Understanding Health Inequalities Research Articles

End-of-life care among patients with schizophrenia and cancer: a population-based cohort study from the French national hospital database

Patients with schizophrenia represent a vulnerable, underserved, and undertreated population who have been neglected in health disparities work. Understanding of end-of-life care in patients with schizophrenia and cancer is poor. We aimed to establish whether end-of-life care delivered to patients with schizophrenia and cancer differed from that delivered to patients with cancer who do not have diagnosed mental illness. We did a population-based cohort study of all patients older than 15 years who had a diagnosis of advanced cancer and who died in hospital in France between Jan 1, 2013, and Dec 31, 2016. We divided this population into cases (ie, patients with schizophrenia) and controls (ie, patients without a diagnosis of mental illness) and compared access to palliative care and indicators of high-intensity end-of-life care between groups. In addition to unmatched analyses, we also did matched analyses (matched in terms of age at death, sex, and site of primary cancer) between patients with schizophrenia and matched controls (1:4). Multivariable generalised linear models were done with adjustment for social deprivation, year of death, time from cancer diagnosis to death, metastases, comorbidity, and hospital type (ie, specialist cancer centre vs non-specialist centre). The main analysis included 2481 patients with schizophrenia and 222 477 controls. The matched analyses included 2477 patients with schizophrenia and 9896 controls. Patients with schizophrenia were more likely to receive palliative care in the last 31 days of life (adjusted odds ratio 1·61 [95% CI 1·45-1·80]; p<0·0001) and less likely to receive high-intensity end-of-life care-such as chemotherapy and surgery-than were matched controls without a diagnosis of mental illness. Patients with schizophrenia were also more likely to die younger, had a shorter duration between cancer diagnosis and death, and were more likely to have thoracic cancers and comorbidities than were controls. Our findings suggest the existence of disparities in health and health care between patients with schizophrenia and patients without a diagnosis of mental illness. These findings underscore the need for better understanding of health inequalities so that effective interventions can be developed for this vulnerable population. Assistance Publique des Hôpitaux de Marseille and Aix-Marseille University.

Egészségegyenlőtlenség, hozzáférés, térbeliség – a szívizominfarktus ellátásának néhány földrajzi jellegzetessége Magyarországon

Access to health care is one of determinative factors in understanding health inequalities. It is not an easy task to define it, because its conceptualisation and measuring depend on different approaches and socio-economic characteristics. In our three year course research project the main aim is to analyse the Hungarian health inequality and its regional differences related to the role of access to health care. The multi-factorial way in determination of barriers in access to health care means using mixed method with combination of quantitative and qualitative techniques. Acute myocardial infarction is one of non-communicable cardiovascular diseases, which was the example in the case study of our project. This was used to study the connection among accessibility, inequality and spatiality. The primary results of statistical analysis confirm a paradox situation in Hungary based on improving health with increasing inequalities. The most important experiences of making semi-structured interviews with medical stakeholders and patients can discover individual and institutional influencing factors in access to health care. The aim of this paper is to interpret basic theoretical and empirical framework of our research project with its most important results. In addition, many experiences of our examinations are suitable for making proposals for evidence based policy-making.

Intersectional inequalities and the U.S. opioid crisis: challenging dominant narratives and revealing heterogeneities

ABSTRACT Dominant narratives of prescription opioid misuse (POM) in the U.S. have portrayed it as an issue primarily affecting White communities. In this study we explore POM as reported in data from the 2015 National Survey on Drug Use and Health, using an intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). We map the risk of POM through a series of multilevel models with individuals (N = 43,409) nested within strata formed by the intersections of gender, race/ethnicity, income, and age. We find meaningful heterogeneity between and within strata. The ten strata with the greatest risk for POM were comprised of individuals identifying as White, African American, and non-White Hispanic, and included individuals of low, medium, and high income. We uncover intersections of social position with high risk for POM that are often excluded from dominant narratives, including young high-income African American women. Intersectional approaches are essential for advancing our understanding of health inequalities and unfolding epidemics such as that of POM in the U.S.

