Understanding Health Inequalities Research Articles

Editorial introduction: Social and spatial inequalities in health and mortality: The analysis of longitudinal register data from selected European countries

AbstractHealth inequalities—systematic differences in health outcomes between social groups and across spatial units—are ubiquitous, but not necessarily inevitable. They are the product of a complex interplay of social and economic processes operating at various scales. The unequal pattern of infection and death seen in the Covid‐19 pandemic has served to highlight the stark social gradient in health that exists within many European countries. Although the complex social determinants of health have been studied for many decades, there is still a great deal of work to do to elucidate explanations for health inequalities across time and space. To rise to the challenge, we need high‐quality, representative data capable of capturing multi‐scalar longitudinal processes. This special issue brings together eight new studies which all use national population register data linked with various other sources of administrative data (e.g., residence, tax and health records) to investigate different vectors of inequalities in health and mortality, covering spatial, socioeconomic, ethnic and migrant status. This editorial outlines their contributions, argues for the invaluable role of population register data to understand health inequalities and suggests promising future research avenues.

Qualitative evaluation of a mandatory health insurance ‘wait period’ in a publicly funded health system: understanding health inequities for newcomer im/migrant women

ObjectivesTo evaluate impacts of a residency-based waiting period for health insurance coverage on lived experiences of health and settlement for im/migrant women in British Columbia, Canada.DesignThe IRIS study is a...

The benefits of an innovative community engagement model in dental undergraduate education

ABSTRACT Dental healthcare students at the Peninsula Dental School, University of Plymouth, UK undertake community engagement projects as a core part of their undergraduate curriculum. Students work with their peers to develop a student-led, evidence-based project working with target groups in the local community to address oral health needs. The aim of the programme is to further the students’ understanding of health inequalities and the health needs of different groups in the community, while developing skills that will help them deliver holistic dental care as part of their future professional practice. This report highlights our model of education delivery in collaboration with the community, the student-learning outcomes and discusses some of the benefits of this approach including examples of projects that have benefitted the community. We highlight the further work needed to evaluate the longer-term impacts on students of undertaking social accountability programmes.

The Importance of Primary Care Research in Understanding Health Inequities in the United States.

Eliminating health and health care inequities is a longstanding goal of multiple United States health agencies, but overwhelming scientific evidence suggests that health and health care inequities persist in the United States, despite decades of research and initiatives to alleviate them. Because of its comprehensiveness, studying health inequities in the context of primary care allows for the use of multiple paradigms and methodologic approaches to understanding almost any state of health, disease, social challenge, or societal circumstance a patient or group of patients might face. We argue in this special communication that the many features/advantages of primary care research have valuable contributions to make in reducing health inequity, and scientists, journals, and funders should increase the incorporation of primary care approaches and findings into their portfolios to better understand and end health inequity.

Social inequalities in the associations between urban green spaces, self-perceived health and mortality in Brussels: Results from a census-based cohort study.

This study examines the associations between residential urban green spaces (UGS) and self-perceived health and natural cause mortality, applying an intersectional approach across gender, education and migrant background. We used data from the 2001 Belgian census linked to register data on emigration and mortality for the period 2001-2014, including 571,558 individuals aged 16-80 residing in Brussels (80% response rate). Residential UGS were assessed with the Normalized Difference Vegetation Index (NDVI) within a 300m buffer from the residential address and perceived neighbourhood greenness. Multilevel logistic and Cox proportional hazards regression models were conducted to estimate associations between UGS and poor self-perceived health at baseline and natural cause mortality during follow-up. Residential UGS were inversely associated with both outcomes, but there were differences between groups. The strongest beneficial associations among women were found in the lower educated, regardless of their migrant background. For men the strongest association was found in those with tertiary education and Belgian origin. No significant beneficial associations were found in men originating from low and middle-income countries. Applying an intersectionality approach is crucial to understand health inequalities related to UGS exposure. Further research in different geographical contexts is needed to contrast our findings.

