Scoping review: national monitoring frameworks for social determinants of health and health equity

Equity and trends in general practitioners' allocation in China: based on ten years of data from 2012 to 2021

BACKGROUND

General practitioners (GP) are the gatekeepers of residents' health, 2021 is the 10th year of the establishment of the GP system in China. This study aims to assess the equity and trends of GP allocation in China from 2012 to 2021, summarize the efforts and progress of GPs in China during the decade, predict the development trend of GPs in mainland China in the next 5 years to provide a reference for regional health planning and rational allocation of GPs in China.

METHODS

Data from 2012 to 2021 on GPs in 22 provinces, 5 autonomous regions, and 4 municipalities directly under the central government in mainland China (excluding Hong Kong, Macao, and Taiwan) are collected by us. Gini coefficient, Lorenz curve and health resource agglomeration degree (HRAD) were used to analyze the equity of the allocation of GPs in China from different dimensions, a Grey prediction model was used to forecast the number of GPs in 2022-2026.

RESULTS

The number of GPs in mainland China increased from 109 794 to 434 868 from 2012 to 2021, with 3.08 GPs per 10 000 people in 2021. The Gini coefficient of GPs allocation by population in China decreased from 0.312 to 0.147 from 2012 to 2021, while the Gini coefficient of geographic dimension remained between 0.700 and 0.750. Compared with the degree of curvature of the Lorenz curve in the geographic dimension, the degree of curvature of the population and economic dimension were smaller. In 2021, the HRAD in the Eastern region was 4.618, the Central region was 1.493, with different degrees of imbalance among regions, the HRAD/PAD (population agglomeration degree) in the Eastern, Central and Western regions were 1.196, 0.880 and 0.821, respectively. GPs in the Eastern region is still concentrated, while the Central and Western regions were at a similar level, GPs were more scarce. The GM (1,1) model predicts that the number of GPs in mainland China will reach about 720 000 in 2026, the number of GPs per 10 000 people will reach 4.9.

CONCLUSION

After a decade of development, the number of GPs in China has increased significantly. It has reached the goal of the GP system when it was first established. However, the equity of the geographical dimension, both in terms of Gini coefficient and HRAD, has great differences between different regions. The average Gini coefficient at the geographic dimension is 0.723. The average HRAD index was 4.969 in the East and 0.293 in the West. The Western region has the problem of insufficient GP allocation in both population and geographical dimension. In the future, the number of GPs in China will continue to grow rapidly with the support of policies. The "2030" goal, proposed in 2018, is expected to be achieved by 2026. Due to certain factors (such as COVID-19), the actual situation may be different from the predicted results.

Cumulative Risk Evaluation of Phthalates Under TSCA

The U.S. Environmental Protection Agency (EPA) is currently conducting separate Toxic Substances Control Act (TSCA) risk evaluations for seven phthalates: dibutyl phthalate (DBP), butyl benzyl phthalate (BBP), di(2-ethylhexyl) phthalate (DEHP), diisobutyl phthalate (DIBP), dicyclohexyl phthalate (DCHP), di-isodecyl phthalate (DIDP), and diisononyl phthalate (DINP). Phthalates are highly abundant plastic additives used primarily to soften materials and make them flexible, and biomonitoring shows widespread human exposure to a mixture of phthalates. Evidence supports biological additivity of phthalate mixture exposures, including the enhancement of toxicity affecting common biological targets. Risk estimates based on individual phthalate exposure may not be protective of public health. Thus, a cumulative risk approach is warranted. While EPA initially did not signal that it would incorporate cumulative risk assessment (CRA) as part of its current risk evaluation for the seven phthalates, the agency recently announced that it is reconsidering if CRA for phthalates would be appropriate. Based on our review of existing chemical mixtures risk assessment guidance, current TSCA scoping documents for the seven phthalates, and pertinent peer-reviewed literature, we delineate a CRA approach that EPA can easily implement for phthalates. The strategy for using CRA to inform TSCA risk evaluation for existing chemicals is based upon integrative physiology and a common adverse health outcome algorithm for identifying and grouping relevant nonchemical and chemical stressors. We recommend adjustments for how hazard indices (HIs) or margins of exposure (MOEs) based on CRA are interpreted for determining "unreasonable risk" under TSCA.

