Intervention-generated Inequalities Research Articles

Equity and local health systems: a qualitative evaluation of the experiences of local health service leads during the first two years of the NHS Low Calorie Diet programme pilot

Background: Obesity and type 2 diabetes (T2DM) can both profoundly impact health and wellbeing. Their prevalence largely follows a social gradient. The National Health Service Low Calorie Diet programme in England aims to support people to achieve T2DM remission while also reducing health inequalities. We aimed to explore the experiences of local health service leads and identify barriers and facilitators in relation to the equitable mobilisation of the Low Calorie Diet programme. Methods: Twenty semi-structured interviews were completed with 24 locality leads across the first two years of the Low Calorie Diet programme. Interviewees were purposively sampled from the 10 localities who undertook the Low Calorie Diet programme pilot. Each interview explored a number of topics of interest, including referrals, training, communication, incentivisation, governance and engagement, before being subjected to a thematic analysis. Results: From the data, seven core themes were identified: COVID-19 and primary care capacity and engagement; methods of communication; approaches to training; approaches to incentivisation; approaches to referrals; barriers to referrals; and the importance of collaboration. COVID-19 presented a specific challenge to the mobilisation and delivery of the Low Calorie Diet programme; however, our findings demonstrate the large variation and differences in the approaches taken when delivering the programme across 10 geographically and demographically distinct pilot sites. We also identified a lack of a recognised approach or strategy to mobilisation and delivery support for the Low Calorie Diet programme, such as proportionate universalism, which is a social policy response to tackling health inequalities by ensuring that service delivery is equitable. Conclusions: Health inequalities remain a significant challenge, and health service leads have the potential to adopt an equity perspective from the start of programme mobilisation. In doing so, resources at their disposal can be managed equitably and can therefore contribute to efforts to reduce the potential occurrence of intervention-generated inequalities.

P043 Income-Related Health Inequality and Osteoarthritis Intervention Outcomes: a Cohort Study

Abstract Background/Aims Osteoarthritis (OA) management programmes have been lately developed to tackle the osteoarthritis burden. Though beneficial, OA management programmes can be less effective on people in lower socioeconomic positions and widen the possible pre-existing inequalities gap (‘intervention-generated inequalities’). In Sweden, an OA management programme was implemented in the national healthcare system, including exercise and education. Its results are recorded in the ‘Better Management of People with Osteoarthritis’ (BOA) register, one of the most extensive OA datasets worldwide. Hence, this study investigated the influence of this Swedish osteoarthritis management programme on income-related inequality. Methods A register-based study with data from the BOA register. We calculated Erreygers’ and Wagstaff’s concentration indices and how they changed throughout time. We considered the variables ‘Pain intensity’, ‘Self-efficacy‘, ‘Use of NSAIDs’ and ‘Desire for surgery’ at three-time points (baseline, after three and twelve months from the beginning of the programme). Concentration indices’ values range from -1 to + 1. Zero indicates no income inequality. A positive (or negative) sign indicates an unequal concentration of the variables of interest among those with higher (or lower) income. We used bootstrapping (1000 replications) to compute 95% confidence intervals for changes in the concentration indices from baseline. Results A total of 115,403 people with knee and hip OA were identified. ‘Pain intensity’ and ‘Desire for surgery’ were disproportionately concentrated among those with lower income at the baseline, while the opposite happened for ‘Use of NSAIDs’ and ‘Self-efficacy’ (Table 1). Income inequalities for ‘Pain intensity’, ‘Self-efficacy’ and ‘Desire for surgery’ widened following the programme, though their magnitude was small. Conversely, income-related inequality in the ‘Use of NSAIDs’ narrowed after attending the programme. Conclusion Considering the concentration indices’ values, people with lower income were already experiencing higher levels of pain and desire for surgery and lower levels of self-efficacy than their higher counterparts. This trend got even worse after attending the abovementioned programme. Instead, people with higher income were keener on using NSAIDs but attending this programme narrowed this gap. These results highlighted ‘intervention-generated inequalities’ in the BOA data. OA management programmes should be structured to reduce inequalities among people with different incomes. Disclosure S. Battista: None. A. Kiadaliri: None. M. Englund: None. T. Jönsson: None. K. Gustafsson: None. M. Testa: None. A. Dell'Isola: None.

