Advancing tools to promote health equity across European Union regions: the EURO-HEALTHY project

Frameworks for measuring population health: A scoping review

INTRODUCTION

Many regions in the world are using the population health approach and require a means to measure the health of their population of interest. Population health frameworks provide a theoretical grounding for conceptualization of population health and therefore a logical basis for selection of indicators. The aim of this scoping review was to provide an overview and summary of the characteristics of existing population health frameworks that have been used to conceptualize the measurement of population health.

METHODS

We used the Population, Concept and Context (PCC) framework to define eligibility criteria of frameworks. We were interested in frameworks applicable for general populations, that contained components of measurement of health with or without its antecedents and applied at the population level or used a population health approach. Eligible reports of eligible frameworks should include at least domains and subdomains, purpose, or indicators. We searched 5 databases (Pubmed, EMBASE, Web of Science, NYAM Grey Literature Report, and OpenGrey), governmental and organizational sites on Google and websites of selected organizations using keywords from the PCC framework. Characteristics of the frameworks were summarized descriptively and narratively.

RESULTS

Fifty-seven frameworks were included. The majority originated from the US (46%), Europe (23%) and Canada (19%). Apart from 1 framework developed for rural populations and 2 for indigenous populations, the rest were for general urban populations. The numbers of domains, subdomains and indicators were highly variable. Health status and social determinants of health were the most common domains across all frameworks. Different frameworks had different priorities and therefore focus on different domains.

CONCLUSION

Key domains common across frameworks other than health status were social determinants of health, health behaviours and healthcare system performance. The results in this review serve as a useful resource for governments and healthcare organizations for informing their population health measurement efforts.

The Direct and Indirect Influences of Interrelated Regional-Level Sociodemographic Factors on Heat-Attributable Mortality in Europe: Insights for Adaptation Strategies

BACKGROUND

Heat is a significant cause of mortality, but impact patterns are heterogenous. Previous studies assessing such heterogeneity focused exclusively on risk rather than heat-attributable mortality burdens and assume predictors are independent.

OBJECTIVES

We assessed how four interrelated regional-level sociodemographic predictors-education, life expectancy, the ratio of older to younger people (aging index), and relative income-influence heterogeneity in heat-attributable mortality burdens in Europe and then derived insights into adaptation strategies.

METHODS

We extracted four outcomes from a temperature-mortality study covering 16 European countries: the rate of increase in mortality risk at moderate and extreme temperatures (moderate and extreme slope, respectively), the minimum mortality temperature percentile (MMTP), and the underlying mortality rate. We used structural equation modeling with country-level random effects to quantify the direct and indirect influences of the predictors on the outcomes.

RESULTS

Higher levels of education were directly associated with lower heat-related mortality at moderate and extreme temperatures via lower slopes and higher MMTPs. A one standard deviation increase in education was associated with a - 0.46 ± 0.14 , - 0.41 ± 0.12 , and 0.41 ± 0.12 standard deviation (± standard error ) change in the moderate slope, extreme slope, and MMTP, respectively. However, education had mixed indirect influences via associations with life expectancy, the aging index, and relative income. Higher life expectancy had mixed relations with heat-related mortality, being associated with higher risk at moderate temperatures (0.33 ± 0.11 for the moderate slope; - 0.19 ± 0.097 for the MMTP) but lower underlying mortality rates (- 0.72 ± 0.097 ). A higher aging index was associated with higher burdens through higher risk at extreme temperatures (0.13 ± 0.072 for the extreme slope) and higher underlying mortality rates (0.93 ± 0.055 ). Relative income had relatively small, mixed influences.

DISCUSSION

Our novel approach provided insights into actions for reducing the health impacts of heat. First, the results show the interrelations between possible vulnerability-generating mechanisms and suggest future research directions. Second, the findings point to the need for a dual approach to adaptation, with actions that explicitly target heat exposure reduction and actions focused explicitly on the root causes of vulnerability. For the latter, the climate crisis may be leveraged to accelerate ongoing general public health programs. https://doi.org/10.1289/EHP11766.

