Regional Health Disparities Research Articles

Addressing Regional Health Disparities: Estonia’s Approach to Burden of Disease Studies

Abstract Background Estonia, a small country defined by NUTS2 regions, faces challenges in assessing health disparities across its different counties when using global health data such as the Global Burden of Disease (GBD). Recognizing this limitation, Estonia initiated independent burden of disease studies in Estonia since 2013, with the findings being biennially published through the health statistics database of the National Institute for Health Development. The objective of this research is to assess the strengths and limitations inherent in various methods when calculating the years of life lost due to premature mortality (YLLs). Methods The approach to assess the burden of disease in Estonia differs somewhat from the Global Burden of Disease (GBD) methodology. One key distinction lies in our utilization of a national life expectancy table and our presentation of results at the LAU1 regional level. These burden of disease studies utilize region-specific life tables supplied by Statistics Estonia, categorized by county and gender, to compute Years of Life Lost (YLLs), offering an opportunity to pinpoint and tackle regional health issues. Results Since the calculation of YLL (Years of Life Lost) in these past studies has relied upon Estonia’s regionalized life tables, categorized by county and gender, the results exhibit substantial disparities when juxtaposed with the Global Burden of Disease study conducted by the Institute for Health Metrics and Evaluation (IHME). Conclusions This research aims to delve deeper into these variations, examining the challenges related to methodology, the availability, and the quality of data, and most importantly, knowledge translation. Our own burden of disease studies empowers us to formulate informed policy recommendations precisely tailored to the distinctive needs of each county, thereby facilitating targeted interventions, and driving improvements in overall public health outcomes.

Burden of disease and socioeconomic deprivation in Germany – regional patterns and variations

Abstract Within the scope of the BURDEN 2020 project (Burden of disease in Germany at the National and Regional Level) carried out by Robert Koch Institute (RKI) in collaboration with the German Environmental Agency and AOK Scientific Institute, burden of disease estimates for Germany and its regions become available for the first time. The national estimates of YLL, YLD and DALY are provided not only stratified by age and sex, but also by detailed regional level (96 spatial planning regions). The regional estimates provide valuable information and support the evidence-based decisions in health policies aiming at reducing the burden of disease in the country. To facilitate further the interpretation and usability of these estimates, the provided indicators were linked to the regional information on deprivation. For this purpose, the German index of socioeconomic deprivation (GISD) was used. The index was developed at the RKI and the last revised version was published in 2022. It is based on nine indicators which reflect the three subdimensions of deprivation: education, employment, and income. That is why GISD is a very suitable index for evaluating regional health disparities. Connecting both informations on BoD and deprivation, gives deeper insides in the regional differences within the country. Some diseases exhibit east/west differences, while others show north/south patterns or rural/urban distinctions. These differences reflect the variation in the prevention and health care needs for the different diseases in Germany. The results underline the necessity to study the regional inequalities separately for each disease. Different health conditions are connected to variations in settings and outline different needs in intervention programs and allocation of means.

What works to reduce regional health inequalities? A case of East vs West Germany post reunification

Abstract Regional inequalities in mortality are rising across the globe. 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 a period of less than 15 years. Drawing from theory on health inequalities, we investigate the contribution of material, behavioural and psychosocial factors likely related to the narrowing of the life expectancy gap between East and West Germany following reunification. We used regional 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. We find 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 standard deviation increase in social security benefits, life expectancy at birth increased by an additional 0.20 [0.07,0.33] years for males and by 0.15 [-0.01,0.31] years for females in East relative to West Germany. We find the protective effect of social security benefits also for women at 65 years (additional 0.14 years [0.006,0.268]) but not for men. Overall, our findings suggest that increasing social security expenditure could be an effective policy-based tool for reducing health disparities across regions with different levels of economic development. This provides additional support for the relevance of the materialist hypothesis and the political economy of root causes of health inequalities. Key messages • Our findings suggest that increasing social security expenditure could be an effective policy-based tool for reducing regional health disparities. • We find support for the materialist and political economy approaches to explaining health inequalities.