Trauma and resilience informed research principles and practice: A framework to improve the inclusion and experience of disadvantaged populations in health and social care research.

Trauma, socio-economic, cultural and structural issues are associated with poor outcomes for most health conditions and may also make research participation difficult and onerous, perpetuating intervention-generated inequalities by generating evidence from those least in need. Trauma-informed and resilience-informed approaches to care may help address these concerns across health and social care research. These approaches take an empowerment-based response to adversity, and are suitable for integration and extension as Trauma and Resilience Informed Research Principles and Practice (TRIRPP) for studies beyond the topics of resilience and trauma. Four TRIRPP aims were identified: addressing the adversity context that may underpin the lives of research participants and the phenomenon under study; improving study accessibility and acceptability for individuals and populations facing adversity; recognising and addressing traumatisation in potential participants; and recognising and promoting resilience. Recommendations include interview participant control of recording devices, over-sampling of under-represented populations in population surveys, and actively seeking to engage disenfranchised individuals in patient and public involvement from design to dissemination. The practice of research has the power to address adversity and trauma or to perpetuate it at both an individual and a societal level. It is feasible and worthwhile to integrate trauma-informed and resilience-informed approaches across research topics and designs. Further work should extend the TRIRPP recommendations and evaluate their use.

A critique of the English national policy from a social determinants of health perspective using a realist and problem representation approach: the \u2018Childhood Obesity: a plan for action\u2019 (2016, 2018, 2019)

BackgroundThe UK government released Chapter 1 of the ‘Childhood Obesity: a plan for action’ (2016), followed by Chapter 2 (2018) and preliminary Chapter 3 was published for consultation in 2019 (hereon collectively ‘The Policy’). The stated policy aims were to reduce the prevalence of childhood obesity in England, addressing disparities in health by reducing the gap (approximately two-fold) in childhood obesity between those from the most and least deprived areas.MethodsCombining a realist approach with an analysis of policy discourses, we analysed the policies using a social determinants of health (SDH) perspective (focusing on socio-economic inequalities). This novel approach reveals how the framing of policy ‘problems’ leads to particular approaches and interventions.ResultsWhile recognising a social gradient in relation to obesity measures, we critique obesity problem narratives. The Policy included some upstream, structural approaches (e.g. restrictions in food advertising and the soft-drinks industry levy). However, the focus on downstream individual-level behavioural approaches to reduce calorie intake and increase physical activity does not account for the SDH and the complexity and contestedness of ‘obesity’ and pays insufficient attention to how proposals will help to reduce inequalities. Our findings illustrate that individualising of responsibility to respond to what wider evidence shows is structural inequalities, can perpetuate damaging narratives and lead to ineffective interventions, providing caution to academics, practitioners and policy makers (local and national), of the power of problem representation. Our findings also show that the problem framing in The Policy risks reducing important public health aims to encourage healthy diets and increase opportunities for physical activity (and the physical and mental health benefits of both) for children to weight management with a focus on particular children.ConclusionsWe propose an alternative conceptualisation of the policy ‘problem’, that obesity rates are illustrative of inequality, arguing there needs to be policy focus on the structural and factors that maintain health inequalities, including poverty and food insecurity. We hope that our findings can be used to challenge and strengthen future policy development, leading to more effective action against health inequalities and intervention-generated inequalities in health.

