Reduce Health Inequalities Research Articles

Closing the life expectancy gap: an ecological study of the factors associated with smaller regional health inequalities in post-reunification Germany

Regional health inequalities are rising globally. The case of German reunification offers a unique opportunity to explore how such inequalities can be reduced, or even eliminated: following reunification, a long-standing life expectancy gap between East and West Germany was closed for women and markedly reduced for men in less than 15 years.We used data from official national statistics covering the period 1994-2020 for 15 regions in East and West Germany. Using fixed-effects models with an interaction term for regions in the East, we investigated whether within-region changes in key hypothesised factors (social security expenditure, healthcare improvements, changes in alcohol consumption, and life satisfaction), have had differential impacts on life expectancy at birth and at 65 years.Our results show that increases in social security benefits in the East following reunification has been the most important factor for lowering inequalities between the two parts of Germany: for every 10% increase in social security benefits, life expectancy at birth increased by an additional 1.05 [0.68;1.41] months for males and by 0.57 [0.18;0.97] months for females in East relative to West Germany. We find the protective effect of social security benefits also for women at 65 years (additional 0.38 [0.06;0.70] months) but not for men.Our findings suggest that increasing social security expenditure could be an effective policy tool for reducing health inequalities across regions with different levels of economic development. This provides additional support for the materialist hypothesis and the political economy theory of the root causes of health inequalities.

California Mortality and the Healthy Places Index.

We investigated California mortality and social determinants of health, as measured by the Healthy Places Index (HPI), which is a composite measure of 23 indicators of neighborhood (census tract) economic conditions, education, transportation, housing, social capital, environmental pollution, built-environment, and access to health care. We aggregated deaths to 2010 census tract boundaries for leading causes, 2015 to 2019, and COVID-19, 2020-2021, from death certificates and populations from the American Community Survey, 2015 to 2019. We age-adjusted and stratified death rates by HPI deciles, age, gender, and race/ethnicity, and examined HPI dose-response with segmental regression. For all causes, cancer, cardiovascular disease, COVID-19, diabetes, cirrhosis of the liver, injuries, and Alzheimer's disease (ages 65-74 years), mortality rates were inversely related to HPI decile. For all causes mortality, the rate ratio between the 1st and 10th decile (reference) was 1.63 (CI95%: 1.60-1.66), and, for COVID-19, the rate ratio was 7.61 (CI95%: 7.14-8.12). The population attributable fraction was 24% for all causes and 72% for COVID-19. Age, gender, race/ethnicity modified the steepness and shape of dose-response curves. The findings illustrate opportunities to incorporate area-based socioeconomic measures in routine public health surveillance, and to reinforce policies and programs that reduce health inequities.

Comparing the economic burden of disease by physical activity levels among persons with and without disabilities in the Republic of Korea

IntroductionThe World Health Organization recommends at least 150 min of physical activity per week for persons with and without disabilities. This study compared the differences in the economic burden of diseases between persons with and without disabilities based on their physical activity. What is known in the field is that physical activity is beneficial to health, but there is a disparity between persons without disabilities and persons with disabilities, and our research aims to increase physical activity among persons with disabilities.MethodsEconomic burden of disease includes service costs such as outpatient, hospitalization, and pharmaceutical expenses for disease treatment, and persons with disabilities are those who have received a disability classification legally registered by the Korean Ministry of Health and Welfare, and there are 15 types of disabilities. For exercise records, we calculated the cost in 2020 for people with exercise records in 2018 so that they can have at least 1 year of exercise records, as health checkups are available from January to December of the year. Physical activity attainment is defined as 150 min or more of physical activity per week based on World Health Organization guidelines.ResultsCalculating the economic burden of disease by physical activity for persons with and without disabilities, both experienced a difference in hospitalization costs owing to fewer hospital days with physical activity achievement, with the difference being greater for persons with disabilities. Regarding disability type, achievers showed a 41.1% difference in total costs for mental class disorders, 16.7% for external bodily function disorders, and 11.1% for internal organ disorders.DiscussionPhysical inactivity has a significant impact on the economic burden of persons with disabilities compared to persons without disabilities, with 11.8% fewer persons without disabilities who were physically active for 150 min or more per week compared to 21.4% fewer persons with disabilities. In terms of healthcare spending, exercise can help keep persons with disabilities healthy. Therefore, there is a need for exercise programs tailored to persons with disabilities to increase physical activity in line with World Health Organization recommendations to reduce health inequalities between persons with and without disabilities.