Patientologien nyfortolket

Patientology traditionally signifies the scientific study of the patients through medical sociological and anthropological perspectives. The last decades have witnessed notable changes in the understanding of what it means to be a patient and what role patients play in healthcare processes, with the rise of concepts such as patient-centered care, patient empowerment, and patient participation. This article develops a reconceptualization of patientology, proposes a model hereof, and exemplifies its use through the application to an illustrative case.
 Our reconceptualization of patientology considers the patient as the central actor in a network of healthcare actors. Being a patient requires health capital that is comprised of health-relevant aspects of Bourdieusian forms of capitals: economic, social, and cultural capital. The patient role is constructed through the patient’s interaction with a range of healthcare actors such as health professionals, relatives, and other patients. The proposed model allows for understanding health inequalities as based on differences in (cultural) health capital, opening up new avenues of investigating and ameliorating patients’ challenges in health interactions. The model allows for a fresh take on the reciprocity of Parsons social sick role, allowing to clarify both how patients can contribute to their own health and healthcare and where and how health professionals ought to meet their patients.

The value of general health perception in health equity research: A community-based cohort study of long-term mortality risk (Finnmark cohort study 1987–2017)

BackgroundGeneral health perception as measured by self-rated health (SRH) is an individual's synthesis of personal overall health and has value in its own right. In addition, this subjective perspective has a unique predictive power of subsequent mortality and adds valuable information not captured by objective measures. We studied the relationship between SRH and subsequent mortality to demonstrate how simple self-ratings can enhance our understanding of health inequities. MethodsData from a population-based survey conducted in Finnmark 1987/1988 were linked to the Norwegian Cause of Death Registry for information on all deaths by the end of 2017. We used Cox proportional hazard regression modelling to estimate the relative effects of all-cause mortality separately for sex and age (30–49 and 50–62 years) with stepwise adjustment for socio-demographics and various other health status and behavioural measures. ResultsThe age-adjusted power of mortality prediction of SRH was strong (most pronounced in the youngest age-group) but markedly attenuated by other factors. Education inequality in mortality was most substantial in the youngest age-group, which might partly be due to a combination of selective mortality and historical changes in health inequality. In comparison, educational inequality in SRH was clearly pronounced regardless of age. Work disability pension appeared as the common key factor affecting the mortality prediction of SRH and educational inequity for both subsequent mortality and SRH. ConclusionSRH adds unique information to our understanding of health inequities. The consistency in shared predictors of educational inequity concerning both mortality and SRH underscores the correspondence of these measures. In addition to predicting the fatal effects of social selection mechanisms, SRH adds non-fatal effects and seems less prone to selective mortality. The results are relevant to approaches in health equity research and have important policy implications.

From cohort to community: The emotional work of birthday cards in the Medical Research Council National Survey of Health and Development, 1946-2018.

The Medical Research Council National Survey of Health and Development (NSHD) is Britain’s longest-running birth cohort study. From their birth in 1946 until the present day, its research participants, or study members, have filled out questionnaires and completed cognitive or physical examinations every few years. Among other outcomes, the findings of these studies have framed how we understand health inequalities. Throughout the decades and multiple follow-up studies, each year the study members have received a birthday card from the survey staff. Although the birthday cards were originally produced in 1962 as a method to record changes of address at a time when the adolescent study members were potentially leaving school and home, they have become more than that with time. The cards mark, and have helped create, an ongoing evolving relationship between the NSHD and the surveyed study members, eventually coming to represent a relationship between the study members themselves. This article uses the birthday cards alongside archival material from the NSHD and oral history interviews with survey staff to trace the history of the growing awareness of importance of emotion within British social science research communities over the course of the 20th and early 21st centuries. It documents changing attitudes to science’s dependence on research participants, their well-being, and the collaborative nature of scientific research. The article deploys an intertextual approach to reading these texts alongside an attention to emotional communities drawing on the work of Barbara Rosenwein.

Undergraduate students’ perspectives on the impact of a prison health course

Objective:The stigmatisation of incarceration has significant negative effects on the health and well-being of individuals and communities. At the University of British Columbia in Canada, an undergraduate course on prison health included instruction by people with lived experience of incarceration as part of a teaching approach aimed to reduce stigma. In this study, we sought to understand the impact of this course as described by students.Design:Qualitative interviews with students who completed the course in 2017 were conducted by another former student of the course. Interviews were transcribed and interpretive descriptive methods were used to elucidate findings.Results:Nine former students participated in the study, eight (89%) were women and the median age was 23 years. Analysis yielded the following themes: (1) learning from people with lived experience, (2) de-mystifying through knowledge and understanding, (3) broadened perspectives and self-reflection, (4) future choices and actions and (5) changing views on incarceration.Conclusion:Findings suggest that approaches to address stigma in teaching prison health in an undergraduate course provided students with a deepened understanding of health inequities and determinants of health; increased feelings of compassion and interest in health equity for populations impacted by incarceration; and fostered opportunities for reflection, critical thinking and broadened perspectives.

