Increase Health Inequalities Research Articles

Trends in Health and Mortality Inequalities in the United States

Recent literature has documented a widening gap in mortality in the United States between individuals with high socioeconomic status (SES) and low SES. An important question is whether this trend will continue. In this paper we document trends and inequalities in the health status at ages 54 to 60 of individuals born between 1934 and 1959. We do so by using detailed subjective and objective measures of health in the Health and Retirement Study to examine contributors to mortality inequality and to forecast life expectancy. We found that the health of individuals 54 to 60 years old has generally declined in recent years. In particular, we found large increases in obesity rates, notable increases in diabetes and reported levels of pain, and lower self-reported health and subjective survival probabilities. We also found strong evidence for increasing health inequalities, as the health of individuals in these cohorts with high SES remained largely stable while that for individuals with low SES declined. When we forecast life expectancies using these predictor variables, as well as gender- and SES-specific time trends, we predict overall life expectancy to increase further. However, the increase is concentrated among high SES individuals, suggesting growing mortality inequality. Results are similar among men and women.

Crossing the Digital Divide in Online Self-Management Support: Analysis of Usage Data From HeLP-Diabetes.

BackgroundDigital health is increasingly recognized as a cost-effective means to support patient self-care. However, there are concerns about whether the “digital divide,” defined as the gap between those who do and do not make regular use of digital technologies, will lead to increased health inequalities. Access to the internet, computer literacy, motivation to use digital health interventions, and fears about internet security are barriers to use of digital health interventions. Some of these barriers disproportionately affect people of older age, black or minority ethnic background, and low socioeconomic status. HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a theoretically informed online self-management program for adults with type 2 diabetes, was developed to meet the needs of people from a broad demographic background.ObjectiveThis study aimed to determine whether there was evidence of a digital divide when HeLP-Diabetes was integrated into routine care. This was achieved by (1) comparing the characteristics of people who registered for the program against the target population (people with type 2 diabetes in inner London), (2) comparing the characteristics of people who registered for the program and used it with those who did not use it, and (3) comparing sections of the website visited by different demographic groups.MethodsA retrospective analysis of data on the use of HeLP-Diabetes in routine clinical practice in 4 inner London clinical commissioning groups was undertaken. Data were collected from patients who registered for the program as part of routine health services.. Data on gender, age, ethnicity, and educational attainment were collected at registration, and data on webpage visits (user identification number, date, time, and page visited) were collected automatically by software on the server side of the website.ResultsThe characteristics of people who registered for the program were found to reflect those of the target population. The mean age was 58.4 years (SD=28.0), over 50.0% were from black and minority ethnic backgrounds, and nearly a third (29.8%) had no qualifications beyond school leaving age. There was no association between demographic characteristics and use of the program, apart from weak evidence of less use by the mixed ethnicity group. There was no evidence of the differential use of the program by any demographic group, apart from weak evidence for people with degrees and school leavers being more likely to use the “Living and working with diabetes” (P=.03) and “Treating diabetes” (P=.04) sections of the website.ConclusionsThis study is one of the first to provide evidence that a digital health intervention can be integrated into routine health services without widening health inequalities. The relative success of the intervention may be attributed to integration into routine health care, and careful design with extensive user input and consideration of literacy levels. Developers of digital health interventions need to acknowledge barriers to access and use, and collect data on the demographic profile of users, to address inequalities.

E-cigarette use in England 2014-17 as a function of socio-economic profile.