Exploring system drivers of gender inequity in development assistance for health and opportunities for action

Background: Deep-rooted and widespread gender-based bias and discrimination threaten achievement of the Sustainable Development Goals. Despite evidence that addressing gender inequities contributes to better health and development outcomes, the resources for, and effectiveness of, such efforts in development assistance for health (DAH) have been insufficient. This paper explores systemic challenges in DAH that perpetuate or contribute to gender inequities, with a particular focus on the role of external donors and funders. Methods: We applied a co-creation system design process to map and analyze interactions between donors and recipient countries, and articulate drivers of gender inequities within the landscape of DAH. We conducted qualitative primary data collection and analysis in 2021 via virtual facilitated discussions and visual mapping exercises among a diverse set of 41 stakeholders, including representatives from donor institutions, country governments, academia, and civil society. Results: Six systemic challenges emerged as perpetuating or contributing to gender inequities in DAH: 1) insufficient input and leadership from groups affected by gender bias and discrimination; 2) decision-maker blind spots inhibit capacity to address gender inequities; 3) imbalanced power dynamics contribute to insufficient resources and attention to gender priorities; 4) donor funding structures limit efforts to effectively address gender inequities; 5) fragmented programming impedes coordinated attention to the root causes of gender inequities; and 6) data bias contributes to insufficient understanding of and attention to gender inequities. Conclusions: Many of the drivers impeding progress on gender equity in DAH are embedded in power dynamics that distance and disempower people affected by gender inequities. Overcoming these dynamics will require more than technical solutions. Groups affected by gender inequities must be centered in leadership and decision-making at micro and macro levels, with practices and structures that enable co-creation and mutual accountability in the design, implementation, and evaluation of health programs.

Ethics Priorities of the Curing Coma Campaign: An Empirical Survey

BACKGROUND

The Curing Coma Campaign (CCC) is a multidisciplinary global initiative focused on evaluation, diagnosis, treatment, research, and prognostication for patients who are comatose due to any etiology. To support this mission, the CCC Ethics Working Group conducted a survey of CCC collaborators to identify the ethics priorities of the CCC and the variability in priorities based on country of practice.

METHODS

An electronic survey on the ethics priorities for the CCC was developed using rank-choice questions and distributed between May and July 2021 to a listserv of the 164 collaborators of the CCC. The median rank for each topic and subtopic was determined. Comparisons were made on the basis of country of practice.

RESULTS

The survey was completed by 93 respondents (57% response rate); 67% practiced in the United States. On the basis of respondent ranking of each topic, the prioritization of ethics topics across respondents was as follows: (1) clinical care, (2) diagnostic definitions, (3) clinical research, (4) implementation/innovation, (5) family, (6) data management, (7) public engagement/perceptions, and (8) equity. Respondents who practiced in the United States were particularly concerned about public engagement, the distinction between clinical care and research, disclosure of results from clinical research to families, the definition of "personhood," and the distinction between the self-fulfilling prophecy/nihilism and medical futility. Respondents who practiced in other countries were particularly concerned about diagnostic modalities for clinical care, investigational drugs/devices for clinical research, translation of research into practice, and the definition of "minimally conscious state."

CONCLUSIONS

Collaborators of the CCC considered clinical care, diagnostic definitions, and clinical research the top ethics priorities of the CCC. These priorities should be considered as the CCC explores ways to improve evaluation, diagnosis, treatment, research, and prognostication of patients with coma and associated disorders of consciousness. There is some variability in ethics priorities based on country of practice.

What public health interventions do people in Canada prefer to fund? A discrete choice experiment

Objective

To assess public support of tailored and targeted public health interventions for marginalized communities.

