Population Health Inequalities Research Articles

Quantitative approaches to structural intersectionality research: Conceptual and methodologic considerations.

There has been a recent influx in the development of novel measures of structural forms of discrimination, including structural racism, xenophobia, sexism, heterosexism, and cisgenderism. These systems of power and oppression are inherently interdependent and mutually constitutive, yet a paucity of research has investigated their joint impacts; this gap is likely reflective of the limited guidance that exists regarding how to effectively combine multiple measures of structural discrimination to examine their joint impacts on population health and health inequities. In this commentary, we seek to redress this by describing conceptual and methodologic considerations for population health researchers interested in conducting quantitative structural intersectionality research - an intersectionality-informed research approach focused on examining how systems of power and oppression intersect to shape population health and health inequities. Developing best practices for measuring and analyzing the joint impacts of structural forms of discrimination is crucial for effectively describing and quantifying their impacts on population health and health inequities, and for informing interventions, laws, and policies to advance health equity and social justice.

Xenotransplantation as a business solution to the organ shortage.

Xenotransplantation has the potential to alter the U.S. transplant system in profound ways. However, this emerging "spare parts" solution spearheaded by biotechnology companies raises concerns about its impact on the organ shortage, healthcare systems, population health, and health inequalities. We contend that xenotransplantation may have limited benefits in improving health, could prove prohibitively expensive for many, and may divert resources away from proven public health measures. Additionally, it carries the risk of perpetuating stigma. Xenotransplantation may thereby exacerbate existing healthcare inequities across racial, ethnic, socio-economic, and geographic lines. To mitigate these risks, we contend that public health expert input is integral for xenotransplant policy development and outreach and that this underscores the importance of federal government investment in transplant infrastructure.

The impacts on population health by China's regional health data centers and the potential mechanism of influence.

China recently established a series of pilot regional health data centers with a mandate to acquire, consolidate, analyze, and translate data into evidence for health policy decision-making. This experiment with "big data" has the potential to influence population health and is the focus of this study. This study used national longitudinal survey data from the China Family Panel Studies over the period 2014-2020 to empirically assess the impact of China's establishment of pilot regional health data centers on population health and health inequality. A difference-in-differences model was employed to investigate the policy effect on population health, with additional exploration of possible mechanisms of influence. The corrected concentration index was used to measure health inequality, while Wagstaff decomposition method was applied to examine the marginal influence of the policy effect on health inequality. Overall health status of local residents has improved after the establishment of the pilot regional health data centers. Using mechanism analysis, the findings demonstrated that improvements to population health were driven by promoting healthy lifestyles and innovations in medical practices. Furthermore, due to differences in individual e-health literacy, the pilot centers produced "pro-rich" health inequality where high-income groups benefited more from the establishment of the pilot centers in terms of health than low-income groups. This study has highlighted the potential to improve population health, in general, with the advent of big data centers, but for these benefits be unevenly distributed among the resident population.

Regional Differences in the Years of Potential Life Lost in the Context of Avoidable Mortality from Cardiovascular Diseases

Disparities in mortality rates within a country indicate social inequalities in population health across different regions. Initiatives aimed at reducing mortality have shown to effectively decrease preventable deaths and extend the lives of individuals with cardiovascular diseases; therefore, it is relevant to compare regions based on years of potential life lost (YPLL) due to premature preventable mortality.The aim of the study was to compare YPLL for individuals who died from avoidable and unavoidable causes of cardiovascular diseases in Russian regions with different levels of available specialized medical care.The results align with the hypothesis that regions with limited access to specialized medical care show higher rates of YPLL due to preventable cardiovascular disease deaths regardless of the morbidity, i.e., regional differences in mortality rates are highly related to social inequalities. To the greatest extent, premature preventable mortality from cardiovascular diseases is influenced by the availability of cardiology professionals.The majority of cardiovascular deaths were avoidable. On the eve of the COVID-19 pandemic, YPLL were more than 27 years per 1,000 population among men and more than 9 years among women, accounting for 69.2% and 69.8% of total preventable YPLL for men and women, respectively.