Informing the Design of Data Visualization Tools to Monitor the COVID-19 Pandemic in Portugal: A Web-Delphi Participatory Approach

Due to the large amount of data generated by new technologies and information systems in the health arena, health dashboards have become increasingly popular as data visualization tools which stimulate visual perception capabilities. Although the importance of involving users is recognized in dashboard design, a limited number of studies have combined participatory methods with visualization options. This study proposes a novel approach to inform the design of data visualization tools in the COVID-19 context. With the objective of understanding which visualization formats should be incorporated within dashboards for the COVID-19 pandemic, a specifically designed Web-Delphi process was developed to understand the preferences and views of the public in general regarding distinct data visualization formats. The design of the Delphi process aimed at considering not only the theory-based evidence regarding input data and visualization formats but also the perception of final users. The developed approach was implemented to select appropriate data visualization formats to present information commonly used in public web-based COVID-19 dashboards. Forty-seven individuals completed a two-round Web-Delphi process that was launched through a snowball approach. Most respondents were young and highly educated and expressed to prefer distinct visualisation formats for different types of indicators. The preferred visualization formats from the participants were used to build a redesigned version of the official DGS COVID-19 dashboard used in Portugal. This study provides insights into data visualization selection literature, as well as shows how a Delphi process can be implemented to assist the design of public health dashboards.

How Do We Define and Measure Health Equity? The State of Current Practice and Tools to Advance Health Equity

INTRODUCTION

Healthy People establishes national goals and specific measurable objectives to improve the health and well-being of the nation. An overarching goal of Healthy People 2030 is to "eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all." To inform Healthy People 2030 health equity and health disparities content and products, the US Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion (ODPHP), in collaboration with NORC at the University of Chicago, conducted a review of peer-reviewed and gray literature to examine how health equity is defined, conceptualized, and measured by public health professionals.

METHODS

We reviewed (1) peer-reviewed literature, (2) HHS and other public health organization Web sites, and (3) state and territorial health department plans. We also conducted targeted searches of the gray literature to identify tools and recommendations for measuring health equity.

RESULTS

While definitions of health equity identified in the scan varied, they often addressed similar concepts, including "highest level of health for all people," "opportunity for all," and "absence of disparities." Measuring health equity is challenging; however, strategies to measure and track progress toward health equity have emerged. There are a range of tools and resources that have the potential to help decision makers address health equity, such as health impact assessments, community health improvement plans, and adapting a Health in All Policies approach. Tools that visualize health equity data also support data-driven decision making.

DISCUSSION

Using similar language when discussing health equity will help align and advance efforts to improve health and well-being for all. Healthy People objectives, measures, and targets can help public health professionals advance health equity in their work. HHS ODPHP continues to develop Healthy People tools and resources to support public health professionals as they work with cross-sector partners to achieve health equity.

Trends of amenable deaths due to healthcare within the European Union countries. Exploring the association with the economic crisis and education

The study of premature deaths from causes that are generally preventable given the current availability of healthcare - called amenable deaths due to healthcare - provides information on the quality of services. However, they are not only impacted by healthcare characteristics: other factors are also likely to influence. Therefore, identifying the association between amenable deaths due to healthcare and health determinants, such as education, might be the key to preventing these deaths in the future. Still unclear however, is how this works and how amenable deaths due to healthcare are distributed and evolve within the European Union (EU) below the national level. We therefore studied the geographical and temporal patterns of amenable deaths due to healthcare in the 259 EU regions from 1999 to 2016, including the 2007-2008 financial crisis and the post-2008 economic downturn, and identified whether any association with education exists. A cross-sectional ecological study was carried out. Using a hierarchical Bayesian model, we estimated the average smoothed Standardized Mortality Ratios (sSMR). A regression model was also applied to measure the relative risks (RR) at 95% credible intervals for cause-specific mortality association with education. Results show that amenable deaths due to healthcare decreased globally. Nevertheless, the decrease is not the same across all regions, and inequalities within countries do persist, with lower mortality ratios seen in regions from Central European countries and higher mortality ratios in regions from Eastern European countries. Also, the evolution trend reveals that after the financial crisis, the number of these deaths increased in regions across almost all EU countries. Moreover, educational disparities in mortality emerged, and a statistical association was found between amenable deaths due to healthcare and early exit from education and training. These results confirm that identifying and understanding the background of regional differences may lead to a better understanding of the amenable deaths due to healthcare and allow for the application of more effective policies.