Antibiotic prescribing in health and justice settings (HJS)-surveillance and opportunities for quality improvement

Abstract Introduction Improving surveillance of antibiotic prescribing and reducing health inequalities in antimicrobial resistance (AMR) are priorities in the new 5 year AMR national action plan (2024-2029)1. People in contact with the justice system are one of the inclusion groups in the CORE20plus5, a national NHE England approach to support reduction of health inequalities.2 Aim This project aimed to collate and analyse all antibiotic prescribing data from English prisons in order to identify opportunities for quality improvement. Method This project analysed antibiotic prescribing data from September 2022 to current date for the first time in HJS from the IT system used in all prisons in England. No ethical approval is required as surveillance is of anonymised data only. Data was broken down by age band (18 and under, 19-49, 50 and over), category of prison, region, ICB, individual prison and antibiotic type. The dashboard allows benchmarking across sites and comparison with primary care, as prisoners in HJS are considered to have similar infections to primary care patients. Results The majority of prescribing is in male prisoners, reflecting the male/female population split. The most frequently prescribed antibiotics are those used for: skin and soft tissue (including acne), respiratory tract, dental and urinary tract infections. A number of focus areas for quality improvement have been identified, including: Broad spectrum antibiotics (Cephalosporins, Co-amoxiclav and Quinolones), target of <10% total antibiotic prescribing in primary care, in HJS, currently 11%. Appropriate quinolone prescribing is a target in all settings due to recent MHRA alert3. Acne prescribing represents a significant proportion of antibiotic prescribing in HJS. Lymecycline 12%, whereas in primary care <3%. Duration of Antibiotic Courses: In primary care there is a medicines optimisation opportunity ambition to achieve 75% prescribing amoxicillin 500mg as 5 day duration. In HJS only 27% is for 5 days. When prescribing 100mg doxycycline for respiratory infections, NICE guidance recommends a 5 day course, but in HJS only 3% is prescribed as a 5 day course. For UTI in female prisons, nitrofurantoin 100mg MR is most commonly prescribed, NICE guidance for UTI in women is for 3 days; 47% in HJS are for 3 days, but 35% are 7 day courses. Discussion and Conclusion This dashboard provides insight into antibiotic prescribing data allowing opportunities for quality improvement opportunities to be identified and antimicrobial stewardship interventions to be evaluated. This work will progress to tackle the focus areas identified. Next steps are to work with antibiotic champions from HJS to co-produce intervention plans, share patient safety messages, trial available resources, rollout interventions and monitor impact via the dashboard. Limitations Indications are not available from the data but extrapolated from the antibiotic prescribed. The dashboard is currently an excel spreadsheet in NHSE. It will be moved to a platform that enables access by individual prisons.

Inclusive practice: a study exploring community pharmacists' perspectives, knowledge, and training of Neurodiversity (ND) and the effects on their practice

Abstract Introduction An estimated 1 in 7 people in the UK are neurodivergent, a term encompassing conditions such as autism, attention deficit hyperactivity disorder (ADHD), and other learning differences.1 Neurodivergent individuals have poorer health outcomes, increased risk of premature mortality and reduced access to healthcare.2 The Oliver McGowan case highlighted the need for raising awareness of neurodiversity and mandatory training.2 CPs are uniquely positioned to implement simple adjustments, e.g., adapting communication methods and inclusive pharmacy spaces, consequently reducing health inequalities. CPs’ knowledge, cultural perspectives and current accommodations in their practice for neurodiverse patients must be determined. Aim To explore community pharmacists' perspectives, knowledge and training of neurodiversity and the effects on their practice. Methods A mixed-methods approach was used following ethical approval from Kingston University Ethics Committee. After a pilot study, using random sampling, paper questionnaires comprising 26 mixed-style questions were distributed and collected in person to community pharmacists in East London boroughs within a two-month period. Survey participants were invited for an optional in-person or remote semi-structured interview, conducted using a validated interview guide. The minimum sample size was 129 pharmacists (Raosoft online calculator; 95% confidence interval). Data was analysed using descriptive and inferential statistics, using Microsoft Excel alongside thematic analysis for interview responses. Results Response rate was 80% (n=103/129) and 6 pharmacists participated in interviews. 53% (n=55) were Asian, 21% (n=22) Black, and 19% (n=20) White ethnicity. 52% (n=54) identified as male and 47% (n=48) as female. There was a statistically significant correlation between ethnicity and perception of neurodiversity, with conditions taken less seriously in Asian and Black cultures compared to White culture (p<0.001). White participants were statistically more likely to rate their knowledge as good or above in comparison to Asian or Black participants (p=0.01), with 70% (n=14/20) White participants rating their knowledge as good in comparison to 18% (n=4/22) Black and 29% (n=16/55) Asian participants. 100% (n=103/103) and 94% (n=97/103) participants were able to identify autism and ADHD respectively as neurodiverse conditions but only 20% (n=21/103) and 21% (n=22/103) respectively identified dyspraxia and dyscalculia. 94% (n=97/103) stated no changes were made to accommodate neurodiverse patients with only 3% (n=3/103) offering large-print labels or poster formats and 2% (n=2/103) offering quiet areas. Thematic analysis demonstrated the absence of interventions and awareness was commonly due to systemic barriers and lack of specific training. Participants described diverse cultural attitudes and attached stigma to neurodiversity. Discussion/Conclusion There are significant gaps in knowledge about neurodiversity, possibly linked to a lack of formal training opportunities for CPs. Consequently, minimal adjustments are made to accommodate neurodiverse patients. Changes to pharmacy education and training are needed to develop general understanding, with tools that can be incorporated in pharmacies to aid neurodiverse patients and improve health literacy.2 Simple measures such as ‘quiet hours’ or large-text labels can greatly impact a person’s healthcare experience. However, improvements are required in infrastructure and resources within pharmacies, as well as shifts in cultural attitudes to encourage patients to share their status.3 Study limitations included time constraints and a small but diverse geographical area.