To Trust or to Think

People supported by AI-powered decision support tools frequently overrely on the AI: they accept an AI's suggestion even when that suggestion is wrong. Adding explanations to the AI decisions does not appear to reduce the overreliance and some studies suggest that it might even increase it. Informed by the dual-process theory of cognition, we posit that people rarely engage analytically with each individual AI recommendation and explanation, and instead develop general heuristics about whether and when to follow the AI suggestions. Building on prior research on medical decision-making, we designed three cognitive forcing interventions to compel people to engage more thoughtfully with the AI-generated explanations. We conducted an experiment (N=199), in which we compared our three cognitive forcing designs to two simple explainable AI approaches and to a no-AI baseline. The results demonstrate that cognitive forcing significantly reduced overreliance compared to the simple explainable AI approaches. However, there was a trade-off: people assigned the least favorable subjective ratings to the designs that reduced the overreliance the most. To audit our work for intervention-generated inequalities, we investigated whether our interventions benefited equally people with different levels of Need for Cognition (i.e., motivation to engage in effortful mental activities). Our results show that, on average, cognitive forcing interventions benefited participants higher in Need for Cognition more. Our research suggests that human cognitive motivation moderates the effectiveness of explainable AI solutions.

Inequalities in the uptake of, adherence to and effectiveness of behavioural weight management interventions: systematic review protocol

IntroductionIt has been suggested that interventions focusing on individual behaviour change, such as behavioural weight management interventions, may exacerbate health inequalities. These intervention-generated inequalities may occur at different stages, including...

A qualitative investigation of lived experiences of long-term health condition management with people who are food insecure

BackgroundAs more people are living with one or more chronic health conditions, supporting patients to become activated, self-managers of their conditions has become a key health policy focus both in the UK and internationally. There is also growing evidence in the UK that those with long term health conditions have an increased risk of being food insecure. While international evidence indicates that food insecurity adversely affects individual’s health condition management capability, little is known about how those so affected manage their condition(s) in this context. An investigation of lived experience of health condition management was undertaken with food insecure people living in north east Scotland. The study aimed to explore the challenges facing food insecure people in terms of, i. their self-care condition management practices, and ii. disclosing and discussing the experience of managing their condition with a health care professional, and iii. Notions of the support they might wish to receive from them.MethodsTwenty in-depth interviews were conducted with individuals attending a food bank and food pantry in north east Scotland. Interview audio recordings were fully transcribed and thematically analysed.ResultsIndividuals reporting multiple physical and mental health conditions, took part in the study. Four main themes were identified i.e.: 1. food practices, trade-offs and compromises, that relate to economic constraints and lack of choice; 2. illness experiences and food as they relate to physical and mental ill-health; 3. (in) visibility of participants’ economic vulnerability within health care consultations; and 4. perceptions and expectations of the health care system.ConclusionsThis study, the first of its kind in the UK, indicated that participants’ health condition management aspirations were undermined by the experience of food insecurity, and that their health care consultations in were, on the whole, devoid of discussions of those challenges. As such, the study indicated practical and ethical implications for health care policy, practice and research associated with the risk of intervention-generated health inequalities that were suggested by this study. Better understanding is needed about the impact of household food insecurity on existing ill health, wellbeing and health care use across the UK.

Telemedicine and Health Disparities During COVID-19.

* Abbreviations: ASL — : American Sign Language COVID-19 — : coronavirus disease 2019 ED — : emergency department The coronavirus disease 2019 (COVID-19) pandemic has resulted in rapid and large-scale expansion of telemedicine. At a time when physical contact with the medical system poses a risk of infection, telemedicine offers a vehicle for delivering medical care at a safe social distance. It allows for attention to acute concerns as well as routine screening for medical and social needs, which may be heightened during this time. For families with limited resources, telemedicine offers particular advantages, obviating the need for transportation, child care, and additional time needed for in-person office visits. For these reasons, telemedicine has been proposed as a solution to health care inequities in the past and implemented with success in select populations.1 Although the promise of telemedicine is an expansion of access, reliance on technology is likely to highlight existing vulnerabilities and widen disparities if precautions are not taken. Previous reports have outlined how technology-based solutions are highly susceptible to intervention-generated inequalities driven by underlying inequalities in access and uptake.2 Because rollout of telemedicine on this scale is unprecedented, the use of telemedicine in ambulatory settings during this time may illuminate important lessons for the field of telemedicine as a whole. As medical systems have shifted resources … Address correspondence to Michelle W. Katzow, MD, MS, 410 Lakeville Rd, Suite 311, New Hyde Park, NY 11040. E-mail: mkatzow{at}northwell.edu