Health equity and synergistic abatement strategies of carbon dioxide and air pollutant emissions reduction in China’s eastern coastal area

Abstract Quantifying regional health disparities linked to air pollution is essential for enhancing air quality and attaining carbon neutrality objectives. Nonetheless, the efficacy of proactive policies in ensuring equitable health protection in China’s Eastern Coastal Area (ECA) remains uncertain. Here, we employed an integrated assessment model to assess the combined reduction of carbon dioxide (CO2) and atmospheric pollutants and their health repercussions in the ECA of China. Our findings reveal that 273 000 premature deaths are attributable to air pollution in 2060 in the ECA in the absence of mitigation policies. Conversely, carbon reduction policies are poised to curtail 80% of CO2 emissions, alongside reductions of 76% for NOx, 79% for SO2, 80% for PM2.5, 72% for VOCs, and 66% for NH3 emissions. Air pollution control policies could mitigate premature deaths by 19 600, while carbon reduction policies could potentially lower them by 50 800. The health inequality coefficient among provinces stands at 0.19, primarily attributable to significantly higher mortality rates in Hebei and Shandong. These findings yield valuable insights for crafting synergistic abatement strategies in similarly imbalanced developmental regions grappling with comparable environmental challenges.

Adoption of region-specific diets in China can help achieve gains in health and environmental sustainability.

The vast heterogeneity in dietary practices across China has led to profound regional disparities in health and environment. To address this issue, we developed a region-specific reference diet (RRD) that is better aligned with Chinese culinary traditions, affordable, sparing of natural and environmental resources, and contributes to health. The adoption of the RRD has proven to be a viable solution to facilitate a rapid transition towards a healthy and environmentally sustainable diet across the country when compared to dietary guidelines from the World Health Organization, the EAT-Lancet Commission and the Chinese Nutrition Society. The RRD improved health in all regions and resulted in reductions of all five environmental impacts measured. Given China's huge population and its major impact on global sustainability, the widespread adoption of the RRD would not only yield substantial health benefits domestically, but also contribute significantly to global food security and sustainability efforts.

Health and Nutritional Status of Women in Sant Kabir Nagar, District of Uttar Pradesh: Deviation from State

This study investigates the health and nutritional status of women in Sant Kabir Nagar, Uttar Pradesh, and offers a comparative analysis with broader trends observed across the state. The research addresses significant issues related to women's health, including malnutrition, anemia, and access to delivery care services. Utilizing data from the National Family Health Survey (NFHS-5) this study explores how far the women of the district stand from state level in terms of women’s health and nutritional status. By comparing the district-specific data of Sant Kabir Nagar with state level, the study aims to identify disparities among health and nutritional status of women. The findings provide insights into regional health disparities and inform potential policy interventions to improve women's health and nutrition in both Sant Kabir Nagar and Uttar Pradesh as a whole.

Unveiling oncologists' geographical journey: Analyzing hematology/oncology fellowship graduates' relocation patterns and their impact on regional disparities in cancer care.

9006 Background: The geographical distribution of Hematology/Oncology fellowship graduates (HOFs) is essential for shaping healthcare delivery and illuminating regional health disparities in cancer care. This study explores the relocation patterns of HOFs during key transitions: from medical school to residency (T1), residency to fellowship (T2), and fellowship to the first attending position (T3). The aim is to gain insights into the geographical aspects of cancer care disparities. Methods: This study analyzes the transitions of 329 graduates from 61 ACGME-accredited HOF programs that offered public data about their alumni from 2019-2022. Geographical relocation was measured by the straight-line distance in miles, with the U.S. divided into four regions for retention assessment. A Welch two-sample t-test was conducted to compare average travel distance between each transition. Additionally, relocation patterns were compared between graduates from top 50 NIH-funded medical schools (T50MS) and others (nonT50MS). Results: During T1, HOFs covered a significant distance (661.7 miles), which decreased during T2 (436.5 miles) and T3 (344 miles) (p<.001). Retention analysis revealed a decrease in the percentage of trainees traveling more than 200 miles from T1 (57%) to T2 (46%) to T3 (35%). No significant distance difference was observed between T50MS and nonT50MS during T1 (616 vs 693 miles) and T2 (431 vs 439 miles). However, T3 showed T50MS graduates traveling less (262 miles) compared to their nonT50MS counterparts (401 miles, p<.05). Regional retention increased from T1 (57.5%), to T2 (70%) to T3 (75.4%), with the Western region demonstrating the highest retention across all transitions (T1: 78%, T2: 92%, T3: 83%). The Southern region displayed the lowest retention rates during T1: (44%) and T2: (48%), whereas the Northern region had the lowest during T3 (62%). Conclusions: The preference for relocation beyond 200 miles during T1 reflects a commitment to expanding clinical expertise and gaining varied perspectives critical in addressing complex cancer challenges. As trainees progress, a shift towards establishing roots near previous training sites suggests the allure of established professional and personal networks. T50MS graduates' inclination to stay within a smaller radius during T3 suggests expertise retention in resource-rich areas, potentially exacerbating regional disparities. Marked retention differences, particularly the Southern region’s low retention during training and the Northern region's during practice establishment, reveal a concerning workforce distribution trend. These findings emphasize the necessity for targeted policy interventions aimed at improving equitable distribution of the oncology workforce, thus ensuring uniform access to quality cancer care nationwide.