Adaptation of the G-NORM (Gender norms scale) in Uganda: An examination of how gender norms are associated with reproductive health decision-making.

Restrictive gender norms exacerbate health inequalities all over the world. More specifically, they prevent women from seeking preventive health services, constrain women's economic empowerment, and are associated with reproductive health decision making. Gender norms, a subset of social norms, are dynamic and change over time. However, we lack data on how they are changing and how these changes affect health outcomes because current measures do not adequately capture the complex concept of gender norms. We originally developed and validated a gender norms scale, the G-NORM, in India. In this study, using cross-sectional data, we adapted the G-NORM from Southeast Asia (India and Nepal) to sub-Saharan Africa (Uganda) in four steps: 1. Formulation of new scale items (via qualitative analysis) 2. Cognitive Interviewing 3. Questionnaire Administration (n = 2422 women of reproductive age) and 4. Psychometric analysis (Confirmatory Factor Analysis). Like the original scale, descriptive norms and injunctive norms comprised two unique sub scales with high Cronbach's alphas (.80 & .92). Average scores differed depending on the type of norm suggesting that some gender norms are changing faster than others. Specifically, more equitable injunctive norms were associated with lower odds of partner-dominated contraceptive decision making but descriptive norms were not. Gender norms serve as a multi-faceted determinant of health and wellbeing and require measurement tools which account for their conceptual complexity. Validating the G-NORM in Uganda expands measurement options for researchers in the sub-Saharan African region working to change norms to reduce health inequalities or to understand the gender normative context before beginning a study.

Use of Standardized Nursing Terminologies to Capture Social Determinants of Health Data: An Integrative Review.

Addressing social determinants of health in nursing care is important for improving health outcomes and reducing health inequities. Using standardized nursing terminologies to capture this information generates sharable data that can be used to achieve these goals and create new knowledge. The purpose of this integrative review was to examine use of standardized nursing terminologies for collecting social determinants of health data in nursing research and practice. The CINAHL, MEDLINE, and Web of Science databases were searched using the terms "social determinants of health" [and] "nursing" [and] "standardized terminology" or names for each of the 12 American Nurses Association-approved terminologies. Limiters included peer-reviewed and English language. After removal of duplicates, 120 articles were found and screened for relevance and quality using a three-step process. This yielded a final sample of seven articles. Article data were extracted and analyzed for themes. In all articles, retrospective, observational, or secondary analysis research designs were used to analyze previously collected data from large, deidentified datasets or research studies. The Omaha System was the only standardized nursing terminology represented in the sample. All operational definitions of social determinants of health included behavioral items. In most studies, a social determinants of health index score was calculated, and data were analyzed using descriptive statistics and visualization methods. Results reported across the articles were diverse; some themes were identified. This review revealed published literature on this topic is limited. More quality improvement and multisite studies that examine the use of standardized nursing terminologies by nurses to collect and use social determinants of health data are needed.