E-cigarettes have the potential either to decrease or increase health inequalities, depending on socio-economic differences in their use and effectiveness. This paper estimated the associations between socio-economic status (SES) and e-cigarette use and examined whether these associations changed between 2014 and 2017. A monthly repeat cross-sectional household survey of adults (16+) between January 2014 and December 2017. This time-period was chosen given that the prevalence of e-cigarette use stabilized in England in late 2013. England. Participants in the Smoking Toolkit Study, a monthly household survey of smoking and smoking cessation among adults (n=81 063; mean age=48.4years, 49% were women) in England. Subsets included past year smokers (n=16 232; mean age=42.8, 46% women), smokers during a quit attempt (n=5305, mean age=40.6, 49% women) and long-term ex-smokers (n=13 562, mean age=59.3, 44% women). The outcome measure for the analyses was current e-cigarette use. We also included smokers during a quit attempt where use of an e-cigarette during the most recent quit attempt was the outcome measure. Social grade based on occupation was the SES explanatory variable, using the National Readership Survey classification system of AB (higher and intermediate managerial, administrative and professional), C1 (supervisory, clerical and junior managerial, administrative and professional), C2 (skilled manual workers), D (semi-skilled and unskilled manual workers) and E (state pensioners, casual and lowest-grade workers, unemployed with state benefits only). The analyses were stratified by year to assess the changes in these associations over time. Among past-year smokers, lower SES groups had lower overall odds of e-cigarette use compared with the highest SES group AB (D: odds ratio=0.53, 95% confidence interval=0.40-0.71; E: 0.67, 0.50-0.89). These differences in e-cigarette use reduced over time. The use of e-cigarettes during a quit attempt showed no clear temporal or socio-economic patterns. Among long-term ex-smokers, use of e-cigarettes increased from 2014 to 2017 among all groups and use was more likely in SES groups C2 (2.03, 1.08-3.96) and D (2.29, 1.13-4.70) compared with AB. From 2014 to 2017 in England, e-cigarette use was greater among smokers from higher compared with lower socio-economic status (SES) groups, but this difference attenuated over time. Use during a quit attempt was similar throughout SES groups. Use by long-term ex-smokers increased over time among all groups and was consistently more common in lower SES groups.

Socioeconomic inequalities in health during the Great Recession: A scoping review of the research literature.

Aims: The so-called 'Great Recession' in Europe triggered widespread concerns about population health, as reflected by an upsurge in empirical research on the health impacts of the economic crisis. A growing body of empirical studies has also been devoted to socioeconomic inequalities in health during the Great Recession. The aim of the current study is to summarise this health inequality literature by means of a scoping review. Methods: We have performed a scoping review of the research literature (English language) published in the years 2012-2017. Only empirical papers with (a) health status measured on the individual level, (b) information on socioeconomic position (i.e. employment status, educational level, income/wealth, and/or occupational class), and (c) data from European countries in both pre- and post-crisis years were considered relevant. In total, 49 empirical studies fulfilled these inclusion criteria. Results: The empirical findings in the 49 included studies predominantly show that socioeconomic inequalities in health either increased or remained stable from pre- to post-crisis years. Two-thirds (65%) of the studies found evidence of either increasing or partially increasing health inequalities. Thus, people in lower socioeconomic strata fared worse overall in terms of health during the Great Recession, compared to people with higher socioeconomic status. Conclusions: The Great Recession in Europe tends to be followed by increasing socioeconomic inequalities in health. Policymakers should take note of this finding. Widening socioeconomic inequalities in health is a major cause of concern, in particular if health deterioration among 'vulnerable groups' is caused by accelerating cumulative disadvantages.

The Causes of the Causes: A Systematic Review of Reviews of the Impact of Political Economy on Population Health

Background: The relationship between political economy and population health is only partially understood with no systematic review of research available. Our systematic review of reviews explores the conclusions, extent, quality, and research gaps concerning political economy and health outcomes within and between populations over time. Methods: We undertook a systematic review of reviews. The exposure of interest was any aspect of political economy defined as a difference or change in: policy, law or rules; economic conditions; institutions or social structures, including; politics, power or conflict. Relevant outcomes were any overall measure of population health, but not specific health conditions, diseases or causes of death. Research databases and the grey literature were searched, included studies critically appraised and synthesised narratively. Results: A total of 4,912 citations were identified of which 58 reviews were identified as relevant. Only 10 were assessed as high or very high quality, with marked variation in the quality of the underlying primary studies. Many reviews assessed similar questions relating to the impact of economic recession, income inequality, welfare state type, some aspects of employment policy, urban regeneration, housing, healthcare policy and trade. Social democratic welfare states and states with greater public spending seem to have better overall population health, whilst neoliberal restructuring seems to be associated with increased health inequalities. Greater income inequality is associated with lower self-rated health and higher mortality. Fair trade policies, extensions to compulsory education provision, microfinance initiatives in low income countries, health and safety policy, improved access to healthcare, and high quality affordable housing are all found to have positive impacts on population health. Conclusion: Political economy and public policy are important influences on population health. Generally, countries with social democratic institutional arrangements, higher public spending, lower income inequalities and policy to ensure safe workplaces and access to education and housing have populations with better health. Providing a nuanced and contextualised understanding of these factors for policymakers and the public could have marked beneficial health impacts through improved public policy making. Funding Statement: This work was funded by NHS Health Scotland through part payment of PhD fees for GM by NHS Health Scotland. FP is funded by the Medical Research Council UK and the Chief Scientist’s Office Scottish Government (MC_UU_12017/13 and SPHSU13). The funders had no part in interpreting the findings. No other specific funding was received for this work. Declaration of Interests: The authors declare they have no competing interests.