Transbordering assemblages: Power, agency and autonomy (re)producing health infrastructures in the South East of England

This paper discusses how intersecting identities, stigma and health-based infrastructures are spatially affiliated and territorialised in the South East of England through the findings of three research projects aimed at understanding health inequalities among urban Black, Asian and Ethnic Minorities including Gypsies and Travellers (BAME and GT) groups. It problematises Wacquant’s approach to territorial stigma by explaining how Butler’s notion of vulnerability and Castoriadis’ notion of autonomous agency help to expand our understanding of the interplay between stigma and health infrastructures. Moreover, it suggests that such interplay requires an intersectional approach to identity as performative and embodied practice using illustrative examples. We propose that these health settings and infrastructures can be characterised as ‘transbordering assemblages’, following Irazábal who describes its embedded notions of pluri-locality (here and there: ‘[T]Here’), pluri-identity and practices of bordering (being in or out/in and out/in between) when experiencing health needs.

Health disparities and equity in the era of COVID-19.

Over the last year, COVID-19 has emerged as a highly transmissible and lethal infection. As we address this global pandemic, its disproportionate impact on Black, Indigenous, and Latinx communities has served to further magnify the health inequities in access and treatment that persist in our communities. These sobering realities should serve as the impetus for reexamination of the root causes of inequities in our health system. An increased commitment to strategic partnerships between academic and nonacademic health systems, industry, local communities, and policy-makers may serve as the foundation. Here, we examine the impact of the recent COVID-19 pandemic on health care inequities and propose a strategic roadmap for integration of clinical and translational research into our understanding of health inequities.

Toward an Intersectional Approach to Health Justice.

Despite unprecedented global wealth creation, health inequity-the unjust health inequality between classes and groups among and within countries-persists, reviving the relevance of social justice as a lens to understand and as an instrument to intervene in these issues. However, the theoretical aspects and polysemous character of social justice as applied in the field of public health are often assumed rather than explicitly explained. An intersectional justice approach to understanding health inequality, inequity, and injustice might be useful. It argues that preexisting class-, race/ethnicity-, and gender-based health injustice and the socially differentiated impacts of the COVID-19 pandemic are shaped, interconnectedly, by economic maldistribution, cultural misrecognition, and political misrepresentation. Pursuing health justice requires analyses, strategies, and interventions that integrate the economic, cultural, and political spheres of redistribution, recognition, and representation, respectively. Such an intersectional approach to health justice is even more relevant and compelling in light of the COVID-19 pandemic. This article is broadly about class, race/ethnicity, and gender political economy of public health-but with a narrower focus on maldistribution, misrecognition, and misrepresentation, shaping social and health injustices.

A Confluence of Policy Inequality: Health Disparities in Old Age Among American Indian and Alaska Native Populations

Racial health disparities in old age are well established, and new conceptualizations and methodologies continue to advance our understanding of health inequality across the life course. One group that is overlooked in many of these analyses, however, is the aging American Indian/Native Alaskan (AI/NA) population. While scholars have attended to the unique health inequities faced by the AI/NA population as a whole due to its discordant political history with the US government, little attention has been paid to unique patterns of disparity that might exist in old age. I propose to draw critical gerontology into the conversation in order to establish a framework through which we can uncover barriers to health, both from the political context of the AI/NA people as well as the political history of old age policy in the United States. Health disparities in old age are often described through a cumulative (dis)advantage framework that offers the benefit of appreciating that different groups enter old age with different resources and health statuses as a result of cumulative inequalities across the life course. Adding a framework of age relations, appreciating age as a system of inequality where people also gain or lose access to resources and status upon entering old age offers a path for understanding the intersection of race and old age. This paper will show how policy history for this group in particular as well as old age policy in the United States all create a unique and unequal circumstance for the aging AI/NA population.