China's dusty lung crisis: Rural-urban health inequity as social and spatial injustice

This paper examines rural-urban inequities in dusty lung (pneumoconiosis) deaths in China from 2002 to 2016 and possible causes for such inequities in the framework of social and spatial justice. The research reveals alarming results that have not been reported before. Dusty lung death rates for rural men increased twice as fast as those among urban men. The rural rates were particularly higher among middle-aged men, but lower in older age groups, as compared to urban rates. There were dramatic increases in death rates from 2011 to 2016 particularly among rural men aged 40–49 years old, who were many times more likely to die from dusty lung than urban men of a similar age. Chinese rural male victims also die at a younger age, compared to men in any of the seven countries or regions included in the study. For example, rural Chinese men aged 35–59 years old were many times more likely to die from dusty lung than their American, German, Polish, and Spanish counterparts. A possible explanation for the high death rates among middle-aged rural Chinese men is the tendency for rural migrant workers to be employed in unhealthy and unsafe working conditions in decent decades. Other explanations for the severe spatial injustice include the Hukou (household registration) system and the development policies that prioritize economic growth and urban development over occupational health and safety. The paper demonstrates the usefulness and weakness of the social and spatial justice concepts in understanding health inequity. Therefore, it proposes new definitions and models of social justice and spatial justice that combine the competing distribution and capabilities approaches and highlight interactions among multiple attributes.

Role of the nurse in identifying and addressing health inequalities

This article aims to improve nurses' knowledge and understanding of health inequalities. Health inequalities are responsible for variation in health outcomes observed across different population groups. Therefore, it is essential that nurses have an understanding of the health inequalities that can occur, and their causes. This knowledge will enable nurses to address the challenges that health inequalities can create in nursing practice. This article raises awareness of this important aspect of care, so that nurses can successfully identify and address the health inequalities that they encounter in their practice, thus enabling a holistic approach to patient care.

Social Class for Collective Health Research: A Conceptual and Empirical Challenge

ABSTRACTSocial Determination of Health (SDH)/Collective Health is a Latin American framework that sees the Marxist core concept of social class as fundamental for understanding health inequalities. In contrast to social stratification approaches, Marxist proposals seek to understand health as part of the historical transformations of capitalism’s mode of production. In this article we aim to analyze the relationship between social class and health inequalities using data from the IV Oral Health National Study in Colombia. We conducted hierarchical cluster analyses to classify the population in five class positions and three living conditions clusters, which reflect how the spheres of production and social reproduction relate to social classes in Colombia. To measure oral health we use DMFT, as well as care and treatment needs indexes. Through variance analysis models we found that people from more exploited class positions and worse living conditions have more active disease and higher treatment needs. Despite technical and conceptual challenges, we conclude that a social class analytical framework can be operationalised via the interrelated spheres of production and social reproduction, which sheds light on the relationship between health inequalities and the class structure of the capitalist system.

Canadian trends in the social determinants of health inequalities, a census-mortality linkage approach

IntroductionMortality inequalities by income and education levels have historically been estimated using an area-based approach in Canada. Although useful in measuring socioeconomic inequalities overtime, this method underestimates the level of inequality and only allows the examination of a single dimension at a time.&#x0D; Objectives and ApproachTo create a series of census linked datasets that allowed for the examination of health inequalities across different socioeconomic dimensions. Specifically, five census cycles (beginning with the 1991 Census) were probabilistically and deterministically linked to different health outcomes (mortality, cancer, hospitalization) to create the Canadian Census Health and Environment Cohort (CanCHEC). Each dataset was created using a similar methodological approach which allowed for the measurement of these health inequalities over time. Mortality inequalities by both income and education level (including multidimensional) for all causes and cause-specific groups were examined.&#x0D; ResultsFive census linked datasets were constructed that followed mortality for a period of up to 20 years. The 1991 CanCHEC includes 2.6 million adults, the 1996 and 2001 CanCHECs include 3.5 million adults respectively, and the 2006 and 2011 CanCHECs include 5.9 and 6.5 million people respectively. Findings revealed a stair-stepped gradient in all-cause and cause-specific mortality by educational attainment and income quintile across each time period. The lowest mortality rates were among the university educated and richest income quintile and highest mortality rates among those with less than high school graduation and the poorest income quintile. The gradient differed by cause of death groupings. Over the 25-year time period, the mortality gradient trend varied by socioeconomic dimension and cause of death.&#x0D; Conclusion/ImplicationsThese data show clear mortality inequalities by socioeconomic position across the different time periods. These linked datasets can help advance knowledge in understanding health inequalities in Canada as well as provide a tool for on-going surveillance of health inequalities by different socioeconomic dimensions.