How could 20-minute neighbourhoods impact health and health inequalities? A policy scoping review

Background‘Twenty-minute neighbourhoods’ (or variations, such as 15-minute cities) are receiving increasing policy attention with anticipated impacts on population health (inequalities) outcomes alongside sustainability improvements. Yet, factors contributing to possible health impacts are not well understood. This scoping review aimed to identify proposed and evidenced pathways to health (inequality) outcomes from international policy plans.MethodsWe first identified relevant academic literature, searching Scopus, (Ovid) Medline and Embase databases. A second search aimed to identify local or national planning or policy documents on government websites and related organisations. We followed a snowball search strategy to retrieve examples identified from the academic literature search and from the C40 cities network. These policy documents were our primary target for extraction, and we extracted and analysed by individual place. Pathways to health and health inequality outcomes identified in these documents were inductively coded thematically. We used Sankey diagrams to visually aggregate the thematic codes for each place relating to pathways to health outcomes and social determinants (mechanisms).ResultsIn total, 36 places across 17 countries were included, described across 96 academic articles, policy plans and reports. While different health improvement outcomes were included as a goal in nearly all policy plans, most frequently references were to health in general rather than specific health outcomes. Pathways to health were discussed in numerous policy plans across three overarching themes: proximity, place redesign, and environmental action. Proximity pathways were most frequently outlined as the means to achieve health outcomes, with active travel acting through increased physical activity/reduced obesity as the most frequent individual pathway. However, few plans specified what would actually be implemented in practice to achieve the increased proximity to services. Health inequalities were only mentioned by six places specifically, although nearly half of all places mentioned broader inequality aims (e.g., poverty reduction). Possible unintended consequences to health inequalities also received some attention, for example through displacement of residents.DiscussionPathways to assumed health (inequality) outcomes require better specification and evidence. Health inequalities are particularly under-explored, and scenario modelling might provide a means to explore the dynamic aspects necessary to examine these important outcomes pre-implementation.

New Ways of Working to Manage and Improve Quality in Integrated Care Systems in England

Background: Integrated Care Systems (ICSs) in England were formally established in July 2022 to coordinate the planning and delivery of health and care services. A key responsibility was to address the quality of these services. Our study aimed to examine how ICSs approach this responsibility and to identify opportunities and barriers experienced in their early establishment and development. Method: A sample of four ICSs were recruited to participate. Interviews and meeting observations were undertaken in two phases (before and after the inception of ICSs) around 12 months apart. A total of 112 interviews were carried out with senior figures in the four ICSs supplemented by observation of relevant meetings and analysis of relevant documents. Results: Regarding quality, ICSs demonstrated several new ways of working. They set-up new structures for quality governance and created whole-system strategies for quality centred on major responsibilities regarding population health and health inequalities. These strategies required new and relevant metrics to assess quality and outcomes and a greater focus upon co-production in the development of services. They aimed to strike a fine balance between long-standing requirements for quality assurance and new responsibilities for quality improvement. New approaches were underpinned by new collaborations between system partners extending beyond healthcare to include Local Authorities (responsible for social care and public health) and local communities. Conclusion: To address the many challenges of quality, ICSs have created new ways of working cultivating different kinds of collaborative relationships compared to established hierarchical, siloed and top-down ways of working prior to their formation. A focus on improving population health and reducing inequalities has required a shift from ‘here and now’ urgent problem-solving to working with longer timelines. Such changes require patience in the context of political pressure to devote efforts to more salient problems such as waiting lists.