The willingness to transition to a more plant-based diet among omnivores: determinants and socioeconomic differences

Plant-based diets benefit individual health and the environment, yet most people eat omnivorous diets. We aim to (1) assess the role of multiple determinants for transitioning to more plant-based diets in a sample of omnivorous respondents, such as recommendations from doctors, scientists and politicians; lower costs; and increased availability, and to (2) identify which subpopulations are most receptive to which determinants. Using data from a survey on the use and acceptance of Traditional, Complementary and Integrative Medicine in Germany (N=4,065; N omnivorous=3,419; 84%), we find that the overall willingness to change to a more plant-based diet is low (mean=2.25 on a scale of 1 to 4). Respondents are most willing based on doctors’ recommendations (mean=2.61), and if prices for plant-based products were lower (mean=2.55), and least willing based on scientists’ and politicians’ recommendations (mean=1.86). Regression analyses reveal that men, the baby boomer cohort, and respondents with lower levels of education have a significantly lower willingness to transition to more plant-based diets. Further, recommendations from doctors, scientists, and politicians appear to be promising interventions for addressing the dietary behavior of men and older cohorts. Interventions by doctors and lower prices for plant-based products have the highest potential to induce dietary change even among the reluctant, reducing health inequalities and promoting environmentally friendly behavior.

Understanding and improving the quality of primary care for people in prison: a mixed-methods study.

People in prison are generally in poorer health than their peers in the community, often living with chronic illness and multimorbidity. Healthcare research in prisons has largely focused on specific problems, such as substance use; less attention has been paid to conditions routinely managed in primary care, such as diabetes or hypertension. It is important to understand how primary care in prisons is currently delivered in the United Kingdom and how it can be improved, in order to reduce health inequalities. To understand the quality of primary care in prison, including gaps and variations in care, in order to recommend how quality of prison health care can be improved. A mixed-methods study with six interlinked work packages. Predominantly the North of England. Between August 2019 and June 2022, we undertook the following work packages: (1) International scoping review of prison healthcare quality indicators. (2) Stakeholder consensus process to identify United Kingdom focused prison healthcare quality indicators. (3) Qualitative interview study with 21 people who had been in prison and 22 prison healthcare staff. (4) Quantitative analysis of anonymised, routinely collected data derived from prison healthcare records (~ 25,000 records across 13 prisons). (5) Stakeholder deliberation process to identify interventions to improve prison health care. (6a) Secondary analysis of the qualitative data set, focusing on mental health and (6b) analysis of the quantitative data set, focusing on health care of three mental health subgroups. Our scoping review found predominantly only papers from the United States of America and of variable rigour with the main finding being that performance measurement is very challenging in the prison healthcare setting. In collaboration with stakeholders, we prioritised, refined and applied a suite of 30 quality indicators across several healthcare domains. We found considerable scope for improvement in several indicators and wide variations in indicator achievement that could not be attributed to differences in prison population characteristics. Examples of indicators with scope for improvement included: diabetes care, medicines reconciliation and epilepsy review and control. Longer length of stay in prison was generally associated with higher achievement than shorter stays. Indicator achievement was generally low compared to that of community general practice. We found some encouraging trends and relatively good performance for a minority of indicators. Our qualitative interviews found that quality of health care is related to factors that exist at several levels but is heavily influenced by organisational factors, such as understaffing, leading to a reactive and sometimes crisis-led service. Our stakeholder deliberations suggested opportunities for improvement, ideally drawing on data to assess and drive improvement. Our mental health work package found that coded mental illness had mixed associations with indicator achievement, while the interviews revealed that mental distress is viewed by many as an inevitable facet of imprisonment. Our analyses of indicator achievement were limited by the quality and coverage of available data. Most study findings are localised to England so international applicability may differ. Marked variations in the quality of primary care in prisons are likely to be attributable to the local organisation and conditions of care delivery. Routinely collected data may offer a credible driver for change. This study is registered at researchregistry.com (Ref: 5098). This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/26) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 46. See the NIHR Funding and Awards website for further award information.

Development of Undergraduate Competencies in Caring for People Experiencing Homelessness.

Nurses play a critical role in reducing health inequities in people experiencing homelessness (PEH), a key social determinant of health. Health disparities specific to PEH are exacerbated by numerous factors, including bias, stigma, and a lack of nursing competency in caring for PEH. The purpose of this study was to validate registered nurse key competencies; associated knowledge, skills, and attitudes; and concepts, content, and learning activities to serve as an educational framework in providing care for PEH. Twenty-four nursing experts on the care of PEH rated draft competency and subcompetency statements for relevance and clarity, proposed revisions and missing competencies, and identified essential and useful content, concepts, and learning activities. Four key competencies, 38 subcompetencies, and associated concepts, content, and learning activities were validated by the experts. This framework can be used to guide curricular development across nursing programs to advance health equity for PEH.