Impact of Public Smoking Bans on Social Inequalities in Children's Exposure to Tobacco Smoke at Home: An Equity-Focused Systematic Review.

A systematic review was conducted to evaluate the impact of public smoking bans on social inequalities in children's secondhand smoke (SHS) exposure at home. Five databases were electronically searched for articles on children's SHS exposure at home related to public smoking bans. In addition, the gray literature and German public health journals were considered. Search was restricted to English and German publications. Of 3037 records screened, 25 studies fulfilled the inclusion criteria by either measuring SHS exposure before and after public smoking ban introduction or by comparing exposure between regions with and without smoke-free legislation. Studies were further examined whether they additionally reported on impacts on social inequalities in SHS exposure. Information on children's SHS exposure at home in relation to smoke-free legislation were extracted by one reviewer and checked for accuracy by a second reviewer. According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity (PRISMA-E) guidelines for equity-focused systematic reviews, the PROGRESS-Plus framework was applied to data extraction and analysis with focus on social inequalities in SHS exposure. Results were visualized by a harvest plot. Eight studies gave results on the impact of public smoking bans on social inequalities in children's SHS exposure. Whereas only one study indicated widening of the social gap in exposure, seven studies showed no impact or a reduction of social inequalities in exposure. First evidence on short-term impact of public smoking bans does not support the assumption of intervention-generated inequalities in children's SHS exposure at home. Future studies should focus on long-term equity impacts of smoke-free legislation. There are substantial social inequalities in children's SHS exposure in many countries. Both hypotheses on the effect of smoke-free legislation on children's SHS exposure at home, the displacement hypothesis and the social diffusion hypothesis, did not take social inequalities into account. Up to now, only few studies analyzed the effects of smoke-free legislation on social inequalities in children's SHS exposure at home. Public smoking bans had overall no negative impact on social inequalities in children's SHS exposure at home. More consistent reporting of absolute and relative inequalities is needed to comprehensively assess equity impact of smoke-free legislation.

Good intentions are not enough: how informatics interventions can worsen inequality.

Health informatics interventions are designed to help people avoid, recover from, or cope with disease and disability, or to improve the quality and safety of healthcare. Unfortunately, they pose a risk of producing intervention-generated inequalities (IGI) by disproportionately benefiting more advantaged people. In this perspective paper, we discuss characteristics of health-related interventions known to produce IGI, explain why health informatics interventions are particularly vulnerable to this phenomenon, and describe safeguards that can be implemented to improve health equity. We provide examples in which health informatics interventions produced inequality because they were more accessible to, heavily used by, adhered to, or effective for those from socioeconomically advantaged groups. We provide a brief outline of precautions that intervention developers and implementers can take to guard against creating or worsening inequality through health informatics. We conclude by discussing evaluation approaches that will ensure that IGIs are recognized and studied.

Designing equitable workplace dietary interventions: perceptions of intervention deliverers