Understanding Health Inequalities in Federal Capital Territory (FCT) Nigeria

Understanding Health Inequalities in Federal Capital Territory (FCT) Nigeria

The Importance of Teaching History of Inequities in Public Health Programs

Learning the history of inequities is typically not a major part of public health degree programs but can be fundamental to truly understanding health inequities and identifying potential solutions. A historical perspective on inequities can help understand present-day inequities as constructed over time, provide needed context for community engagement efforts, and help identify the system of advantages and disadvantages based on race, gender, and class that have been built into U.S. society. There are many ways to integrate a historical perspective on inequities into public health degree programs, and this article provides an example course on historical roots of health inequities. To more effectively reduce health inequities, it is imperative that Schools and Programs of Public Health adopt curriculum content to provide public health professionals and researchers a much-needed historical perspective on inequities.

The Education of Multiple Family Members and the Life-Course Pathways to Cognitive Impairment.

This article asks how the educational attainments of multiple family members, including parents and offspring, are associated with the cognitive health of older adults in the United States. We use panel data from the U.S. Health and Retirement Study (2000-2012) to examine how the education of an individual, their parent(s), and their offspring are associated with the prevalence of moderate/severe cognitive impairment and the onset of cognitive impairment among older adults using logistic regression and discrete-time event history analysis, respectively. We found that when combined, only the education of the individual is inversely associated with cognitive impairment at baseline. However, both the educational attainments of an individual and their offspring are negatively associated with the risk of becoming cognitively impaired, among individuals who were not already cognitively impaired. Conversely, parental education was not predictive of being cognitively impaired or the onset of impairment. Furthermore, we found that respondent gender did not moderate the relationship between a family member's education and respondent cognitive health. This study adds to current research by asking how resources from earlier and subsequent generations matter for older adults' cognitive health. Although we found little evidence that parental education matters at this life stage, results suggest that offspring education has a salient positive effect on later-life cognitive health. This finding underscores an overlooked source of health disparities-offspring resources-and highlights how a family perspective remains a powerful tool for understanding health inequalities in later life.

Intersectionality and Smoking Cessation: Exploring Various Approaches for Understanding Health Inequities.

Many marginalized groups smoke at higher rates and have greater difficulty quitting than less marginalized groups. Most research on smoking cessation inequities has focused on a single sociodemographic attribute (eg, race or socioeconomic status), yet individuals possess multiple attributes that may increase risk. The current study used an intersectionality framework to examine how the interplay between multiple marginalized attributes may impact smoking cessation outcomes. A diverse sample of 344 adults enrolled in a smoking cessation program and reported on sociodemographic attributes (eg, race/ethnicity, gender, income) and continuous smoking abstinence on their quit date and at 1, 2, and 4 weeks postquit date. A Cox proportional hazard regression model was used to estimate whether intersectional links among race/ethnicity, gender, and income were related to smoking cessation outcomes. Lower household income may be related to higher risk of smoking cessation failure. There were no significant interactions among race/ethnicity, gender, and income in predicting relapse. Pairwise intersectional group differences suggested some groups may be at higher risk of relapse. Number of marginalized sociodemographic attributes did not predict relapse. Intersectionality may be a promising framework for addressing health inequities, and may help elucidate how to best design and target intervention efforts for individuals characterized by sociodemographic intersections that concur particularly high risk for poor tobacco cessation outcomes. Despite an overall decline in smoking rates, socioeconomic inequities in smoking prevalence and cancer mortality are widening. Efforts targeting tobacco cessation should incorporate new theory to capture the complex set of factors that may account for tobacco cessation inequities (eg, multiple aspects of identity that may influence access to tobacco cessation treatment and exposure to certain stressors that impede cessation efforts). Intersectionality may be a promising framework for addressing health inequities in tobacco use and cessation and may help elucidate how to best design and target intervention efforts for individuals that concur particularly high risk for poor tobacco cessation outcomes.

Abstract P468: Geographic and Socioeconomic Inequalities in Poor Cardiovascular Health in Canada