Regional disparities in health and employment outcomes of China’s transition to a low-carbon electricity system

Understanding the costs and the spatial distribution of health and employment outcomes of low-carbon electricity pathways is critical to enable an equitable transition. We integrate an electricity system planning model (GridPath), a health impact model (InMAP), and a multiregional input–output model to quantify China’s provincial-level impacts of electricity system decarbonization on costs, health outcomes, employment, and labor compensation. We find that even without specific CO2 constraints, declining renewable energy and storage costs enable a 26% decline in CO2 emissions in 2040 compared to 2020 under the Reference scenario. Compared to the Reference scenario, pursuing 2 °C and 1.5 °C compatible carbon emission targets (85% and 99% decrease in 2040 CO2 emissions relative to 2020 levels, respectively) reduces air pollution-related premature deaths from electricity generation over 2020–2040 by 51% and 63%, but substantially increases annual average costs per unit of electricity demand in 2040 (21% and 39%, respectively). While the 2 °C pathway leads to a 3% increase in electricity sector-related net labor compensation, the 1.5 °C pathway results in a 19% increase in labor compensation driven by greater renewable energy deployment. Although disparities in health impacts across provinces narrow as fossil fuels phase out, disparities in labor compensation widen with wealthier East Coast provinces gaining the most in labor compensation because of materials and equipment manufacturing, and offshore wind deployment.

Diverse methodological approaches to a Circumpolar multi-site case study which upholds and responds to local and Indigenous community research processes in the Arctic

ABSTRACT This paper outlines the methodological approaches to a multi-site Circumpolar case study exploring the impacts of COVID-19 on Indigenous and remote communities in 7 of 8 Arctic countries. Researchers involved with the project implemented a three-phase multi-site case study to assess the positive and negative societal outcomes associated with the COVID-19 pandemic in Arctic communities from 2020 to 2023. The goal of the multi-site case study was to identify community-driven models and evidence-based promising practices and recommendations that can help inform cohesive and coordinated public health responses and protocols related to future public health emergencies in the Arctic. Research sites included a minimum of 1 one community each from Canada (Nunavut,) United States of America (Alaska), Greenland, Iceland, Norway, Sweden, Finland. The approaches used for our multi-site case study provide a comprehensive, evidence-based account of the complex health challenges facing Arctic communities, offering insights into the effectiveness of interventions, while also privileging Indigenous local knowledge and voices. The mixed method multi-site case study approach enriched the understanding of unique regional health disparities and strengths during the pandemic. These methodological approaches serve as a valuable resource for policymakers, researchers, and healthcare professionals, informing future strategies and interventions.

The Role of Childhood Circumstances in Healthy Aging Inequalities Among Older Adults - China, 2011-2020.