"As Natural as the Air Around Us": On the Origin and Development of the Concept of Structural Violence in Health Research.

This article examines the concept of "structural violence." Originating in the work of Johan Galtung in 1969 and popularized by Paul Farmer, structural violence is increasingly invoked in health literature. It is a complex concept - rich in its explanatory potential but vague in its operational definition and arguably limited in its theoretical precision. Its potential lies in the focus it gives to the deep structural roots of health inequities; in contrast to the more passive term "social determinants of health," structural violence explicitly identifies social, economic, and political systems as the causes of the causes of poor health. It is also evocative in its framing of health inequities as an act of violence. Yet the formulation of structure used in this literature is largely atheoretical and, by extension, apolitical. Development of the concept hinges on clarifying the precise aspects of structure it points to (perhaps through using the concept in conjunction with larger theoretical frameworks) as well as improving operational definitions to enable its use in quantitative social epidemiology. We argue that the concept of structural violence can provide a useful lens for understanding health inequities, but its full potential is only realized when combined with larger theoretical frameworks.

The interplay of contextual layers: A multilevel analysis of income distribution, neighborhood infrastructure, socioeconomic position and self-rated health in Brazil

Our hypothesis is that neighborhood infrastructure modifies the association between state-level income distribution and self-rated health. In our findings neighborhood infrastructure amplifies the association between income equality and self-rated health, yet with a differential impact on health according to sex, race and education level favoring individuals at higher socioeconomic positions. Most of the individual health variation attributed to context happens at neighborhood level, based on random effects analyses. Our findings contribute to a further understanding of health inequalities in Brazil. The demonstrated synergism between state, neighborhood and individual level determinants of health supports inter-sectoral policies and interventions in a clearly multileveled way.

Slovenian Version of The European Deprivation Index at Municipal Level.

IntroductionEcological deprivation indices belong to essential instruments for monitoring and understanding health inequalities. Our aim was to develop the SI-EDI, a newly derived European Deprivation Index for Slovenia. We intend to provide researchers and policy-makers in our country with a relevant tool for measuring and reducing the socioeconomic inequalities in health, and even at a broader level.MethodsData from the European survey on Income and Living Conditions and Slovenian national census for the year 2011 were used in the SI-EDI construction. The concept of relative deprivation was used where deprivation refers to unmet need(s), which is caused by lack of all kinds of resources, not only material. The SI-EDI was constructed for 210 Slovenian municipalities. Its geographical distribution was compared to the distribution of two existing deprivation scores previously applied in health inequality research in Slovenia.ResultsThere were 36% of adults recognized as deprived in Slovenia in 2011. SI-EDI was calculated using 10 census variables that were associated with individual deprivation. A clear east-to-west gradient was detected with the most deprived municipalities in the eastern part of the country. The two existing deprivation scores correlate significantly with the SI-EDI.ConclusionsA new deprivation index, the SI-EDI, is grounded on the internationally established scientific concept, can be replicated over time and, crucially, provides an account of the socioeconomic and cultural particularities of the Slovenian population. The SI-EDI could be used by the stakeholders and the governmental and nongovernmental sectors in Slovenia, with the goal of better understanding health inequalities in Slovenia.

Relative Roles of Race Versus Socioeconomic Position in Studies of Health Inequalities: A Matter of Interpretation.

An abundance of research has documented health inequalities by race and socioeconomic position (SEP) in the United States. However, conceptual and methodological challenges complicate the interpretation of study findings, thereby limiting progress in understanding health inequalities and in achieving health equity. Fundamental to these challenges is a lack of clarity about what race is and the implications of that ambiguity for scientific inquiry. Additionally, there is wide variability in how SEP is conceptualized and measured, resulting in a lack of comparability across studies and significant misclassification of risk. The objectives of this review are to synthesize the literature regarding common approaches to examining race and SEP health inequalities and to discuss the conceptual and methodological challenges associated with how race and SEP have been employed in public health research. Addressing health inequalities has become increasingly important as the United States trends toward becoming a majority-minority nation. Recommendations for future research are presented.