Background: Poor cardiovascular health (CVH), characterized by clinical risk and unhealthy lifestyle habits, is a leading cause of death and disease worldwide. Despite advances in healthcare and policy, there remains an inequitable burden of poor CVH among Canadian sub-populations based on socioeconomic status and geographic region. Using recently published data and a national toolkit, this study aimed to quantify inequalities in poor CVH across the Canadian population. Methods: We conducted a cross-sectional study on Canadian adults, ≥20 years, from the nationally representative Canadian Community Health Survey 2017. Using the American Heart Association’s CVH Index, CVH was defined for each individual as a summed score of 7 components, where 1 point was awarded for achieving ideal health in each component. A total score of 0-2 points indicated poor overall CVH. The Canadian Institute for Health Information (CIHI) Measuring Health Inequalities Toolkit, a standardized methodological approach to analyzing health inequalities in population-based data using pre-defined stratifications and second-level interactions, was used to quantify inequalities in poor CVH based on Toolkit-defined stratifications in sex, income, urban/rural status, and region of residence. The regional distribution of CVH was mapped using ArcGIS software. Results: Approximately 7% of Canadians had poor CVH, representing 2 million Canadians. Poor dietary habits were noted in 99.0% of the population, with poor body mass index and poor physical activity noted in 58.1% and 42.3%, respectively. The eastern provinces of Newfoundland and Labrador and New Brunswick had the greatest proportion of health regions with poor CVH. An examination of the largest CVH inequalities across provinces revealed that females in the lowest income tercile residing in Prince Edward Island were 8-times more likely to experience poor CVH than females in the highest income tercile (RR 8.43, 95%CI 7.09-10.04). Additionally, females in New Brunswick residing in rural regions were almost 3-times more likely to experience poor CVH than females residing in urban regions (RR 3.07, 95%CI 1.07-4.87). In most provinces, income and urban/rural inequalities among males were observed but were of smaller magnitude than the inequalities among females. Conclusion: The greatest inequalities in poor CVH were experienced by females in the lowest income groups. Urban/rural inequalities in CVH were complex and varied by geographic region. The CIHI toolkit is a robust and systematic approach to understanding health inequalities that will enable comparison between studies and health/disease states, and thus facilitate comparative policy evaluation and population health priority setting.

Next steps in the development of the social determinants of health approach: the need for a new narrative.

During the past 15-20 years the Social Determinants of Health (SDoH) framework has become the main approach to understand health inequalities. With this model a range of factors important for health and inequalities in health over the life-course have been connected into a larger framework. Despite its usefulness and popularity within the field, and wide use in influential reviews, the SDoH framework has not been easy to communicate to stakeholders in other sectors, and we cannot as yet see much of substantial societal change as a result of it. In this Commentary I try to discuss possible reasons behind our difficulties to communicate the SDoH perspective. Some of these reasons relate to how we frame and present the different parts of the framework, others are more linked to common beliefs and practices that I think we should rethink. In both cases, I believe that we would benefit from a more general discussion around these fundamental issues, both in order to communicate our important insights but also to better understand our own key study objective, namely how health inequalities are generated, sustained and potentially reduced.

Workshop: Social-to-biological processes over the lifecourse and social inequalities in health

Abstract Context Socioeconomic inequalities in health and ageing are observed across contexts and over time, presenting a challenge for public health. The mechanisms driving associations between social conditions and health include biological responses, which in turn are associated with health outcomes. This workshop aims to describe and discuss evidence on the biological embedding of the social environment from research carried out within a large European consortium, and place it within the context of public health. Methods The Lifepath project was funded by the European Commission between 2014-19 and brought together longitudinal datasets from across Europe, as well as an interdisciplinary collective of researchers keen to examine how social inequalities in health are constructed over the lifecourse. Results Four separate studies are presented here. First, Carmeli et al examine the relationship between social position and systemic inflammation through the mediating role of gene regulation. Second, Fraga et al describe the social patterning of chronic inflammation observed in early adolescence. Third, Castagné et al analyse the relationship between social position across the lifecourse and systemic inflammation, and the role of inflammation within the allostatic load heuristic. Fourth, Chadeau-Hyam et al describe social gradients in a multi-system biological health score, and its subsequent relationship with a number of major health outcomes. Discussion We will coordinate a discussion between the audience and workshop participants. The contribution of the inflammatory system to capturing social inequalities and in its association with chronic disease will be discussed. Is it a key player in the construction of health inequalities, or merely an effective signal for many diverse processes? The role biological markers can play in enhancing our understanding of health inequalities, and how the public health community can respond to the evidence will be discussed. Conclusions Socially patterned biological responses begin early in the lifecourse and may be key factors in the construction of social inequalities in health and ageing. As such, they should be taken into account in public health activities and policy. Key messages The biological embodiment of social conditions is observed from early life and across the lifecourse. Systemic inflammation appears to be a central mechanism which is socially patterned and associated with many health outcomes.