The joint distribution of years lived in good and poor health

BackgroundIncidence-based multistate models of population health are commonly applied to calculate state expectancies, such as a healthy life expectancy (HLE), or unhealthy life expectancy (UHE). These models also allow the computation of other summary indices, such as the distributions of healthy or unhealthy lifespans.ObjectiveWe aim to show how a multistate health model implies a multistate death distribution, giving joint information on years lived in good and poor health. We also propose three aggregate indices of joint health and mortality inequality.MethodsWe propose a double-accounting approach to increment-decrement life table methods to intuitively derive a multistate health distribution over age and cumulative duration spent in each state. We then define a variety of summary lifespan inequality indices based on different distance metrics, namely Euclidean, Chebyshev, and Manhattan distances.ResultsWe apply the method to multistate transition probabilities between health states based on the activities of daily living index for Italian women from the Survey of Health, Ageing and Retirement in Europe in 2015-2017. We demonstrate the added value of accounting for joint years lived in health states in multistate models for our understanding of the period health and mortality conditions from the perspective of health-specific lifespans of individuals.ConclusionsMultivariate state distributions and summary indices derived from them give a holistic representation of population health inequality. We offer selected summary indices of the multivariate distribution with different demographic interpretations from the measures derived from univariate distributions. Although more theoretical and methodological work is required to motivate a single comprehensive population health inequality index, this direction is a promising path for a better understanding of population health dynamics and relationships between univariate statistics.

Modeling the Population Equity of Alzheimer Disease Treatments in the US

The arrival of new medications for Alzheimer disease (AD) has prompted efforts to measure their value using conventional cost-effectiveness analyses; however, these analyses focus on how much health improvement new medications generate per dollar spent. As AD disproportionately affects older adults, women, racial and ethnic minority individuals, and individuals with lower socioeconomic and educational levels, it is critical to also examine the health equity outcomes of treatment. To estimate the health equity impact of a hypothetical disease-modifying treatment for early AD in the US and to examine targeted policies to mitigate health care disparities. This economic evaluation, which used a distributional cost-effectiveness analysis, was conducted from June 16, 2022, to January 11, 2024. The study included subgroups defined by race and ethnicity and by social vulnerability quintiles in the US. A hypothetical disease-modifying treatment compared with best supportive care. The main outcomes were population-level quality-adjusted life-years (QALYs), lifetime costs, and net health benefits. The social welfare impact and change in health inequality were estimated using the Atkinson index. The distributional cost-effectiveness analysis simulated 316 037 100 individuals from the US population, including 25 subgroups defined by 5 categories of race and ethnicity and population quintiles of social vulnerability, with the fifth quintile representing the most socially vulnerable group. At an opportunity cost benchmark of $150 000 per QALY, treatment was associated with improved population health, adding 28 197 QALYs per year to the US population. Accounting for health inequality preferences (using an aversion level of 11, based on an Atkinson inequality aversion parameter that can range from 0 to infinity, with higher values assigning greater weight to health gains that accrue to the population with the lowest lifetime quality-adjusted life expectancy), treatment was associated with a 0.009% reduction in existing population health inequalities annually. Scenario analyses examining earlier and expanded treatment access suggested a population health improvement of up to 221 358 QALYs. The findings of this economic evaluation suggest that treatment for AD could improve population health and health equity. Policies to enable earlier diagnosis and treatment initiation, as well as expanded access to treatment, may further improve treatment and health equity impacts.

Unmasking population undercounts, health inequities, and health service access barriers across Indigenous populations in urban Ontario