How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care

Scotland is faced with pernicious health inequalities, which stem from inequalities in living conditions and the societal structures that create them. While action is needed to address the wider structural causes of health inequalities, the role of general practitioners (GPs) merits attention due to health care’s potential to mitigate or exacerbate health inequalities. Minimal research, however, has explored how GPs understand the fundamental causes of health inequalities nor how they conceptualise their role in mitigating these. This paper aims to fill this gap using in-depth qualitative interviews with 24 GPs working in some of Scotland’s most socio-economically disadvantaged, urban areas. Using Raphael’s SDH discourse framework, this paper found clear linkages between GPs’ perceptions of their patients, how they defined the ‘problem’ of health inequalities, and what they thought could be done to tackle them in disadvantaged areas. In general, there was convergence on how interviewees viewed their role in mitigating health inequalities through their work with individual patients. However, greater variation was found when describing the boundaries of their role and how far these extended beyond individual encounters. Specifically, only those GPs fluent in discussing structural causes of health inequalities discussed obligations to change local systems via strengthening community linkages and to influence higher level policies related to the SDH. This suggests that while there is a degree of what Metzl and Hansen deem ‘structural competency’ amongst some GPs working in disadvantaged areas, the scope remains to deepen this competency more broadly.

Understanding Health Inequalities and Justice: New Conversations across the Disciplines. Mara Buchbinder, Michelle Rivkin-Fish, and Rebecca Walker, eds. Chapel Hill: University of North Carolina Press, 2016, 350 pp.

Understanding Health Inequalities and Justice: New Conversations across the Disciplines. Mara Buchbinder, Michelle Rivkin-Fish, and Rebecca Walker, eds. Chapel Hill: University of North Carolina Press, 2016, 350 pp.

Despairing about Health Disparities

AbstractI have never doubted that the problem of inequalities in health status and access to needed care is a difficult ethical and political challenge. After reading the essays in Understanding Health Inequalities and Justice: New Conversations across the Disciplines, edited by Mara Buchbinder, Michele Rivkin‐Fish, and Rebecca Walker, I concluded that despair was the only suitable response in the face of daunting ethical and political complexity.The editors of this volume have three questions in mind that they asked contributors to address. (1) How do scholars from various disciplines approach relations between health inequalities and ideals of justice? Social scientists want to offer empirical descriptions of inequalities in health status across a range of social groups, but there are numerous ways of offering such descriptions. Are they all “correct”? Philosophers and medical ethicists want to make normative judgments regarding which inequalities matter, ethically speaking. So (2) do we need to know when considerations of justice are relevant to assessing health inequalities and which considerations of justice are most relevant in specific contexts? Ultimately, (3) the question is which of these scholarly approaches is most useful for improving health policy.

The Portuguese Version of the European Deprivation Index: An Instrument to Study Health Inequalities.

Tackling socioeconomic health inequalities is a big public health challenge and ecological deprivation indexes areessential instruments to monitor and understand them. In Portugal, no standard ecological deprivation index exists, contrasting withother countries. We aimed to describe the construction of the Portuguese version of a transnational deprivation index, EuropeanDeprivation Index. The European Deprivation Index was developed under the Townsend theorization of deprivation. Using datafrom the European Union - Statistics on Income and Living Conditions Survey, we obtained an indicator of individual deprivation. Thisindicator became the gold-standard variable, based on what we selected the variables at aggregate level (census) to be included in theEuropean Deprivation Index, a total of eight. The European Deprivation Index was produced for the smallest area unit possible (n = 16094, mean/area = 643 inhabitants) and resulted from the weighted sum of the previous variables. It was then classified into quintiles. The first quintile (least deprived) comprised 20.9% national population and the fifth quintile (most deprived) 18.0%. TheEuropean Deprivation Index showed a clear geographic pattern - most deprived areas concentrated in the South and in the inner Northand Centre of the country, and the least deprived areas in the coastal areas of North and Centre and in the Algarve. The development of the European Deprivation Index was grounded on a solid theoretical framework, individual andaggregate variables, and on a longitudinal Europe-wide survey allowing its replication over the time and in any European country. Hopefully, the European Deprivation Index will start being employed by those interested in better understand healthinequalities not only in Portugal but across Europe.