Empowering Global Health Systems to Protect, Promote and Support Optimal Breastfeeding.

Breastfeeding is a critical public health strategy for optimal child development and maternal health across the life course. The 2021 Global Burden of Diseases, Injuries and Risk Factors Study reveals that, despite reductions in mortality and disability-adjusted life years (DALYs) attributed to suboptimal breastfeeding practices-namely, non-exclusive breastfeeding during the first 6 months or early discontinuation within the first 2 years-low- and middle-income countries (LMICs) continue to bear a staggering 50-fold higher burden compared to high-income nations. This inequity signals a pressing global health priority. Hence, we propose to address these challenges by first, expanding the Baby-Friendly Hospital Initiative (BFHI) reach through community-driven efforts such as the Baby-Friendly Community Initiative (BFCI) to enhance breastfeeding support in both clinical and community settings; second, embedding breastfeeding counselling within national health and social protection programmes to fill in gaps in culturally competent care, drawing on large scale breastfeeding peer counselling programme experiences like the one being implemented by the US Supplemental Nutrition Program for Women, Infants and Children (WIC); third, improving maternity leave policies and workplace accommodations for breastfeeding women and fourth, stringent regulation of exploitative commercial milk formula (CMF) marketing to combat misinformation and reduce health inequities. Governments must implement strong, evidence-driven policies-such as strict monitoring and regulation of product labelling and digital media marketing-to establish safeguards against the powerful influence of the CMF industry. Collectively, these strategies will enhance breastfeeding outcomes, reduce health disparities and drive progress across countries towards meeting the UN Sustainable Development Goals.

Co-designing postpartum contraceptive services with and for immigrant women in Sweden: lessons learned from the IMPROVE-it project

Background and aimImmigrant women in many high-income countries including Sweden, report unmet need of sexual and reproductive health and rights, and face worse pregnancy outcomes and higher risk of unintended pregnancies. Postpartum contraceptive services are often inadequate to meet their needs. Co-design has shown to reduce health inequities, yet little is known about using this method for postpartum contraceptive service development and even less in collaborating with immigrant populations. The aim of this paper is to describe the co-design process and the strategies that were developed to help develop tailored and acceptable postpartum contraceptive services for immigrant women in Sweden.MethodsThe paper describes a co-design process that took place during 2022–2023, including the cyclical digital consultations with Arabic and Somali speaking immigrant women, midwives and researchers, as well as the outputs from the process. The theoretical framework for the co-design process was the ‘Double Diamond’ Design Process Model. Data analysis included qualitative content analysis.ResultsThe co-design process led to the joint development of intervention materials and strategies to improve postpartum contraceptive services. Specifically, the process revealed ideas on how to improve contraceptive counseling within three pre-identified areas of change: improve physical access to contraceptive services; improved communication strategies using visual aids and information charts; and empowerment strategies that focus on reflective practice without assumptions about what a group of women might expect. We found that participants contributed actively to the process with ideas and suggestions, and that the co-design process facilitated positive reflections on ongoing counseling practices.ConclusionThe co-design process resulted in the successful and participative development of innovative tools and activities to improve contraceptive counseling services. This approach is original because it involves both immigrant women, often left behind, and midwives delivering the services. Whilst this interplay allowed for careful refinement of services and tools by using an iterative process, it also facilitated reflective midwifery practice.

Bridging the gap: how education transforms health outcomes and influences health inequality in rural China.

This study focuses on the impact of education on health and health inequalities in rural areas of China. Education significantly enhances economic status and health, driving economic growth and improving public health standards. Integral to the "Healthy China Strategy," it provides essential guidance for public policy and underscores the need for strategic human capital investments to achieve these goals. The study utilizes data from the China Family Panel Studies (CFPS) spanning 2010-2020 and employs the average educational level within counties as an instrumental variable. The causal impact of education on health and health inequalities is estimated using the two-stage least squares (2SLS) method. The findings reveal a significant positive correlation between enhancing education levels and health improvements. Specifically, after controlling for endogeneity, the duration of individual education significantly improves both subjective and objective health outcomes. It reduces health inequalities, with these effects being more pronounced among women and low-income groups. Mechanistically, education positively impacts health primarily by altering health behaviors and social network levels and reducing health inequalities through socio-economic factors. This paper provides important implications for public policy, suggesting that enhancing educational investments can drive economic development and improve population health standards.