Methods

We conducted a discrete choice experiment using a web-based survey advertised to Facebook and Instagram users living in Canada, aged > 16. Participants were asked to choose between funding two hypothetical public health programs. Each program was described by its purpose; expected increase in life expectancy; and target audience. Demographically weighted generalized linear mixed-effects models were constructed to identify program factors associated with program selection.

Results

Participants completed up to 8 discrete choice comparison exercises each resulting in 23,889 exercises were completed by 3054 participants. Selected programs were less likely to focus on prevention (vs. treatment). For each 1-year increase in the marginal years of life gained, there was a 15% increase in the odds of a program being selected. Interventions tailored to marginalized communities or targeting stigmatized health conditions were less likely to be selected compared to interventions targeted to the general population or targeting chronic health conditions. Noteworthy exceptions included an increased preference for interventions aligning with the perceived needs or cultural expectations for marginalized communities.

Conclusions

Stigmatizing perceptions of health conditions and key populations likely influence public health programming preferences of Canadians.

Public health implications

Informational campaigns highlighting disparities experienced by marginalized populations may improve support for targeted and tailored interventions.

Connections and Biases in Health Equity and Culture Research: A Semantic Network Analysis

Health equity is a rather complex issue. Social context and economical disparities, are known to be determining factors. Cultural and educational constrains however, are also important contributors to the establishment and development of health inequities. As an important starting point for a comprehensive discussion, a detailed analysis of the literature corpus is thus desirable: we need to recognize what has been done, under what circumstances, even what possible sources of bias exist in our current discussion on this relevant issue. By finding these trends and biases we will be better equipped to modulate them and find avenues that may lead us to a more integrated view of health inequity, potentially enhancing our capabilities to intervene to ameliorate it. In this study, we characterized at a large scale, the social and cultural determinants most frequently reported in current global research of health inequity and the interrelationships among them in different populations under diverse contexts. We used a data/literature mining approach to the current literature followed by a semantic network analysis of the interrelationships discovered. The analyzed structured corpus consisted in circa 950 articles categorized by means of the Medical Subheadings (MeSH) content-descriptor from 2014 to 2021. Further analyses involved systematic searches in the LILACS and DOAJ databases, as additional sources. The use of data analytics techniques allowed us to find a number of non-trivial connections, pointed out to existing biases and under-represented issues and let us discuss what are the most relevant concepts that are (and are not) being discussed in the context of Health Equity and Culture.

Healthy aging determinants and disability among older adults: SABE Colombia

Objective.

To identify the main factors associated with disability in older adults in Colombia, adjusted according to structural and intermediary determinants of healthy aging.

Methods.

This study used cross-sectional data from 23 694 adults over 60 years of age in the SABE Colombia nationwide survey. Structural determinants such as demographic and socioeconomic position variables were analyzed. Intermediary variables were classified into three blocks: intrinsic capacity, physical and built environment, and health care systems. Data analysis employed multivariate logistic regression.

Results.

The prevalence of overall disability was 21% for activities of daily living, 38% for instrumental activities of daily living, and 33% for mobility disability. Disability was associated with sociodemographic structural determinants such as older age, female sex, rural residence, never married/divorced, living alone, low educational level, and Indigenous/Black ethnicity. With regard to determinants of socioeconomic position, net low income, poor socioeconomic stratum, insufficient income perception, and a subsidized health insurance scheme exerted a major influence on disability. Intermediary determinants of intrinsic capacity, such as poor self-rated health, multimorbidity, low grip strength, sedentary lifestyle, early childhood economic adversity, no social support, and no participation in activities, were significantly associated with disability.

Conclusions.

Actions that affect the main factors associated with disability, such as reducing health inequities through policies, strategies, and activities, can contribute significantly to the well-being and quality of life of Colombian older adults.

Adapted fairness benchmarks for the evaluation of Iran health system reform

INTRODUCTION

This study has been designed to localize fairness benchmarks for the evaluation of health system reform with an ethical approach.

METHODS

A descriptive-analytic study was applied in which a questionnaire with selected indicators and based on main fairness benchmarks was validated. Besides, the final indicators were chosen for surveys of 255 health equity experts from 31 provinces of Iran to localize fairness benchmarks using the exploratory factor analysis through the SPSS software.

