" approach of the World Health Organization, and focus on the strong processes that organizations and partnerships need to develop and implement strategies. The Awards have been developed in partnership with four initial applicants from primary care trusts, and one partnership applicant spanning a primary care trust, local authority and Council for Voluntary Services. Assessment of applications is through peer review and a panel challenge. Examples of evidence from the five initial applicants, and how they relate to the criteria for the Awards, are showcased in this article. They are: Sefton's Health-Promoting Settings Network; the North East Essex Youth Health Trainers scheme; Health Equity Audits in Rotherham; public engagement in North Lancashire; and Health at Work in Plymouth.

PCT Commissioning: how community nurse involvement can be encouraged

Commissioning is the process by which PCTs identify the health needs of their population and make prioritized decisions to secure care to meet those needs within available resources. It includes longer term strategic planning, medium term planning (three year Local delivery Plans) and the shorter term agreement and performance management of service level agreements. The process should involve the public, engage clinicians, and be conducted on a whole system basis, informed by health equity audits, and carried through with the full participation of other stakeholders including NHS Trusts, local authority(s) and the voluntary sector (NHS Modernization Agency, 2004).

Dealing with incomplete and inaccurate data in public health: case study of a health equity audit of health visiting services

Dealing with incomplete and inaccurate data in public health: case study of a health equity audit of health visiting services

Rapid assessment methods used for health-equity audit: Diabetes mellitus among frail British care-home residents

To perform a health-equity audit of diabetes care among elderly care-home residents. Health-need assessment using rapid-evaluation methods. Residents of care homes in Newcastle upon Tyne, UK. All care-home residents in the city. OUTCOME MEASURES FOR DIABETES: To carry out health-need assessment, agree partners and issues, assess equity profile, and to agree high-impact local action to narrow the gap, according to the guidance on health-equity audit provided by the Department of Health. A combination of qualitative and quantitative methods were used to develop a methodology to complete the health-need assessment component of the health-equity audit. A number of criteria for an appropriate standard of care, and how the current service met these standards, were reported in a timely fashion to the primary care trust. The domains comprised national standards for care, diabetes prevalence, adequacy of coverage and standard of care delivered, and environment, including availability of equipment and knowledge and attitudes of care staff. The output was structured to identify a number of key issues: the diabetes register under-represents the number of cases of known diabetes mellitus (3.5% vs. 11.5%); weights and blood-pressure measurements were incorporated into the care-home environment; this population had inappropriately high rates of glucose monitoring, secondary care involvement and little evidence of co-ordinated eye screening; and staff needed training for diabetes care, which they recognized. Finally, recommendations were agreed for the immediate response and a local action plan agreed to narrow the health gap. It is feasible to use rapid-evaluation methodologies to initiate a health-equity audit of current diabetes services for care-home residents in a large health district, informing the primary care trust about health equity for this vulnerable group of patients. The tools developed can be used again to inform the iterative process of health-equity audit in the future. We would recommend the use of these methods and similar combined qualitative/quantitative techniques as valuable alternatives for a health-equity audit in the absence of extensive databases on which to assess health equity.

Using the UK primary care Quality and Outcomes Framework to audit health care equity: preliminary data on diabetes management

The incentivization of UK primary care through the Quality and Outcomes Framework (QOF) has released an unprecedented supply of data that in theory could aid health equity audit and reduce health inequalities. The current system allows for 'exception reporting' whereby patients can be excluded from calculation of payment for reasons such as failure to attend review. We speculated that such exclusions could be linked to socioeconomic deprivation. We assessed 'exception reporting' rates for 15 diabetes indicators using 2004/05 QOF data for 49 general practitioner (GP) practices in Brighton and Hove and related it to a deprivation ranking for each practice. The standardized diabetes prevalence was 26% higher (P < 0.001) in the highest compared to the lowest quintile of deprivation. Correlations between 'exception reporting' and deprivation were seen for 10 of the 15 diabetes indicators (r = 0.20-0.41, P < 0.05). Practices with a more deprived patient population were more likely to report 'exceptions' for QOF indicators, although there was no such relationship with the achievement of QOF targets. Strategies to reduce health inequalities need to take into account that high levels of exception reporting, particularly in practices with deprived populations, may be disguising unmet need in those populations.

Managing health inequalities locally: a baseline survey of primary care trusts' experience with health equity audit in the implementation year

Health equity audit (HEA), a pragmatic policy tool to ensure that services and resources are focused on issues that have the highest impact on health inequalities, has now become embedded in the national strategy to tackle these inequalities through a new mandatory requirement that primary care trusts (PCTs) conduct one such audit annually. This study aimed to assess their experience through a national baseline survey in 2004, all PCTs (n = 303) being electronically mailed a questionnaire with non-respondent follow-up. Replies were received from 132 PCTs (44%), a representative sample of PCT diversity, most of whom had completed only a few steps in the audit cycle. Audit topics (most frequently coronary heart disease, smoking cessation, and access issues) and dimensions of inequity (mainly area and deprivation) were agreed through only limited engagement with local strategic partnerships. Local public health networks and multiagency teams were infrequent partners in undertaking the HEA. Most PCTs wanted comparator data, good practice examples, and specific methodological expertise. While significant progress has been made, this survey shows only limited use of HEA as a tool for multisectoral use by PCTs in partnership with others and a focus on intra-PCT comparisons at the expense of those with a wider pool of 'look-a-likes'.

Mini-symposium — Public Health Observatories: Building public health skills and capacity in the English regions

Local public health departments have variable access to a public health intelligence function, and information skills are scarce. Public health observatories are supporting the development of professional standards for public health intelligence specialists and offer training opportunities for both defined public health specialists and generalist public health specialists. In addition observatories support public health practice through educational programmes in health impact assessment, health equity audit, public health intelligence, and the provision of toolkits and advice on methods. Observatories have a key role in supporting and developing networks, in particular public health analysts, and the use of interoperable websites is enhancing these opportunities.