Enhancing stroke awareness in schools: efficacy of the HOBIT program in Czechia’s disadvantaged areas

Abstract Background For stroke treatment to be effective, it must be given as soon as possible. Delays are often caused by stroke bystanders failing to recognize symptoms and activate emergency medical services (EMS). This is especially a problem in socially excluded localities. This study evaluated the efficacy of a school-based intervention (HOBIT) in improving determinants and behavior intentions of EMS activation for suspected stroke in Czech socially excluded localities. Methods The quasi-experiment was conducted from May to June 2023 in the Moravian-Silesian region, Czechia. Schools were allocated to the intervention or control group (1:1). The HOBIT is a school-based intervention used to change health-seeking behavior when stroke is suspected. The primary outcome was the percentage change from the pretest to the follow-up test in the intervention group compared to the control group. The primary outcome was assessed in 4 domains: 1) knowledge, 2) behavioral intentions, 3) self-efficacy, and 4) outcome expectations. The intervention and control groups were compared using an unpaired t-test. Results We recruited 138 students aged 10-16 from 4 schools. The absolute differences in improvement between the control and intervention groups were 18% (95% CI 9-26, P < 0.001) for knowledge, 15% (95% CI 2-26, P = 0.01) for behavioral intentions, 6% (95% CI -4-15, P = 0.24) for self-efficacy, and 13% (95% CI 5-21, P < 0.001) for outcome expectations. The subgroup analysis showed that the intervention effect on self-efficacy, outcome expectations, and stroke behavior intentions was significant only in females. Conclusions The HOBIT improved stroke determinants and behavior intentions of EMS activation at schools in socially excluded areas. This study presents a health promotion practice that has the potential to improve stroke outcomes on a community level. It underscores the potential of school settings as an appropriate way to reduce health inequalities in socially excluded communities. Key messages • The HOBIT intervention improved determinants and behavior intentions of EMS activation for suspected stroke among students in socially excluded localities. • The study underscores the potential of school settings in reducing health inequalities and improving stroke-related outcomes in socially excluded localities.

Can we adapt fairly? Systematic review of health equity implications of climate change in coastal communities in the UK

Abstract As climate change becomes more apparent, it is important to evaluate the equity implications of adaptation interventions and policy measures. Many coastal populations experience high levels of social deprivation, which can be compounded by environmental factors. Coastal hazards, such as erosion and flooding can cause short and long term impacts on physical and mental health. To systematically review the published evidence on the differential impacts of coastal change on health inequalities and review the implications of adaptation responses for health inequality. We systemically reviewed the evidence for the UK only on a) inequalities in coastal flood impact or risk, and b) effectiveness and equity implications of current measures to manage the climate risks to an acceptable level of impact. Interventions included: plans and guidance, insurance, and infrastructure, including natural flood management. We found 8 papers quantifying differentials in current and future impacts of coastal flood risk and 6 papers assessing equity implications of adaptation measures. Coastal flood risk is unevenly distributed. Those owning their own home were more likely to experience flood impacts including increased stress and displacement. There is good evidence that policies for household insurance and property level protection measures have the potential to increase inequalities; other measures (community engagement; planning; defences) may reduce health inequalities, depending on implementation and local context. Adaptation to coastal change requires a range of approaches in the short and longer term, which potentially exacerbate current inequalities. Adaptation responses that rely on individual behaviour change, such as relocation, purchasing insurance, or retrofitting dwellings, may exacerbate inequalities within coastal communities. Climate change challenges organisations to deliver national and local policy responses ensuring that adaptation is effective and equitable.

Health Impact Assessment (HIA): a tool to drive health in all policies?