RESULTS

Seven fairness benchmarks were adopted: (1) Efficacy, Efficiency, and Quality of Health Care; (2) Impact of Information Infrastructure on Health Reform; (3) Responsiveness; (4) Equitable Access, and Universal Health Coverage; (5) Equitable Financing; (6) Social Determinant of Health; and (7) Financial Barriers to Equitable Access.

CONCLUSION

The priorities of fairness benchmarking through localization included focusing on the quantity and quality of primary health care, allocating resources based on the need; for equitable efficiency, and paying attention to community-based information infrastructure, and social determinants for fair reform. Moreover, respecting patient rights as a part of democratic accountability was more close to equity. Elimination of financial and nonfinancial barriers for health access and coverage based on vulnerability, through fair financing, was also confirmed.

Analyzing Spatial Patterns of Health Vulnerability to Drought in the Brazilian Semiarid Region

Health determinants might play an important role in shaping the impacts related to long-term disasters such as droughts. Understanding their distribution in populated dry regions may help to map vulnerabilities and set coping strategies for current and future threats to human health. The aim of the study was to identify the most vulnerable municipalities of the Brazilian semiarid region when it comes to the relationship between drought, health, and their determinants using a multidimensional index. From a place-based framework, epidemiological, socio-economic, rural, and health infrastructure data were obtained for 1135 municipalities in the Brazilian semiarid region. An exploratory factor analysis was used to reduce 32 variables to four independent factors and compute a Health Vulnerability Index. The health vulnerability was modulated by social determinants, rural characteristics, and access to water in this semiarid region. There was a clear distinction between municipalities with the highest human welfare and economic development and those municipalities with the worst living conditions and health status. Spatial patterns showed a cluster of the most vulnerable municipalities in the western, eastern, and northeastern portions of the semiarid region. The spatial visualization of the associated vulnerabilities supports decision making on health promotion policies that should focus on reducing social inequality. In addition, policymakers are presented with a simple tool to identify populations or areas with the worst socioeconomic and health conditions, which can facilitate the targeting of actions and resources on a more equitable basis. Further, the results contribute to the understanding of social determinants that may be related to medium- and long-term health outcomes in the region.

Toward Understanding the Value of Missing Social Determinants of Health Data in Care Transition Planning

BACKGROUND

Social determinants of health play an important role in the likelihood of readmission and therefore should be considered in care transition planning. Unfortunately, some social determinants that can be of value to care transition planners are missing in the electronic health record. Rather than trying to understand the value of data that are missing, decision makers often exclude these data. This exclusion can lead to failure to design appropriate care transition programs, leading to readmissions.

OBJECTIVES

This article examines the value of missing social determinants data to emergency department (ED) revisits, and subsequent readmissions.

METHODS

A deidentified data set of 123,697 people (18+ years), with at least one ED visit in 2017 at the University of Alabama at Birmingham Medical Center was used. The dependent variable was all-cause 30-day revisits (yes/no), while the independent variables were missing/nonmissing status of the social determinants of health measures. Logistic regression was used to test the relationship between likelihood of revisits and social determinants of health variables. Moreover, relative weight analysis was used to identify relative importance of the independent variables.

RESULTS

Twelve social determinants were found to be most often missing. Of those 12, only "lives with" (alone or with family/friends) had higher odds of ED revisits. However, relative logistic weight analysis suggested that "pain score" and "activities of daily living" (ADL) accounted for almost 50% of the relevance for ED revisits when compared among all 12 variables.

CONCLUSION

In the process of care transition planning, data that are documented are factored into the care transition plan. One of the most common challenges in health services practice is to understand the value of missing data in effective program planning. This study suggests that the data that are not documented (i.e., missing) could play an important role in care transition planning as a mechanism to reduce ED revisits and eventual readmission rates.