Equity Weights for Socioeconomic Position: Two Methods—Survey of Stated Preferences and Epidemiological Data

BackgroundThere is an implicit equity approach in cost-effectiveness analysis that values health gains of socioeconomic position groups equally. An alternative approach is to integrate equity by weighting quality-adjusted life-years according to the socioeconomic position group. ObjectivesTo use two approaches to derive equity weights for use in cost-effectiveness analysis in Australia, in contexts in which the use of the traditional nonweighted quality-adjusted life-years could increase health inequalities between already disadvantaged groups. MethodsEquity weights derived using epidemiological data used burden of disease and mortality data by Socio-Economic Indexes for Areas quintiles from the Australian Institute of Health and Welfare. Two ratios were calculated comparing quintile 1 (lowest) to the total Australian population, and comparing quintile 1 to quintile 5 (highest). Preference-based weights were derived using a discrete choice experiment survey (n = 710). Respondents chose between two programs, with varying gains in life expectancy going to a low- or a high-income group. A probit model incorporating nominal values of the difference in life expectancy was estimated to calculate the equity weights. ResultsThe epidemiological weights ranged from 1.2 to 1.5, with larger weights when quintile 5 was the denominator. The preference-based weights ranged from 1.3 (95% confidence interval 1.2–1.4) to 1.8 (95% confidence interval 1.6–2.0), with a tendency for increasing weights as the gains to the low-income group increased. ConclusionsBoth methods derived plausible and consistent weights. Using weights of different magnitudes in sensitivity analysis would allow the appropriate weight to be considered by decision makers and stakeholders to reflect policy objectives.

The attitude of healthcare professionals plays an important role in the uptake of diabetes self-management education: analysis of the Barriers to Uptake of Type 1 Diabetes Education (BUD1E) study survey.

To explore reasons for the poor uptake of accredited diabetes self-management education (DSME) in adults with Type 1 diabetes. The study was set in an urban population in South London, UK. A cross sectional survey gathered demographic, diabetes service-use data, psychological scores and reasons for non-attendance at locally-available DSME. In addition, 56 healthcare professionals were surveyed. Responses to surveys were returned by 496 adults with Type 1 diabetes (33% response rate), of whom 263 had attended DSME (53%). Multivariable analysis adjusted for significant variables identified four key variables influencing attendance. Non-attendance was associated with men (OR 0.55 CI 0.37-0.84, p = 0.005), lower educational attainment (OR 0.45 CI 0.28-0.73, p = 0.001), higher glycated haemoglobin (OR 1.74 CI 1.03-2.94, p = 0.04) and healthcare professional encouragement to attend (OR 1.7 CI 1.28-2.3, p = 0.001). The most frequently reported barriers to attendance were work (37%) and time (14%) commitments. Only 49% of healthcare professionals (HCPs) correctly identified the most likely barriers. Those HCPs who had observed courses believed more in their efficacy, with higher uptake within their clinic population. Social determinants of health, particularly educational attainment and gender, increase health inequalities by influencing decisions to attend evidence-based education courses. Healthcare professional communication is paramount to encourage attendance, and observation of a course may facilitate this.