Addressing health disparities is a worldwide priority, with a well-established acknowledgment of the influence of childhood circumstances on these discrepancies. In China, particularly among the elderly, health inequalities are a notable concern. The inequality in healthy aging has increased from 2011 to 2020, both in general and concerning childhood factors. Nevertheless, the impact of early-life healthcare access and parental health behaviors on healthy aging gaps has reduced among older adults in better health within the top segment of healthy aging. Efforts towards reducing regional health disparities and improving healthcare access for children, along with promoting the health and well-being of parents, especially in economically disadvantaged households, are crucial policy considerations.

Atmospheric elemental carbon pollution and its regional health disparities in China

Previous studies have reported that atmospheric elemental carbon (EC) may pose potentially elevated toxicity when compared to total ambient fine particulate matter (PM2.5). However, most research on EC has been conducted in the US and Europe, whereas China experiences significantly higher EC pollution levels. Investigating the health impact of EC exposure in China presents considerable challenges due to the absence of a monitoring network to document long-term EC levels. Despite extensive studies on total PM2.5 in China over the past decade and a significant decrease in its concentration, changes in EC levels and the associated mortality burden remain largely unknown. In our study, we employed a combination of satellite remote sensing, available ground observations, machine learning techniques, and atmospheric big data to predict ground EC concentrations across China for the period 2005–2018, achieving a spatial resolution of 10 km. Our findings reveal that the national average annual mean EC concentration has remained relatively stable since 2005, even as total PM2.5 levels have substantially decreased. Furthermore, we calculated the all-cause non-accidental deaths attributed to long-term EC exposure in China using baseline mortality data and pooled mortality risk from a cohort study. This analysis unveiled significant regional disparities in the mortality burden resulting from long-term EC exposure in China. These variations can be attributed to varying levels of effectiveness in EC regulations across different regions. Specifically, our study highlights that these regulations have been effective in mitigating EC-related health risks in first-tier cities. However, in regions characterized by a highconcentration of coal-power plants and industrial facilities, additional efforts are necessary to control emissions. This observation underscores the importance of tailoring environmental policies and interventions to address the specific challenges posed by varying emission sources and regional contexts.

Geographically varying associations between mentally unhealthy days and social vulnerability in the USA

ObjectivesA growing body of research has incorporated the Social Vulnerability Index (SVI) into an expanded understanding of the social determinants of health. Although each component of SVI and its association with individual-level mental health conditions have been well discussed, variation in mentally unhealthy days (MUDs) at a county level is still unexplored. To systematically examine the geographically varying relationships between SVI and MUDs across the US counties, our study adopted two different methods: 1) aspatial regression modeling (ordinary least square [OLS]); and 2) locally calibrated spatial regression (geographically weighted regression [GWR]). Study designThis study used a cross-sectional statistical design and geospatial data manipulation/analysis techniques. Analytical unit is each of the 3109 counties in the continental USA. MethodsWe tested the model performance of two different methods and suggest using both methods to reduce potential issues (e.g., Simpson's paradox) when researchers apply aspatial analysis to spatially coded data sets. We applied GWR after checking the spatial dependence of residuals and non-stationary issues in OLS. GWR split a single OLS equation into 3109 equations for each county. ResultsAmong 15 SVI variables, a combination of eight variables showed the best model performance. Notably, unemployment, person with a disability, and single-parent households with children aged under 18 years especially impacted the variation of MUDs in OLS. GWR showed better model performance than OLS and specified each county's varying relationships between subcomponents of SVI and MUDs. For example, GWR specified that 69.3% (2157 of 3109) of counties showed positive relationships between single-parent households and MUDs across the USA. Higher positive relationships were concentrated in Michigan, Kansas, Texas, and Louisiana. ConclusionsOur findings could contribute to the literature regarding social determinants of community mental health by specifying spatially varying relationships between SVI and MUDs across US counties. Regarding policy implementation, in counties containing more social and physical minorities (e.g., single-parent households and disabled population), policymakers should attend to these groups of people and increase intervention programs to reduce potential or current mental health illness. The results of GWR could help policymakers determine the specific counties that need more support to reduce regional mental health disparities.

Regional Health Disparities in Hypertension-Related Hospitalization of Hypertensive Patients: A Nationwide Population-Based Nested Case-Control Study.