Health equity monitoring is essential in public health: lessons from Mozambique

Background

Countries must be able to describe and monitor their populations health and well-being needs in an attempt to understand and address them. The Sustainable Development Goals (SDGs) have re-emphasized the need to invest in comprehensive health information systems to monitor progress towards health equity; however, knowledge on the capacity of health information systems to be able do this, particularly in low-income countries, remains very limited. As a case study, we aimed to evaluate the current capacity of the national health information systems in Mozambique, and the available indicators to monitor health inequalities, in line with SDG 3 (Good Health and Well Being for All at All Ages).

Methods

A data source mapping of the health information system in Mozambique was conducted. We followed the World Health Organization’s methodology of assessing data sources to evaluate the information available for every equity stratifier using a three-point scale: 1 - information is available, 2 - need for more information, and 3 - an information gap. Also, for each indicator we estimated the national average inequality score.

Results

Eight data sources contain health information to measure and monitor progress towards health equity in line with the 27 SDG3 indicators. Seven indicators bear information with nationally funded data sources, ten with data sources externally funded, and ten indicators either lack information or it does not applicable for the matter of the study. None of the 27 indicators associated with SDG3 can be fully disaggregated by equity stratifiers; they either lack some information (15 indicators) or do not have information at all (nine indicators). The indicators that contain more information are related to maternal and child health.

Conclusions

There are important information gaps in Mozambique’s current national health information system which prevents it from being able to comprehensively measure and monitor health equity. Comprehensive national health information systems are an essential public health need. Significant policy and political challenges must also be addressed to ensure effective interventions and action towards health equity in the country.

Making Health Research Matter: A Call to Increase Attention to External Validity

Most of the clinical research conducted with the goal of improving health is not generalizable to nonresearch settings. In addition, scientists often fail to replicate each other's findings due, in part, to lack of attention to contextual factors accounting for their relative effectiveness or failure. To address these problems, we review the literature on assessment of external validity and summarize approaches to designing for generalizability. When investigators conduct systematic reviews, a critical need is often unmet: to evaluate the pragmatism and context of interventions, as well as their effectiveness. Researchers, editors, and grant reviewers can implement key changes in how they consider and report on external validity issues. For example, the recently published expanded CONSORT figure may aid scientists and potential program adopters in summarizing participation in and representativeness of a program across different settings, staff, and patients. Greater attention to external validity is needed to increase reporting transparency, improve program dissemination, and reduce failures to replicate research.

Identifying health policy and systems research priorities on multisectoral collaboration for health in low-income and middle-income countries

Introduction

While efforts to achieve Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) have reinvigorated interest in multisectoral collaborations (MSCs) among the global health and development community, there remains a plethora of questions about how best to conceptualise, plan, implement, evaluate and sustain MSCs. The objective of this paper is to present research priorities on MSC for health from researchers and policymakers around the globe, with an emphasis on low-income and middle-income countries.

Methods

The authors identified 30 priority research questions from two sources: (1) 38 review articles on MSC for health, and (2) interviews and focus groups with a total of 81 policymakers, including government officials (largely from ministries of health and state/provincial departments of health, but also offices of planning, public service, social development, the prime minister and others), large multilateral or bilateral organisations, and non-governmental organisations. In a third phase, questions were refined and ranked by a diverse group of researchers from around the globe using an online voting platform.

Results

The top-ranked questions focused predominantly on pragmatic questions, such as how best to structure, implement and sustain MSCs, as well as how to build stakeholder capacity and community partnerships. Despite substantial variation between review articles, policymakers’ reflections and online ranking by researchers, two topics emerged as research priorities for all three: (1) leadership, partnership and governance structures for MSCs; and (2) MSC implementation strategies and mechanisms. The review articles underscored the need for more guidance on appropriate study designs and methods for investigating MSCs, which may be a prerequisite for other identified research priorities.

Conclusion

These findings could inform efforts within and beyond the health sector to better align research objectives and funding with the evidence needs of policymakers grappling with questions about how best to leverage MSCs to achieve UHC and the SDGs.