Exploring the experience of a ‘diagnosis’ of pre-diabetes and factors influencing uptake of a lifestyle intervention programme in areas of socio-economic deprivation

BackgroundPeople living in socio-economically deprived areas are at higher risk of developing diabetes and have worse health outcomes when they do. A Diabetes Prevention Programme (DPP) is being rolled out across England with eligibility linked to a HbA1c screening test to ‘diagnose’ pre-diabetes (42–47 mmol/mol). The DPP is a lifestyle intervention offering a 9-month individualised programme aiming to reduce progression to diabetes, through optimization of diet and physical activity to achieve weight loss. Previous studies suggest that patients from lower socioeconomic groups are less likely to engage with and benefit from lifestyle interventions. The DPP may increase health inequalities unless barriers to engagement are considered.AimTo explore patients’ understanding of and reactions to a ‘diagnosis’ of pre-diabetes and to identify the barriers and facilitators to uptake of a lifestyle intervention programme in a socio-economically deprived, pre-diabetic population.MethodA literature review will inform development of a topic guide. A purposive sample of ‘pre-diabetic’ patients who have been offered referral to the DPP and are registered at practices within the Yorkshire and Humber ‘Deep End’ Research Cluster will be invited to participate in a semi-structured interview study. Data will be systematically analysed to identify emerging concepts and themes. Interviews will continue until data saturation is reached. A thematic framework will be developed, justified by and linked to the interview data.ResultsHealth literacy, relationship with healthcare provider and level of activation all influence how the diagnosis is received and the decision to engage with the programme. Practical barriers to engaging with the programme exist but are secondary to other factors.ConclusionA ‘diagnosis of ‘pre-diabetes’ provokes healthy lifestyle change without causing anxiety. Healthcare professionals have considerable influence in determining whether a patient engages with the DPP.

The role of health literacy in explaining the association between educational attainment and the use of out-of-hours primary care services in chronically ill people: a survey study

BackgroundLow socioeconomic status (SES) is persistently associated with poor health and suboptimal use of healthcare services, and more unplanned healthcare use. Suboptimal use of emergency and acute healthcare services may increase health inequalities, due to late diagnosis or lack of continuity of care. Given that health literacy has been associated with healthcare utilisation and with education attainment, we sought to explore whether health literacy is related to the use of out-of-hours (OOH) Primary Care Services (PCSs). Additionally, we aimed to study whether and to what extent health literacy accounts for some of the association between education and OOH PSC use.MethodsA survey including measures of education attainment, health literacy (assessed by means of the Dutch version of the nine-dimension Health Literacy Questionnaire) and use of PCS was conducted among a sample of adults diagnosed with (any) somatic chronic condition in the Netherlands (response 76.3%, n = 1811). We conducted linear and logistic regression analyses to examine associations between education level and PCS use in the past year. We performed mediation analyses to assess whether the association between education and PCS use was (partly) explained by different aspects of health literacy. We adjusted the models for patient characteristics such as age and morbidity.ResultsHigher education attainment was associated with higher scores on the health literacy aspects Appraisal of health information, and Navigating the healthcare system. Additionally, appraisal and navigating the healthcare system partially accounted for educational differences in PCS use. Finally, higher appraisal of health information scores were associated with higher PCS utilisation.ConclusionSeveral aspects of health literacy were demonstrated to relate to PCS use, and partly accounted for educational differences herein. Accordingly, developing health literacy within individuals or communities may help to reduce inappropriate PCS use among people with low education.

Promoting inequality? Self-monitoring applications and the problem of social justice

When it comes to improving the health of the general population, mHealth technologies with self-monitoring and intervention components hold a lot of promise. We argue, however, that due to various factors such as access, targeting, personal resources or incentives, self-monitoring applications run the risk of increasing health inequalities, thereby creating a problem of social justice. We review empirical evidence for “intervention-generated” inequalities, present arguments that self-monitoring applications are still morally acceptable, and develop approaches to avoid the promotion of health inequalities through self-monitoring applications.

Mechanisms in endocrinology: Antipsychotic medication and type 2 diabetes and impaired glucose regulation.