Objective: This study aims to explore regional health disparities in hypertension-related hospitalizations and confirm this difference according to the states of continuity of care (COC). Methods: We used the National Health Insurance Service National Sample Cohort data from 2002 to 2019. The dependent variable, hypertension-related hospitalization, included hospitalization for hypertensive diseases (I10-I13, I15), ischemic heart disease (I20-I25), and cerebrovascular disease (I60-I69). Nested case-control matching was performed according to age, sex, and income level. We compared hypertension-related hospitalization fractions in urban and rural areas by classifying them according to the state of COC and analyzed them using conditional logistic regression suitable for matched data. Results: The odds of hypertension-related hospitalization of hypertensive patients were higher in the rural areas than in the urban areas; however, as the COC increased, the difference decreased. There was no change in the results according to the COC observation period. Conclusion: To reduce regional health disparities, both the promotion of COC and the improvement of the quality of primary care must be achieved.

Assessing and Addressing the Determinants of Appalachian Population Health: A Scoping Review.

Residents of Appalachia experience elevated rates of morbidity and mortality compared to national averages, and these disparities are associated with inequitable exposures to various determinants of population health. Social and environmental determinants of health are a useful lens through which to develop and evaluate programs to mitigate regional health disparities. This 2023 scoping review was conducted of studies linking determinants of Appalachian health with leading causes of regional mortality and morbidity. The search strategy employed a keyword search that included geographic terms for the Appalachian Region and the primary adverse health outcomes in that region. Studies meeting the following inclusion criteria were reviewed: original article, published in the last five years, involving an Appalachian population, and includes a rigorous assessment of an association between a population health determinant and one or more leading causes of Appalachian morbidity and mortality. The search returned 221 research articles, including 30 interventional studies. The top three health outcomes included cancer (43.59%), diseases of despair (23.08%), and diabetes (12.82). Access to care (27.3%), rurality (18.9%), and education (14.8%) were the most common population health determinants identified. Interventional studies were categorized by program types: education, technology, partnerships, and multilevel interventions. Due to the heterogeneity of study types, the studies were combined using a narrative synthesis. The results of this work can inform the development and evaluation of additional programs to promote Appalachian population health. Our study team will use these results to inform community-based discussions that develop strategic plans to mitigate health disparities in Central and Southcentral Appalachian Virginia.

Impact of Interprofessional Student Teams at a Remote Area Medical Event in Rural Appalachia.

Education in interprofessional collaboration is vital to expand healthcare access, especially in areas of higher disparity. To address this need, interprofessional faculty collaborators incorporated undergraduate and graduate health profession students into teams at an annual Remote Area Medical event in rural Appalachia between 2017 and 2020. This article evaluates the impact of an interprofessional student teams model on both patient care experience and students' interprofessional collaboration attitudes and behaviors. Student volunteers completed pre- and post-event surveys containing questions about demographics, open-ended questions, and questions from two instruments: the Student Perceptions of Interprofessional Clinical Education-Revised Instrument, Version 2 (SPICE-R2) and the Interprofessional Collaborative Competency Attainment Scale-Revised (ICCAS-R). Quantitative data were analyzed statistically; qualitative data thematically. Tally forms collected patient care interventions that were compared to regional health disparities. Two years of survey data and four years of intervention data were analyzed. There was an increase (p < 0.001) in the post-event survey SPICE-R2 factors (teamwork, healthcare outcomes, and roles and responsibilities) in 2020 but not in 2019. ICCAS-R mean post-event composite scores increased (p < 0.05) in both 2019 and 2020. Qualitative coding of open-ended responses revealed interprofessional competency themes and provided event feedback. Over 5,900 health-disparity-focused interventions were completed between 2017 and 2020. Students participating in interprofessional teams demonstrate changes in attitudes towards the interprofessional approach to care, an improved ability to collaborate interprofessionally, and a positive impact on patient care interventions. The findings allow educators to understand how experiential interprofessional education influences students' interprofessional attitudes and beliefs while benefitting patient care.

The Ninth Myth of Appalachia.