BackgroundWorkplaces are a good setting for interventions that aim to support workers in achieving a healthier diet and body weight. However, little is known about the factors that impact on the feasibility and implementation of these interventions, and how these might vary by type of workplace and type of worker. The aim of this study was to explore the views of those involved in commissioning and delivering the Better Health at Work Award, an established and evidence-based workplace health improvement programme.MethodsOne-to-one semi-structured interviews were conducted with 11 individuals in North East England who had some level of responsibility for delivering workplace dietary interventions. Interviews were transcribed verbatim and analysed using thematic framework analysis.ResultsA number of factors were felt to promote the feasibility and implementation of interventions. These included interventions that were cost-neutral (to employee and employer), unstructured, involved colleagues for support, took place at lunchtimes, and were well-advertised and communicated via a variety of media. Offering incentives, not necessarily monetary, was perceived to increase recruitment rates. Factors that militate against feasibility and implementation of interventions included worksites that were large in size and remote, working patterns including shifts and working outside of normal working hours that were not conducive to workers being able to access intervention sessions, workplaces without appropriate provision for healthy food on site, and a lack of support from management.ConclusionsIntervention deliverers perceived that workplace dietary interventions should be equally and easily accessible (in terms of cost and timing of sessions) for all staff, regardless of their job role. Additional effort should be taken to ensure those staff working outside normal working hours, and those working off-site, can easily engage with any intervention, to avoid the risk of intervention-generated inequalities (IGIs).

Can lay health trainers increase uptake of NHS Health Checks in hard-to-reach populations? A mixed-method pilot evaluation.

The NHS Health Check Programme was launched in England in 2009, offering a vascular risk assessment to people aged 40-74 years without established disease. Socio-economic deprivation is associated with higher risk of cardiovascular disease and lower uptake of screening. We evaluated the potential impact of a community-based health check service that sought to address health inequalities through the involvement of lay health trainers. Key stakeholder discussions (n = 20), secondary analysis of client monitoring data (n = 774) and patient experience questionnaires (n = 181). The health check programme was perceived as an effective way of engaging people in conversations about their health. More than half (57.6%) of clients were aged under 50 years and a similar proportion (60.5%) were from socio-economically deprived areas. Only 32.7% from the least affluent areas completed a full health check in comparison with 44.4% from more affluent areas. Eligible men were more likely than eligible women to complete a health check (59.4 versus 33.8%). A community-based, health trainer-led approach may add value by offering an acceptable alternative to health checks delivered in primary care settings. The service appeared to be particularly successful in engaging men and younger age groups. However, there exists the potential for intervention-generated inequalities.

Impacts of the Primary School Free Breakfast Initiative on socio-economic inequalities in breakfast consumption among 9–11-year-old schoolchildren in Wales

Universal interventions may widen or narrow inequalities if disproportionately effective among higher or lower socio-economic groups. The present paper examines impacts of the Primary School Free Breakfast Initiative in Wales on inequalities in children's dietary behaviours and cognitive functioning. Cluster-randomised controlled trial. Responses were linked to free school meal (FSM) entitlement via the Secure Anonymised Information Linkage databank. Impacts on inequalities were evaluated using weighted school-level regression models with interaction terms for intervention × whole-school percentage FSM entitlement and intervention × aggregated individual FSM entitlement. Individual-level regression models included interaction terms for intervention × individual FSM entitlement. Fifty-five intervention and fifty-six wait-list control primary schools. Approximately 4500 children completed measures of dietary behaviours and cognitive tests at baseline and 12-month follow-up. School-level models indicated that children in intervention schools ate a greater number of healthy items for breakfast than children in control schools (b = 0·25; 95 % CI 0·07, 0·44), with larger increases observed in more deprived schools (interaction term b = 1·76; 95 % CI 0·36, 3·16). An interaction between intervention and household-level deprivation was not significant. Despite no main effects on breakfast skipping, a significant interaction was observed, indicating declines in breakfast skipping in more deprived schools (interaction term b = -0·07; 95 % CI -0·15, -0·00) and households (OR = 0·67; 95 % CI 0·46, 0·98). No significant influence on inequality was observed for the remaining outcomes. Universal breakfast provision may reduce socio-economic inequalities in consumption of healthy breakfast items and breakfast skipping. There was no evidence of intervention-generated inequalities in any outcomes.

PP32 Are there Socio-Inequalities Associated With Type 2 Diabetes Care?

BackgroundThere has been increasing research interest in the adverse effects of public health interventions; notably concern that processes in the planning or delivery of an intervention may create or exacerbate...