There have been concerns about the effects of antipsychotics on weight gain and the development of type 2 diabetes (T2DM). This article aims to provide an up-to-date review on the evidence addressing this issue and the practical implications for the management of people taking antipsychotics in the context of T2DM. We carried out searches on MEDLINE/PUBMED and the ClinicalTrials.gov website in August 2017 using the terms 'antipsychotic' and 'diabetes' or 'glucose' citing articles published after 2006 preferentially. Antipsychotics are associated with T2DM and are likely to exert a causal effect of uncertain magnitude. Children and adolescents appear especially vulnerable to these metabolic effects; as T2DM is not common in healthy younger people, the relative risk is more apparent. Antipsychotics act on glucose and insulin homeostasis in a variety of direct and indirect mechanisms. To reduce the increasing health inequalities among individuals with mental illness screening, monitoring and prevention of T2DM is important, as is improved diabetes care in this population. It remains unclear whether these antipsychotic medications exacerbate an underlying predisposition to the development of T2DM or have a direct effect. Potential risks need to be weighed up and balanced between improved and lasting mental health benefits and any detrimental physical health side effects. Achieving parity of esteem between mental and physical health is a worldwide priority if we wish to improve life expectancy and quality of life in people with severe mental illness.

European health inequality through the 'Great Recession': social policy matters.

This paper investigates the association between the Great Recession and educational inequalities in self-rated general health in 25 European countries. We investigate four different indicators related to economic recession: GDP; unemployment; austerity and a 'crisis' indicator signifying severe simultaneous drops in GDP and welfare generosity. We also assess the extent to which health inequality changes can be attributed to changes in the economic conditions and social capital in the European populations. The paper uses data from the European Social Survey (2002-2014). The analyses include both cross-sectional and lagged associations using multilevel linear regression models with country fixed effects. This approach allows us to identify health inequality changes net of all time-invariant differences between countries. GDP drops and increasing unemployment were associated with decreasing health inequalities. Austerity, however, was related to increasing health inequalities, an association that grew stronger with time. The strongest increase in health inequality was found for the more robust 'crisis' indicator. Changes in trust, social relationships and in the experience of economic hardship of the populations accounted for much of the increase in health inequality. The paper concludes that social policy has an important role in the development of health inequalities, particularly during times of economic crisis.

Neighbourhood food environments: food choice, foodscapes and planning for health.

The burden of obesity contributes to increasing health inequality, and placing healthcare systems under huge strain. The modern society could broadly be described to support unhealthful eating patterns and sedentary behaviour; also described as obesogenic. Obesity prevention and treatment has focused on educational and behavioural interventions, with limited overall success. A sustainable approach is to address the environments that promote less healthy eating and high energy intake as well as sedentary behaviour. Approaches which modify the environment have the potential to assist in the prevention of this complex condition. The present paper focuses on food environments within the context of obesogenic environments. Takeaway and fast food, a fixture of our diet, is usually nutrient poor and energy dense. A 'concentration effect' has been observed, where there is a clustering of fast food and takeaway outlets in more deprived areas. Access to food and intake are associated; however, there are methodological challenges in associating the effect of the food environment on obesity. While there is an imperfect evidence base relating to the role of the food environment in terms of the obesity crisis; policy, practice, civic society and industry must work together and take action now, where current evidence suggests a change. Shaping the environment to better support healthful eating decisions has the potential to be a key aspect of a successful obesity prevention intervention.

Devolution and the regional health divide: a longitudinal ecological study of 14 countries in Europe.

Greater regional devolution can reduce economic inequalities between regions; however, the impact on health inequalities is not clear. We investigated the association between changes over time in the level of devolution in European countries and regional economic and health inequalities. We used the proportion of government expenditure controlled by subnational levels of government as our measure of devolution in 14 European countries between 1995 and 2011. Fixed effects linear regression models were used to analyse trends in the level of devolution, trends in regional economic inequalities (Gini-coefficient) and trends in regional health inequalities (slope index) in life expectancy. Each additional percentage of government expenditure managed at subnational level reduced the Gini-coefficient of regional GDP by -0.17 points (95% CI: -0.33 to -0.01; P = 0.04). However, it increased the slope index of regional life expectancy by 23 days (95% CI: -2 to 48; P = 0.07). When trends in regional economic inequalities were controlled for, as a potential mediator-increased devolution-was significantly associated with an increase in health inequalities between regions (P = 0.01). Increased devolution does not appear to reduce regional health inequalities-even when it reduces regional economic inequalities-and it could be associated with increased health inequalities.