ObjectivesOur Health Counts (OHC) methods are designed to address gaps in urban-based Indigenous health information. In partnership with local Indigenous health service providers, we have successfully implemented OHC in six Ontario cities. The aim of this study is to summarize findings regarding Indigenous population undercount, health inequities, and health service access barriers across study sites.MethodsWe estimated Indigenous population size using OHC census participation survey responses and a multiplier approach. Health inequities between Indigenous populations and overall populations in each city were examined using respondent-driven sampling (RDS), adjusted OHC survey results, and existing public data. Measures included health status outcomes; determinants of health; barriers to health service access, including discrimination by health service providers; and unmet health needs.ResultsIndigenous social networks were strong and extensive, and the urban populations demonstrate resilience and cultural continuity across multiple measures. Self-reported rates of census participation for Indigenous populations were markedly lower than those for the general population in each city, and OHC Indigenous population size estimates were consistently 2‒4 times higher than reported in the census. Indigenous to general population health inequities cut across measures of chronic disease, determinants of health, and unmet health needs. Indigenous populations experienced multiple barriers to health services access, including racial discrimination by health service providers.ConclusionThe Canadian census appears to markedly underestimate Indigenous population size in urban areas. Indigenous health inequities and service access barriers are striking and cross-cutting. Timely adaptation of health policies, services, and funding allocations in response to these findings is recommended.

Gun violence exposure and population health inequality: a conceptual framework

This essay establishes a conceptual framework to understand how direct, secondar and community exposures to gun violence converge to influence population health. Our framework asserts that persistent gun violence in...

Using existing data to support the CYP diabetes healthcare community to fully understand their patient population and tackle health inequalities in line with NHSE CORE20PLUS5

Using existing data to support the CYP diabetes healthcare community to fully understand their patient population and tackle health inequalities in line with NHSE CORE20PLUS5

Justice, Equity, Diversity, and Inclusion-Related Curricular Elements in Entry-Level Physical Therapist Education: A Delphi Study.

The purpose of this Delphi study was to determine whether experts in justice, equity, diversity, and inclusion (JEDI) in the field of physical therapy could achieve consensus on the key JEDI-related curricular content topics to be included in entry-level physical therapist education. Inequities exist at all levels of health care for historically underserved populations, including referrals, access, and quality of physical therapy services. The physical therapy field is facing challenges and opportunities in how to best prepare providers to address individual, community, and population health inequities. There is a lack of consensus in physical therapist education regarding essential curricular content related to justice, equity, diversity, inclusion, and antiracism. Eighty-four experts in JEDI in the physical therapy profession were invited through email to participate in the Delphi process. A Delphi survey brought together 39 identified experts in justice, equity, diversity, and inclusion within the field of physical therapy to reach consensus on key JEDI-related curricular topics in physical therapist education. In the first-round survey, participants answered an open-ended question: "What JEDI-related curricular content should be included in entry-level physical therapist education?" The work team coded these free-text responses to populate an initial list of curricular elements. Over 2 subsequent rounds of surveys, the experts came to a consensus on which curricular elements should be addressed within physical therapist education. Nineteen experts completed all survey rounds. In round I, coding of the expert group's responses generated 61 initial JEDI-related curricular elements. By round III, the group refined the list to 43 curricular elements; 41 of the 43 (95%) elements garnered 94% or higher consensus. The expert group deemed 30 of the elements "entry-level" content and 13 as more "advanced practice" topics. Experts had a strong consensus on key JEDI-related curricular elements that physical therapist education programs should include to best prepare providers to improve the health of society. Future scholarship will explore recommendations for how physical therapist education programs might prioritize and implement JEDI-related content.

Critical Feminist Epidemiology in Action: Reflections from a Multidisciplinary Partnership Between Mujeres Unidas y Activas and Academic Researchers.

Critical feminist research addresses social inequities, encourages equitable partnerships between researchers and participants, and acknowledges that research can be inherently political. Building upon critical feminist research practices, community-based participatory research, and social and structural epidemiology, we propose the approach of critical feminist epidemiology. A critical feminist epidemiology approach can study community and population health inequities with an eye towards identifying interventions that reduce inequities, through research processes that center the lived experiences of people from minoritized genders. We describe how our interdisciplinary, community-led team used a critical feminist epidemiology approach for an applied public health research project. Mujeres Unidas y Activas, a community organizing non-profit led by and for Latina and Indigenous immigrant women, partnered with academic researchers to conduct community-led research around how their approach to building community power affected the health and wellbeing of organization members and their families. Critical feminist epidemiology is a promising approach for conducting research that is grounded in and relevant to the lives of women and gender expansive people. Building upon social epidemiology and community-based participatory research, critical feminist epidemiology can be a useful research approach to generate novel evidence to inform action towards health equity for communities and populations.