Many stereotypes afflict our much-maligned region, and the Jonesborough-Washington County History Museum displays eight of these "myths of Appalachia." Here, our Editor-in-Chief suggests a ninth-that the people of Appalachia "do not care" about their health-and argues that regional health disparities result not from apathy but from a confluence of socioeconomic factors.

Nutrition improvement program for rural compulsory education students and individual health.

We use the county-by-county rollout of the program and employ the difference-in-difference (DID) methodology to identify the effects of the implementation of the nutrition improvement program for rural compulsory education students on adolescent health. The results show that the nutrition improvement program reduces the frequency and probability of illness and improves the students' health status. The heterogeneity analysis indicates that the children in western regions and children left behind have a greater marginal improvement. It finds that the nutrition improvement program for rural compulsory education students improves adolescent health through diversifying nutrition intake to alleviate malnutrition and developmental delay in impoverished areas. The program can promote adolescent health in impoverished areas, which has a role in improving regional health disparities and alleviating the intergenerational entrenchment of poverty.

Geographical Variance in Esophagectomy for Esophageal Cancer: A Statewide Analysis of Rural and Regional Health Disparities

Geographical Variance in Esophagectomy for Esophageal Cancer: A Statewide Analysis of Rural and Regional Health Disparities

Contribution of the Technical Efficiency of Public Health Programs to National Trends and Regional Disparities in Unintentional Childhood Injury in Japan.

To achieve the Sustainable Development Goals, strengthening investments in health service inputs has been widely emphasized, but less attention has been paid to tackling variation in the technical efficiency of services. In this study, we estimated the technical efficiency of local public health programs for the prevention of unintentional childhood injury and explored its contribution to national trend changes and regional health disparities in Japan. Efficiency scores were estimated based on the Cobb–Douglas and translog production functions using a true fixed effects model in a stochastic frontier analysis to account for unobserved time-invariant heterogeneity across prefectures. Using public data sources, we compiled panel data from 2001 to 2017 for all 47 prefectures in Japan. We treated disability-adjusted life years (DALYs) as the output, coverage rates of public health programs as inputs, and caregivers' capacity and environmental factors as constraints. To investigate the contribution of efficiency to trend changes and disparities in output, we calculated the predicted DALYs with several measures of inefficiency scores (2001 average, yearly average, and prefecture-year-specific estimates). In the translog model, mean efficiency increased from 0.62 in 2001 to 0.85 in 2017. The efficiency gaps among prefectures narrowed until 2007 and then remained constant until 2017. Holding inefficiency score constant, inputs and constraints contributed to improvements in average DALYs and widened regional gaps. Improved efficiency over the years further contributed to improvements in average DALYs. Efficiency improvement in low-output regions and stagnated improvement in high-output regions offset the trend of widening regional health disparities. Similar results were obtained with the Cobb–Douglas model. Our results demonstrated that assessing the inputs, constraints, output, and technical efficiency of public health programs could provide policy leverage relevant to region-specific conditions and performance to achieve health promotion and equity.

Economic disparities in pollution-related mortality in three municipalities of the Metropolitan Area of the Valley of Mexico

This study explored the nature of health risks in the population of three municipalities within the Metropolitan Area of the Valley of Mexico (MAVM) by means of an empirical analysis of health effects associated with air pollution and temperature variation. Based on the environmental justice theory, we asked whether, in unequal socioeconomic municipalities of the MAVM, the association between PM10 concentrations and mortality depends on socioeconomic disparities. We differ from previous studies that have established a relationship between PM10 and mortality based on a state-space model instead of the Poisson regression model. The state-space model allows estimating the size of the unobserved at-risk population, its hazard rate, the life expectancy of individuals in that population, and the effect of changes in environmental conditions on that life expectancy. Our results show a lower hazard rate in a wealthy municipality, as compared to a higher hazard rate in a poor one. The lower hazard rate of the wealthy municipality extends life expectancy and enhances the likelihood of inhabitants staying long-lasting within the population at risk, thus increasing the size of that population, as compared to the population at risk in the poor municipality, whose members show a lower life expectancy. Thus, the smaller the at-risk population, the sicker its average member and the smaller the impact on long-term mortality. Our study examines how regional health disparities could provide information for public health policy initiatives which might improve living conditions among different communities.