Assessing Urban Health Inequities through a Multidimensional and Participatory Framework: Evidence from the EURO-HEALTHY Project

Urban health inequities often reflect and follow the geographic patterns of inequality in the social, economic and environmental conditions within a city-the so-called determinants of health. Evidence of patterns within these conditions can support decision-making by identifying where action is urgent and which policies and interventions are needed to mitigate negative impacts and enhance positive impacts. Within the scope of the EU-funded project EURO-HEALTHY (Shaping EUROpean policies to promote HEALTH equitY), the City of Lisbon was selected as a case study to apply a multidimensional and participatory assessment approach of urban health whose purpose was to inform the evaluation of policies and interventions with potential to address local health gaps. In this paper, we present the set of indicators identified as drivers of urban health inequities within the City of Lisbon, exploring the added value of using a spatial indicator framework together with a participation process to orient a place-based assessment and to inform policies aimed at reducing health inequities. Two workshops with a panel of local stakeholders from health and social care services, municipal departments (e.g. urban planning, environment, social rights and education) and non-governmental and community-based organizations were organized. The aim was to engage local stakeholders to identify locally critical situations and select indicators of health determinants from a spatial equity perspective. To support the analysis, a matrix of 46 indicators of health determinants, with data disaggregated at the city neighbourhood scale, was constructed and was complemented with maps. The panel identified critical situations for urban health equity in 28 indicators across eight intervention axes: economic conditions, social protection and security; education; demographic change; lifestyles and behaviours; physical environment; built environment; road safety and healthcare resources and performance. The geographical distribution of identified critical situations showed that all 24 city neighbourhoods presented one or more problems. A group of neighbourhoods systematically perform worse in most indicators from different intervention axes, requiring not only priority action but mainly a multi- and intersectoral policy response. The indicator matrices and maps have provided a snapshot of urban inequities across different intervention axes, making a compelling argument for boosting intersectoral work across municipal departments and local stakeholders in the City of Lisbon. This study, by integrating local evidence in combination with social elements, pinpoints the importance of a place-based approach for assessing urban health equity.

Development of a scalable and extendable multi-dimensional health index to measure the health of individuals

BACKGROUND

For population health management, it is important to have health indices that can monitor prevailing health trends in the population. Traditional health indices are generally measurable at different geographical levels with varied number of health dimensions. The aim of this work was to develop and validate a scalable and extendable multi-dimensional health index based on individual data.

METHODS

We defined health to be made up of five different domains: Physical, Mental, Social, Risk, and Healthcare utilization. Item response theory was used to develop models to compute domain scores and a health index. These were normalized to represent an individual's health percentile relative to the population (0 = worst health, 100 = best health). Data for the models came from a longitudinal health survey on 1,942 participants. The health index was validated using age, frailty, post-survey one-year healthcare utilization and one-year mortality.

RESULTS

The Spearman rho between the health index and age, frailty and post-survey one-year healthcare utilization were -0.571, -0.561 and -0.435, respectively, with all p<0.001. The area under the Receiver Operating Characteristic curve (AUROC) for post-survey one-year mortality was 0.930. An advantage of the health index is that it can be calculated using different sets of questions and the number of questions can be easily expanded.

CONCLUSION

The health index can be used at the individual, program, local, regional or national level to track the state of health of the population. When used together with the domain scores, it can identify regions with poor health and deficiencies within each of the five health domains.

The Role of Cohesion Policy Funds in Decreasing the Health Gaps Measured by the EURO-HEALTHY Population Health Index

Social, economic, and environmental differences across the European Union significantly affect opportunities to move forward in achieving greater equity in health. Cohesion Policy (CP) funds can contribute positively through investments in the main determinants of health. The aim of this study is to analyze to what extent the planned investments for 2014-2020 are addressing the regional health gaps, in light of the population health index (PHI), a multidimensional measure developed by the EURO-HEALTHY project. The operational programs of all regions were analyzed, namely, the CP planned investments by field of intervention. Analysis of variance was performed to examine whether the regional scores in the PHI dimensions were statistically different across regions with different levels of development (measured by gross domestic product (GDP)). Results show that 98% of regions with worse performances on the PHI are less developed regions. Overall, all regions present planned investments in intervention fields linked to dimensions appraised within the PHI (e.g., employment, income, education, pollution). Yet, more needs to be done to focus regional investments in health determinants where regions still lag behind. The PHI has the potential to inform future CP restructuring, providing evidence to extend the current eligibility criteria to other dimensions beyond the GDP.