Implications of child poverty reduction targets for public health and health inequalities in England: a modelling study between 2024 and 2033.

We investigated the potential impacts of child poverty (CP) reduction scenarios on population health and health inequalities in England between 2024 and 2033. We combined aggregate local authority-level data with published and newly created estimates on the association between CP and the rate per 100 000 of infant mortality, children (aged <16) looked after, child (aged <16) hospitalisations for nutritional anaemia and child (aged <16) all-cause emergency hospital admissions. We modelled relative, absolute (per 100 000) and total (per total population) annual changes for these outcomes under three CP reduction scenarios between 2024 and 2033-low-ambition (15% reduction), medium-ambition (25% reduction) and high-ambition (35% reduction)-compared with a baseline CP scenario (15% increase). Annual changes were aggregated between 2024 and 2033 at national, regional and deprivation (IMD tertiles) levels to investigate inequalities. All CP reduction scenarios would result in substantial improvements to child health. Meeting the high-ambition reduction would decrease total cases of infant mortality (293; 95% CI 118 to 461), children looked after (4696; 95% CI 1987 to 7593), nutritional anaemia (458, 95% CI 336 to 574) and emergency admissions (32 650; 95% CI 4022 to 61 126) between 2024 and 2033. Northern regions (eg, North East) exhibited the greatest relative and absolute benefit. The most deprived tertile would experience the largest relative, absolute and total benefit; under high-ambition reduction, total infant mortality cases were predicted to fall by 126 (95% CI 51 to 199) in the most deprived tertile compared with 71 (95% CI 29 to 112) in the least between 2024 and 2033. Achieving reductions in CP could substantially improve child health and reduce health inequalities in England.

Social entrepreneurship and public health nursing knowledge: Opportunities for innovating nursing education in population health

Explore opportunities for re-invigorating public health nursing through social entrepreneurship education in nursing-business partnerships in U.S. universities. Reviewed programs in nursing/business school partnerships from Carnegie-classified R1 Universities. Identified appropriate coursework. Of 96 identified nursing schools, eight had business school partnerships, providing 12 programs. Most programs (n=11) targeted graduate students and addressed core competencies for entrepreneurship. Five business schools had entrepreneurship expertise. Five nursing schools had PHN expertise. Three programs included population health competencies. Despite missed opportunities for advancing social entrepreneurship education among undergraduate and graduate nursing students, existing curricular offerings in the partnerships provide promise. Business/nursing partnerships and PHN knowledge can stimulate the preparation and agency of nurses in addressing population health inequities.

The embodiment of exclusionary displacement pressure: Intersections of housing insecurity and mental health in a Hispanic/Latinx immigrant neighborhood

Gentrification, growing income inequality, urban development, and the affordable housing crisis necessitate understanding the impact of the concern of displacement on health - prior to or even in the absence of a displacement event. In this paper, I use the term "exclusionary displacement pressure" to unify the literature on exclusionary displacement and displacement pressure, highlighting the disproportionate and inequitable impacts of displacement pressure among communities of color. Through following 35 residents over 2.5-years (2019-2022) in one predominantly low-income Hispanic/Latinx immigrant neighborhood in Denver, Colorado, I examine how exclusionary displacement pressure shapes their health and wellbeing over time. Through paying attention to how participants' lived experience is shaped by structural vulnerability (e.g. lack of documentation status, inadequate work, limited access to safety net systems), I identify how exclusionary displacement pressure is constantly internalized and responded to as a unique embodied health experience, wearing on individuals over time and reproducing population health inequities. The framework of embodied health experiences captures the wide range of health-related impacts, from diagnosable health conditions to idioms of distress, using participant's own language of suffering to express how they were feeling, battling, and enduring the pressure. Theorizing on structural vulnerability within specific subpopulations with intersecting identities, such as low-income immigrant Hispanic/Latinx communities, provides a bottom-up refinement to existing theories of embodied health. Understanding the place-health experiences of individuals in changing neighborhoods over time is also critically important to define time points at which context-specific supports and interventions are appropriate.