Embodying pervasive discrimination: a decomposition of sexual orientation inequalities in health in a population-based cross-sectional study in Northern Sweden

BackgroundStudies from Sweden and abroad have established health inequalities between heterosexual and non-heterosexual people. Few studies have examined the underpinnings of such sexual orientation inequalities in health. To expand this literature, the present study aimed to employ decomposition analysis to explain health inequalities between people with heterosexual and non-heterosexual orientation in Sweden, a country with an international reputation for heeding the human rights of non-heterosexual people.MethodsParticipants (N = 23,446) came from a population-based cross-sectional survey in the four northernmost counties in Sweden in 2014. Participants completed self-administered questionnaires, covering sexual orientation, mental and general physical health, social conditions and unmet health care needs, and sociodemographic data was retrieved from total population registers. Sexual orientation inequalities in health were decomposed by Blinder-Oaxaca decomposition analysis.ResultsResults showed noticeable mental and general health inequalities between heterosexual and non-heterosexual orientation groups. Health inequalities were partly explained (total explained fraction 64-74%) by inequalities in degrading treatment (24-26% of the explained fraction), but to a considerable degree also by material conditions (38-45%) and unmet care needs (25-43%).ConclusionsPsychosocial experiences may be insufficient to explain and understand health inequalities by sexual orientation in a reputedly ‘gay-friendly’ setting. Less overt forms of structural discrimination may need to be considered to capture the pervasive material discrimination that seems to underpin the embodiment of sexual minority inequalities. This ought to be taken into consideration in research, policy-making and monitoring aiming to work towards equity in health across sexual orientations.

Health inequalities on adolescents' risk behavior indicators in Mexico: analysis of two national health surveys

To document socioeconomic health inequalities on adolescents' risk behaviors in Mexico using gap and gradient measures. Analysis of the national health surveys 2000 and 2012 measuring absolute and relative gaps as well as the slope index of inequality for risk behavior indicators on adolescents using socioeconomic indicators and also measuring gaps for sex, urban/rural residency, and indigenous/non-indigenous population. For sexual risk behaviors, inequalities are reflected in a lower probability of using protection at the first sexual intercourse among those living in households with lower income for women and men as well as higher probability of ever being pregnant for adolescents of lower income. For tobacco and alcohol consumption and for violence related health problems, inequalities imply higher probability of consumption among those in household with larger incomes. Socioeconomic health inequalities are a relevant challenge for adolescents' wellbeing in Mexico, with a complex scenario where resource scarcity is related to increasing risk behaviors that may compromise their future. A better understanding of health inequalities is needed to design effective interventions.

Embodied inequality.

A diverse group of scholars tackles the relationships between health care and social justice

Using Multiple-hierarchy Stratification and Life Course Approaches to Understand Health Inequalities: The Intersecting Consequences of Race, Gender, SES, and Age.

This study examines how the intersecting consequences of race-ethnicity, gender, socioeconomics status (SES), and age influence health inequality. We draw on multiple-hierarchy stratification and life course perspectives to address two main research questions. First, does racial-ethnic stratification of health vary by gender and/or SES? More specifically, are the joint health consequences of racial-ethnic, gender, and socioeconomic stratification additive or multiplicative? Second, does this combined inequality in health decrease, remain stable, or increase between middle and late life? We use panel data from the Health and Retirement Study (N = 12,976) to investigate between- and within-group differences in in self-rated health among whites, blacks, and Mexican Americans. Findings indicate that the effects of racial-ethnic, gender, and SES stratification are interactive, resulting in the greatest racial-ethnic inequalities in health among women and those with higher levels of SES. Furthermore, racial-ethnic/gender/SES inequalities in health tend to decline with age. These results are broadly consistent with intersectionality and aging-as-leveler hypotheses.

Using Multiple-hierarchy Stratification and Life Course Approaches to Understand Health Inequalities: The Intersecting Consequences of Race, Gender, SES, and Age

Using Multiple-hierarchy Stratification and Life Course Approaches to Understand Health Inequalities: The Intersecting Consequences of Race, Gender, SES, and Age