Promoting the Human Rights of Children With Neurologic Conditions

Children with neurologic conditions benefit from international conventions, and national treaties, policies and regulations that safeguard their human rights. These regulations also exist to serve as guidance in the creation of comprehensive systems of care, inclusive environments, accessible societies and communities that allow these children to thrive and to achieve the best of their capacities. This narrative review of issues related to human rights and advocacy in pediatric neurologic disabilities will provide an overview of the human rights conventions that relate to children with disabilities, and the most current approaches implicating health care providers in rights promotion for these individuals and their families. We also suggest venues for professionals to advocate for their patients, and suggest strategies to consider rights-based approaches as a mean to provide holistic care in a social neurology framework.

Cultural primer for cardiometabolic health: health disparities, structural factors, community, pathways to improvement, and clinical applications

The quest to optimize cardiometabolic health has created great interest in nonmedical health variables in the population, community-based research and coordination, and addressing social, ethnic, and cultural barriers. All of these may be of equal or even greater importance than classical health care delivery in achieving individual well-being. One dominant issue is health disparity - causes, methods of reduction, and community versus other levels of solutions. This communication summarizes some major views regarding social structures, followed by amplification and synthesis of central ideas in the literature. The role of community involvement, tools, and partnerships is also presented in this Primer. Recent views of how these approaches could be incorporated into cardiometabolic initiatives and strategies follow, with implications for research. Two examples comparing selected aspects of community leverage and interventions in relation to individual approaches to health care equity are examined in depth: overall performance in reducing cardiovascular risk and mortality, and the recent National Diabetes Prevention Program, both touching upon healthy diets and adherence. Finally, the potential that precision medicine offers, and possible effects on disparities are also discussed.

[Monitoring social determinants of health]

Public health surveillance is the systematic and continuous collection, analysis, dissemination and interpretation of health-related data for planning, implementation and evaluation of public health initiatives. Apart from the health system, social determinants of health include the circumstances in which people are born, grow up, live, work and age, and they go a long way to explaining health inequalities. A surveillance system of the social determinants of health requires a comprehensive and social overview of health. This paper analyses the importance of monitoring social determinants of health and health inequalities, and describes some relevant aspects concerning the implementation of surveillance during the data collection, compilation and analysis phases, as well as dissemination of information and evaluation of the surveillance system. It is important to have indicators from sources designed for this purpose, such as continuous records or periodic surveys, explicitly describing its limitations and strengths. The results should be published periodically in a communicative format that both enhances the public's ability to understand the problems that affect them, whilst at the same time empowering the population, with the ultimate goal of guiding health-related initiatives at different levels of intervention.

Assessing the relevance of indicators in tracking social determinants and progress toward equitable population health in Brazil

BACKGROUND

The importance of the social determinants of health (SDH) and barriers to the access and utilization of healthcare have been widely recognized but not previously studied in the context of universal healthcare coverage (UHC) in Brazil and other developing countries.

OBJECTIVE

To evaluate a set of proposed indicators of SDH and barriers to the access and utilization of healthcare - proposed by the SDH unit of the World Health Organization - with respect to their relevance in tracking progress in moving toward equitable population health and UHC in Brazil.

DESIGN

This study had a mixed methodology, combining a quantitative analysis of secondary data from governmental sources with a qualitative study comprising two focus group discussions and six key informant interviews. The set of indicators tested covered a broad range of dimensions classified by three different domains: environment quality; accountability and inclusion; and livelihood and skills. Indicators were stratified according to income quintiles, urbanization, race, and geographical region.

RESULTS

Overall, the indicators were adequate for tracking progress in terms of the SDH, equity, gender, and human rights in Brazil. Stratifications showed inequalities. The qualitative analysis revealed that many of the indicators were well known and already used by policymakers and health sector managers, whereas others were considered less useful in the Brazilian context.

CONCLUSIONS

Monitoring and evaluation practices have been developed in Brazil, and the set of indicators assessed in this study could further improve these practices, especially from a health equity perspective. Socioeconomic inequalities have been reduced in Brazil in the last decade, but there is still much work to be done in relation to addressing the SDH.