Investigating the Black Birth Experience: A Race-Stratified Analysis of Preterm Birth Risk and Exposure to Metropolitan Statistical Area-Level Police-Related Deaths, US 2018–2019

Police-related violence may be a source of chronic stress underlying entrenched racial inequities in reproductive health in the USA. Using publicly available data on police-related fatalities, we estimated total and victim race-specific rates of police-related fatalities (deaths per 100,000 population) in 2018–2019 for Metropolitan Statistical Areas (MSA) and counties within MSAs in the USA. Rates were linked to data on live births by maternal MSA and county of residence. We fit adjusted log-Poisson models with generalized estimating equations and cluster-robust standard errors to estimate the relative risk of preterm birth associated with the middle and highest tertiles of police-related fatalities compared to the lowest tertile. We included a test for heterogeneity by maternal race/ethnicity and additionally fit race/ethnicity-stratified models for associations with victim race/ethnicity-specific police-related fatality rates. Fully adjusted models indicated significant adverse associations between police-related fatality rates and relative risk of preterm birth for the total population, non-Hispanic Black, and non-Hispanic White groups separately. Results confirm the role of fatal police violence as a social determinant of population health outcomes and inequities, including preterm birth.

Estimating quality-adjusted life expectancy (QALE) for local authorities in Great Britain and its association with indicators of the inclusive economy: a cross-sectional study

ObjectivesQuantifying area-level inequalities in population health can help to inform policy responses. We describe an approach for estimating quality-adjusted life expectancy (QALE), a comprehensive health expectancy measure, for local authorities...

Identifying newborn discharge to child protective services: Comparing discharge codes from birth hospitalization records and child protection case files

Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS. Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation). Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns. Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status.

Transferable lessons learned from improving health literacy responsiveness in Dutch rheumatology care

Abstract Background Health literacy difficulties among (groups of) individuals represent a significant public health challenge. Improving health literacy responsiveness of systems and services could reduce health inequalities in communities and patient populations. Methods We conducted a mixed-methods study to improve health literacy responsiveness in three Dutch rheumatology centres, using the OPtimising HEalth LIteracy and Access (Ophelia) approach. Patients and health professionals were involved in an inclusive needs assessment (n = 895 and 39, respectively) and co-design consultations to identify local solutions (n = 14 and 38, respectively). Based on all steps, we formulated transferable lessons learned (outcome-related or process-related) for public health and health care. Results Outcome-related lessons: a mixed-methods Ophelia approach was successful in identifying health literacy challenges and 175 potential solutions. Challenges are similar between disease groups and centres, but require solutions specific to the local context. Recognising challenges at the point of care is difficult. For a healthcare service to be responsive to health literacy needs, increased awareness alone is not enough; it will require a conscious actions and systemic change at multiple levels, including training. Process-related lessons: prerequisites for a successful health literacy responsiveness project include using multidimensional measurements, an inclusive participatory approach with all stakeholders, collaboration with experts in a community of practice, and strong project governance. Conclusions The Ophelia project in rheumatology care was successful in its aims of finding solutions to improve health literacy responsiveness. Public health and healthcare organisations should consider improving their health literacy responsiveness using a grassroots co-design approach. However, project success will depend on the quality of its governance; future programmes should follow a systematic approach. Key messages • Using a grassroots co-design approach such as Ophelia can help identify locally relevant solutions to health literacy challenges and support organisational efforts to reduce health inequalities. • Successfully improving health literacy responsiveness requires, at minimum, inclusion of people with most complex health literacy challenges, strong project governance, and stakeholder engagement.