Prior Authorization as a Potential Support of Patient-Centered Care

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident.

Interpreting population reach of a large, successful physical activity trial delivered through primary care

BackgroundFailure to include socio-economically deprived or ethnic minority groups in physical activity (PA) trials may limit representativeness and could lead to implementation of interventions that then increase health inequalities. Randomised intervention trials often have low recruitment rates and rarely assess recruitment bias. A previous trial by the same team using similar methods recruited 30% of the eligible population but was in an affluent setting with few non-white residents and was limited to those over 60 years of age.MethodsPACE-UP is a large, effective, population-based walking trial in inactive 45-75 year-olds that recruited through seven London general practices. Anonymised practice demographic data were available for all those invited, enabling investigation of inequalities in trial recruitment. Non-participants were invited to complete a questionnaire.ResultsFrom 10,927 postal invitations, 1150 (10.5%) completed baseline assessment. Participation rate ratios (95% CI), adjusted for age and gender as appropriate, were lower in men 0.59 (0.52, 0.67) than women, in those under 55 compared with those ≥65, 0.60 (0.51, 0.71), in the most deprived quintile compared with the least deprived 0.52 (0.39, 0.70) and in Asian individuals compared with whites 0.62 (0.50, 0.76). Black individuals were equally likely to participate as white individuals. Participation was also associated with having a co-morbidity or some degree of health limitation. The most common reasons for non-participation were considering themselves as being too active or lack of time.ConclusionsConducting the trial in this diverse setting reduced overall response, with lower response in socio-economically deprived and Asian sub-groups. Trials with greater reach are likely to be more expensive in terms of recruitment and gains in generalizability need to be balanced with greater costs. Differential uptake of successful trial interventions may increase inequalities in PA levels and should be monitored.Trial registrationISRCTN.com ISRCTN98538934. Registered 2nd March 2012.

Distributive equity in the real world: would targeting the National Health Service Health Check programme to deprived groups be more cost effective?

BackgroundThe effectiveness of the English National Health Service Health Check (HC) programme remains uncertain. We therefore modelled the cost-effectiveness and distributive equity impact using real-world data from Liverpool, a deprived city in the UK with high incidence of cardiovascular disease. MethodsWe built a dynamic, stochastic microsimulation model in R, extending our previously validated IMPACTNCD model, populated with a synthetic population mirroring the Liverpool population demographics and cardiovascular disease risk factors. Outcomes included stroke and coronary heart disease prevalence, mortality, quality-adjusted life-years (QALYs), and health and social care costs. Annualised costs and QALYs were derived from a range of sources from year 2000–11 on the basis of a pragmatic review of previous models. We compared three scenarios against a no health checks baseline scenario: current HC implementation; HC with increased rates of attendances, prescribing, and lifestyle advice; and HC targeted to the most deprived quintile of the population. The changes happened from 2017, and we measured the time until each scenario became cost effective. We used deprivation-adjusted and unadjusted opportunity costs (reflecting how a greater share of displaced health benefits may fall to deprived groups), and different health production costs (£633, £13 000, £20 000) from the research literature. FindingsEach scenario modelled a population of 258 000 people aged 30–84 years. Scenarios did not become cost effective until after 2030. The overall cumulative incremental cost-effectiveness ratio per QALY compared with no Health Checks over the 30 years from 2011 to 2040 was about £17 600 for the current scenario, £13 000 for the increased scenario, and £3000 for the targeted scenario. In a probabilistic sensitivity analysis, the 95% uncertainty intervals for each scenario crossed over from being dominant to dominated, indicating uncertain cost-effectiveness. Health inequalities would increase under the current scenario but would decrease under the targeted scenario. The equity gradient of the increased scenario changed from 0·19 to −0·05 when health production costs were adjusted for deprivation. All scenarios were sensitive to the choice of health production cost. InterpretationThe current implementation of the NHS Health Check programme in Liverpool will probably increase health inequalities whereas a targeted approach may be more cost-effective and reduce inequalities. FundingLiverpool City Council.