Abstract Health Impact Assessment (HIA) is often promoted as a tool to implement ‘health in all policies’ and sustainable development approaches to improve health and equity outcomes. However, is this truly the case? Currently global HIA practice is variable. This paper shares learning from the development and implementation of HIA in Wales to date to understand how HIA has been, and can be, used to inform policies and decisions and reduce health inequalities. The research investigated if, and how, HIA can be used as a tool to mobilise HiAP in reality. It followed a mixed methodological approach and investigated the contribution of HIA to practically advancing HiAP viewed through the lens of Wales and internationally. Primary and secondary evidence and statistics were collected and analysed. A literature review, stakeholder interviews, online statistical questionnaires and case studies were conducted. Thematic and content analysis techniques used. Findings include the importance of conceptual considerations i.e. the perspective on health - social determinant an equity or environmental determinant driven - taken by those carrying out or commissioning a HIA; the importance of centres of expertise to learn from; and practical considerations such as the political and regulatory environment, workforce and organisational knowledge and capacity. Wales has a dedicated expert HIA Unit, an enabling political environment and has led to HIA influencing policies and plans over 20 years. It has transferrable learning for other nations and the research including the online survey has been replicated by others, led to collaborations with nations such as Portugal and contributed to the reviewed literature by providing case studies on a topics like climate change which have influenced decision makers. Tangible ways forward for policy makers, researchers and academics include the need to develop more cross collaboration and fill gaps in the evidence i.e. on institutionalisation of HIA. Key messages • HIA is a excellent process to drive Health in all policies approaches. • HIA needs an enabling environment and workforce support such as that in Wales to thrive.

Incentives to attract and retain physicians to underserved areas - a case study from Portugal

Abstract Issue Physician shortages in underserved areas are a common challenge for governments and policymakers worldwide, including in Europe. Meanwhile, a knowledge gap exists on effective measures to address the issue. Description According to WHO Europe, one of ten actions to strengthen the healthcare workforce is to develop strategies to attract and retain health workers in rural and remote areas. Portugal faces geographical asymmetries in the distribution of physicians, and difficulties in retaining them in certain areas of the country. This case study seeks to describe and analyse the impact of an incentives package introduced in 2015 that aimed to attract and retain physicians in underserved areas. Financial incentives data was gathered via a national health human resources information system. Non-financial incentives data was reported by health institutions through an online form. Document analysis was conducted to understand the scope of the incentives package and its amendments. Results The incentives package implemented in Portugal effectively deployed physicians to underserved areas, since it led to a fourteen-fold increase in physicians settling in underserved areas. In terms of retention, an average of 59% of the physicians that took up the incentives package are still practicing in the same underserved area. However, the difference between the retention levels of physicians under the incentives package and those not covered is minimal. To further reduce health inequities and achieve universal health coverage, a need exists to review the financial and non-financial incentives to better suit physicians’ needs and expectations, as well as those of the National Health Service. Lessons The incentives package introduced in Portugal makes it clear that flexibility in the design of attraction and retention measures is crucial. It requires a long-term commitment and a recognition that each intervention should be assessed and adapted to local circumstances and context. Key messages • The incentives package introduced in Portugal attracted physicians to underserved areas and led to a fourteen-fold increase in physicians settling in underserved areas. • More than half of the physicians are still practicing in the same underserved health institution but the difference in retention against those not covered by the incentives package is minimal.

Social patterning of health misinformation in two Eastern Mediterranean populations

Abstract Background Health misinformation, the spread of false or misleading information relevant to health, has been proposed as a major global public health thread by the WHO. We aimed to identify the major social determinants of health misinformation in the general Greek and Cypriot populations. Methods Following proportional quota sampling we recruited a nationwide sample of 585 adults from Greece and Cyprus between January 2022 and May 2023. A newly developed, culturally adopted questionnaire comprising 48 items, was used to assess misinformation on COVID-19 vaccines and the pandemic. Sociodemographic determinants of interest included gender, age, marital status, area of residence, educational attainment, and income. Multiple linear regression was used to determine associations between the aforementioned social factors and the two dimensions of health misinformation, applying mutual adjustment. Results Misinformation about both vaccination and the pandemic was higher in younger age groups (p-trend 0.026 and 0.007, respectively), among those separated, divorced, or widowed (mean difference, 95% CI compared to those single: 9.73, 0.45, 19.01), and among those living in semi-urban compared to urban areas (11.14, 1.32; 20.97 and 9.44, 1.96; 16.92, respectively). We also detected strong inverse socioeconomic gradients in health misinformation based on educational attainment and income (p-trend <0.001, for both). Conclusions Younger individuals, those living alone, those residing in semi-urban areas, and those with lower educational attainment and income are particularly prone to health misinformation. Our adjusted models show that this social phenomenon is not simply explained by differences in education, hence more complex, cultural, political, perceptual, and psychosocial dynamics might be in place. Addressing the social patterning of health misinformation would help manage the issue more effectively and also reduce health inequalities. Key messages • Health misinformation is strongly socially patterned in two Eastern Mediterranean European populations. • Targeting efforts to tackle health misinformation to those more vulnerable, would render such programmes more effective, also helping reduce social inequalities in health.