PP19 Formative Evaluation of a Community-based NHS Health Check Service

BackgroundCardiovascular disease (CVD) is the leading cause of death in the UK. The national CVD prevention strategy centres on the NHS Health Check Programme, which involves offering a vascular risk...

Why are Socioeconomic Inequalities in Receipt of Treatment Found for Lung Cancer?

177 ISSN 1758-1966 10.2217/LMT.13.12 © 2013 Future Medicine Ltd Lung Cancer Manage. (2013) 2(3), 177–180 Intervention-generated inequalities We would hope that interventions to improve health would also reduce health inequalities, but this is not always the case [1]. Evidence is accumulating that effective treatments for lung cancer are not equally received by individuals across the socioeconomic spectrum [2]. Intervention-generated inequalities (IGIs) have been described as “unintended (and unwanted) variations in outcomes, across population subgroups, that result from any element of any health intervention” [3], where, although overall population health may improve as the result of an intervention, differences in access to the intervention, differential uptake, delays in uptake and differential compliance with, or differences in effectiveness of, an intervention may result in inequalities in outcome [3,4]. The IGI framework expands on previous equity hypotheses that have attempted to describe variations in the provision and uptake of interventions. The ‘inverse care law’ states that “the availability of good quality healthcare is inversely related to need in the population served” [5]. The ‘inverse prevention law’ suggests that a similar socioeconomic gradient also exists in health prevention [6], and the ‘inverse equity hypothesis’ proposed that public health interventions initially widen socioeconomic inequalities due to preferential uptake by more advantaged groups before the less advantaged follow suit, eventually improving health overall [7]. However, none of the above equity laws/hypotheses consider how interventions can be designed to reduce inequality. In order to expand these equity laws into an evidence-based framework and model of intervention inequality, it is necessary to examine all the possible stages where inequalities may be introduced and consider ways in which these can be addressed, as it is likely that IGIs contribute to overall socioeconomic inequalities in morbidity and mortality [3].

Socioeconomic Inequalities in Lung Cancer Treatment: Systematic Review and Meta-Analysis

Intervention-generated inequalities are unintended variations in outcome that result from the organisation and delivery of health interventions. Socioeconomic inequalities in treatment may occur for some common cancers. Although the incidence and outcome of lung cancer varies with socioeconomic position (SEP), it is not known whether socioeconomic inequalities in treatment occur and how these might affect mortality. We conducted a systematic review and meta-analysis of existing research on socioeconomic inequalities in receipt of treatment for lung cancer. MEDLINE, EMBASE, and Scopus were searched up to September 2012 for cohort studies of participants with a primary diagnosis of lung cancer (ICD10 C33 or C34), where the outcome was receipt of treatment (rates or odds of receiving treatment) and where the outcome was reported by a measure of SEP. Forty-six papers met the inclusion criteria, and 23 of these papers were included in meta-analysis. Socioeconomic inequalities in receipt of lung cancer treatment were observed. Lower SEP was associated with a reduced likelihood of receiving any treatment (odds ratio [OR] = 0.79 [95% CI 0.73 to 0.86], p<0.001), surgery (OR = 0.68 [CI 0.63 to 0.75], p<0.001) and chemotherapy (OR = 0.82 [95% CI 0.72 to 0.93], p = 0.003), but not radiotherapy (OR = 0.99 [95% CI 0.86 to 1.14], p = 0.89), for lung cancer. The association remained when stage was taken into account for receipt of surgery, and was found in both universal and non-universal health care systems. Patients with lung cancer living in more socioeconomically deprived circumstances are less likely to receive any type of treatment, surgery, and chemotherapy. These inequalities cannot be accounted for by socioeconomic differences in stage at presentation or by differences in health care system. Further investigation is required to determine the patient, tumour, clinician, and system factors that may contribute to socioeconomic inequalities in receipt of lung cancer treatment.