Potential barriers in healthcare access of the elderly population influenced by the economic crisis and the troika agreement: a qualitative case study in Lisbon, Portugal

BackgroundThe recent economic and financial crisis in Portugal urged the Portuguese Government in April 2011 to request financial assistance from the troika austerity bail out program to get aid for its government debt. The troika agreement included health reforms and austerity measures of the National Health Service (NHS) in Portugal to save non-essential health care costs. This research aimed to identify potential barriers among the elderly population (aged 65 and above) to healthcare access influenced by the economic crisis and the troika agreement focussing on the Memorandum of Understanding on Specific Economic Policy Conditionality (MoU) in Lisbon metropolitan area, Portugal.MethodsThe qualitative study is including 13 semi-structured interviews of healthcare experts, municipality authority, health care providers, negotiator of the troika agreement, hospital managers, health economists and elderly. A content analysis was performed to evaluate the interviews applying Nvivo2011 software. The barriers identified were clustered towards the five areas of the ‘Conceptual framework on health care access’ by Levesque et al. (Int J Equity Health 12:18, 2013).ResultsHealthcare access for the elderly was found inadequate in four areas of the framework: availability; appropriateness; approachability; and affordability. The fifth area on acceptability was not identified since the study neither followed a gender nor ethnic specific purpose. The main identified barriers were: current financial situation and pension cuts; insufficient provision and increased user fees in primary care; inadequate design and availability of hospital care service; lack of long-term care facilities; increased out-of-pocket-payment on pharmaceuticals; limitations in exemption allowances; cuts in non-emergent health transportation; increased waiting time for elective surgery; and poor unadapted housing conditions for elderly.ConclusionsThe health reforms and health budget cuts in the MoU implemented as part of the troika agreement have been associated with increasing health inequalities in access to healthcare services for the elderly population. The majority of responses disclosed an increasing deficiency across the entire National Health Service (NHS) to collaborate, integrate and communicate between the different healthcare sectors for providing adequate care to the elderly. An urgent necessity of restructuring the health care system to adapt towards the elderly population was implied.

Healthcare in the news media: The privileging of private over public

This article reports on a discourse analysis of the representation of healthcare in the print news media, and the way this representation shapes perspectives of healthcare. We analysed news items from six major Australian newspapers over a three-year time period. We show how various framing devices promote ideas about a crisis in the current public healthcare system, the existence of a precarious balance between the public and private health sectors, and the benefits of private healthcare. We employ Bourdieu’s concepts of field and capital to demonstrate the processes through which these devices are employed to conceal the power relations operating in the healthcare sector, to obscure the identity of those who gain the most from the expansion of private sector medicine, and to indirectly increase health inequalities.

Considering health equity when moving from evidence-based guideline recommendations to implementation: a case study from an upper-middle income country on the GRADE approach.

The availability of evidence-based guidelines does not ensure their implementation and use in clinical practice or policy making. Inequities in health have been defined as those inequalities within or between populations that are avoidable, unnecessary and also unjust and unfair. Evidence-based clinical practice and public health guidelines (‘guidelines’) can be used to target health inequities experienced by disadvantaged populations, although guidelines may unintentionally increase health inequities. For this reason, there is a need for evidence-based clinical practice and public health guidelines to intentionally target health inequities experienced by disadvantaged populations. Current guideline development processes do not include steps for planned implementation of equity-focused guidelines. This article describes nine steps that provide guidance for consideration of equity during guideline implementation. A critical appraisal of the literature followed by a process to build expert consensus was undertaken to define how to include consideration of equity issues during the specific GRADE guideline development process. Using a case study from Colombia we describe nine steps that were used to implement equity-focused GRADE recommendations: (1) identification of disadvantaged groups, (2) quantification of current health inequities, (3) development of equity-sensitive recommendations, (4) identification of key actors for implementation of equity-focused recommendations, (5) identification of barriers and facilitators to the implementation of equity-focused recommendations, (6) development of an equity strategy to be included in the implementation plan, (7) assessment of resources and incentives, (8) development of a communication strategy to support an equity focus and (9) development of monitoring and evaluation strategies. This case study can be used as model for implementing clinical practice guidelines, taking into account equity issues during guideline development and implementation.