7.D. Scientific session: Digital health divide in access, use, and effectiveness: Examples from three countries

Abstract The increasing digitalisation of the healthcare system opens up a wide range of opportunities but also poses challenges in reducing inequalities due to unequal technological access as well as social and demographic differences of populations. This so-called digital divide is the opposite of digital inclusion, defined by the United Nations as “equitable, meaningful, and safe access to use, lead, and design of digital technologies, services, and associated opportunities for everyone, everywhere”. Indeed, digitalisation is a global phenomenon that permeates all levels of determinants of health inequities, leading to several populations being more disadvantaged. Age, gender, education, and economic status are significant factors amplifying the digital divide’s impact, with older individuals, women, less educated individuals, and economically deprived populations bearing disproportionate effects. Prior literature suggests three levels of digital divide: 1) access to internet and digital technology, 2) individual cognitive and technical competencies in utilizing digital tools, and 3) effectiveness or the optimal functionality and reach of digital technologies. Although there is less consensus with regards to the scope of the divide in the health sector, the three levels are the common reference. Nonetheless, this lack of agreement resulted in existing literature to be concentrated around digital health literacy, or the cognitive and technical abilities to use digital technologies. In addition, while tools such as the Global Digital Health Monitor are valuable to track, monitor, and assess the enabling environment for digital health worldwide, it does not capture the lived experience of the population, including the disadvantaged population groups. This workshop aims to 1) generate discussion on digital health divide and how it can be operationalized and 2) reflect on potential actions to counteract these injustices. Case studies from Germany, Indonesia and Argentina will be presented to diversely contextualize the inequities in digital health and assess plausible interventions. The workshop will be divided into four parts. First, an introduction to the digital health divide will be presented as well as its public health relevance (10 minutes). Second, researchers representing three countries (i.e., Germany, Indonesia, and Argentina) will present digital health divide case studies within their context of expertise (15 minutes). Third, a case-based discussion will be conducted with participants. Participants will be allocated into groups based on the three levels of the digital health divide (i.e., access, use, and effectiveness) and work on recommendations to best operationalize and narrow the digital health divide (25 minutes). Finally, the workshop will conclude with a wrap-up of the group discussion results (10 minutes). Key messages • The digital health divide affects all regions, regardless of income levels. Narrowing the gap is crucial to reduce health inequity and achieve universal health coverage. • By clearly defining the scope and operationalization of the digital health divide, its measurability and usefulness to inform health policies and programs to address this issue can be enhanced.

Did social inequalities in child development change during the COVID-19 pandemic in Germany?

Abstract Background Early childhood development (aged <6 years) is dependent on the social conditions in which children live and strongly affect their life course trajectory. This study describes changes in social inequalities in language development during the COVID-19 pandemic based on data from the legally prescribed school entry examination in the German federal state of Brandenburg. The aim is to inform public health interventions for individuals at risk of long-term health inequalities. Methods Secondary data from three cohorts of 5-7-year-olds were used [n = 19,2992018|19; n = 19,9162019|20; n = 19,6982020|21]. Language development was assessed as delayed compared to peers [LD yes/no], measured by public health services using validated instruments. Descriptive bivariate and multivariate analyses [OR, 95%CI] examined language delay [%] with social inequalities defined by (1) an index composed of parents’ reported education and occupation [SEP low|high], (2) ‘German native language’ [yes|no] and (3) ‘years of kindergarten attendance’ [<4|≥4]. Results Overall, the proportion of LD decreased over the years (21.1%2018|19; 19.2%2019|20; 18.8%2020|21), both among children from families with high SEP (14.3%2018|19; 13.0%2020|21) and from German-speaking families (20.2%2018|19; 17.8%2020|21). LD rates among children increased with low SEP (42.4%2018|19; 43.4%2020|21) and remained constant with a non-German native language (36.0%2018|19; 35.5%2020|21). The probability for LD differed only for SEP (2018|19: ORlow|high=4.4, 3.93-4.94; 2020|21: ORlow|high=5.12, 4.54-5.77) and for native language (2018|19: ORnon-German|German=2.22, 1.86-2.66; 2020|21: ORnon-German|German=2.54, 2.19-2.95). Conclusions Social inequalities in language development based on SEP and native language increased slightly during the pandemic compared to the pre-pandemic period. Research should examine the effects of the pandemic on early development as well as protective and risk factors on a longitudinal basis. Key messages • Social inequality in early development increased in Germany during the COVID-19 pandemic. • To reduce health inequality in the life course, longitudinal research should assess the impact of the pandemic on child development.