International Journal for Equity in Health最新文献

Background: Access to health services for asylum seekers is legally restricted in Germany. The law is subject to interpretation, therefore the chance of receiving care is not equally distributed among asylum seekers. What services are provided to whom is ultimately decided by health professionals and government employees. The respective prioritization processes and criteria are not transparent. We sought to understand how legal restrictions are translated into daily practices and how this affects the health system. We aimed to outline the complex process of cost coverage for health services for asylum seekers and provide insights into common decision-making criteria.

Methods: We conducted an ethnographic exploration of routines in two outpatient clinics in two federal states over the course of three months, doing participant and non-participant observation. Additionally, we interviewed 21 professionals of health care and government organizations, and documented 110 applications for cost coverage of medical services and their outcome. In addition to qualitative data analysis and documentation, we apply a system-theoretical perspective to our findings.

Results: To perform legal restrictions a cross-sectoral prioritization process of medical services has been implemented, involving health care and government institutions. This changes professional practices, responsibilities and (power) relations. Involved actors find themselves at the intersection of several, oftentimes conflicting priorities, since "doing it right" might be seen differently from a legal, medical, economic, or political perspective. The system-theoretical analysis reveals that while actors have to bring different rationales into workable arrangements this part of the medical system transforms, giving rise to a sub-system that incorporates migration political rationales.

Conclusions: Health care restrictions for asylum seekers are implemented through an organizational linking of care provision and government administration, resulting in a bureaucratization of practice. Power structures at this intersection of health and migration policy, that are uncommon in other parts of the health system are thereby normalized. Outpatient clinics provide low-threshold access to health services, but paradoxically they may unintentionally stabilize health inequities, if prioritization criteria and power dynamics are not made transparent. Health professionals should openly reflect on conflicting rationales. Training, research and professional associations need to empower them to stay true to professional ethical principles and international conventions.

Background: Immigrant populations, especially women, continue facing challenges in accessing quality healthcare, particularly sexual and reproductive health services (SRH). Poor cultural competent health systems contribute to communication challenges between immigrant women and healthcare providers perpetuating health disparities. This exploratory study describes these communication barriers from the perspective of Moroccan and Pakistani immigrant women and healthcare providers within the Catalan health system and its implications to ensure an equitable provision of SRH services.

Methods: An exploratory-descriptive qualitative study was conducted in various municipalities of Barcelona with high concentration of immigrants. Eight focus groups (N = 51) and semi-structured interviews (N = 22) with Moroccan and Pakistani immigrant women were combined with key informant interviews (N = 13) with healthcare professionals. Thematic analysis and data triangulation were performed primarily using an inductive approach.

Results: Language barriers and cultural differences in health needs, expectations, care-seeking behaviours and understanding of quality healthcare provision hindered the ability of immigrant women and providers to interact effectively. Limited availability of intercultural mediators and inadequate cultural competence training opportunities for health staff were also identified. Findings suggest a lack of minority representation in the Catalan health workforce and leadership roles.

Conclusion: This study reinforces the evidence of persistent inequities in accessing healthcare among immigrant populations by focusing on the cultural competence barriers of the Catalan health system in the provision and access to SRH services. The regularization of adequately trained intercultural mediators, quality training in cultural competence for health staff and a commitment to increase workforce diversity would contribute to improve intercultural communication between immigrant patients and providers. An urgent call to action in this direction is needed to ensure an equitable access to SRH services among immigrant women.

Addressing health inequity is a central component of the Sustainable Development Goals and a priority of the World Health Organization (WHO). WHO supports countries in strengthening their health information systems in order to better collect, analyze and report health inequality data. Improving information and research about health inequality is crucial to identify and address the inequalities that lead to poorer health outcomes. Building analytical capacities of individuals, particularly in low-resource areas, empowers them to build a stronger evidence-base, leading to more informed policy and programme decision-making. However, health inequality analysis requires a unique set of skills and knowledge. This paper describes three resources developed by WHO to support the analysis of inequality data by non-statistical users using Microsoft Excel, a widely used and accessible software programme. The resources include a practical eLearning course, which trains learners in the preparation and reporting of disaggregated data using Excel, an Excel workbook that takes users step-by-step through the calculation of 21 summary measures of health inequality, and a workbook that automatically calculates these measures with the user's disaggregated dataset. The utility of the resources is demonstrated through an empirical example.

Background: Breastfeeding is a powerful public health intervention that produces long-term health benefits. However, in high-income countries such as Denmark, breastfeeding rates are suboptimal and unequally distributed across socio-economic positions. The 'Breastfeeding - a good start together' intervention, to promote longer duration of exclusive breastfeeding and reduce social inequity, was implemented in a cluster-randomised trial during 2022-2023 across 21 municipalities in two Danish regions. A process evaluation was conducted to assess the implementation, mechanisms of impact, and possible contextual factors affecting the intervention.

Methods: The study was guided by the Medical Research Council's guidance for conducting process evaluations and employed a mixed-methods approach in a convergence design. Quantitative data: contextual mapping survey (n = 20), health visitor survey (n = 284), health visitor records from 20 clusters and intervention website statistics. Qualitative data: dialogue meetings (n = 7), focus groups (n = 3) and interviews (n = 8).

Results: Overall, the intervention was delivered as planned to intended recipients, with few exceptions. Health visitors responded positively to the intervention, noting that it fitted well within their usual practice and enhanced families' chances of breastfeeding. Mothers expressed having received the intervention with few exceptions, and reacted positively to the intervention. Although health visitors were concerned about the potential stigmatisation of mothers receiving the intensified intervention, none of the interviewed mothers felt stigmatised. Contextual factors impacting the intervention implementation and mechanisms included staff and management turnover, project infrastructure and mothers' context, such as resources, social networks and previous experiences. The overall fidelity of the intervention delivery was high.

Conclusions: Health visitors and families responded well to the intervention. Interventions aimed at enabling health care providers to deliver simplified and structured breastfeeding support, in alignment with support provided in other sectors of the health care system, may increase breastfeeding rates and reduce social inequity in breastfeeding, even in international contexts.

Trial registration: Clinical Trials: NCT05311631. First posted April 5, 2022.

Background: Transgender individuals often face stigma, discrimination, and various forms of abuse, which negatively impact their mental and physical health. They face a significantly greater risk of HIV, with a higher prevalence than the general population. Despite these challenges, transgender people have limited access to healthcare due to violence, legal barriers, and societal stigma, further exacerbated in countries like Uganda, where transgender identities are criminalized. Therefore, this study explored the lived experiences of HIV researchers working with gender minority populations in criminalizing contexts.

Methods: This was an interpretative phenomenological analysis (IPA) qualitative study. Twelve (12) research team members at all levels were involved in the study. Participants had less than five years of involvement in HIV research among gender minority populations. Data were collected using field notes, reflective journals, documentation from daily team debriefing sessions, and semi-structured interviews. The analysis used NVivo software.

Results: Positive experiences, barriers, and challenges were captured. The positive experiences were 'respecting cultural diversity', 'expanding networks', 'addressing misconceptions' and 'finding allies'. The barriers included 'experiencing stigma', 'lengthy research processes', 'feeling isolated', 'fearing for personal safety', 'unexpected logistical costs', and 'criminalization of sexual and gender minorities'. The key themes that emerged from the lessons learned were: 'dealing with gatekeepers', 'diversity and sensitivity training', 'leveraging networks', 'meaningful community engagement', 'reflexivity', 'ensuring safety', 'equal partnership', 'giving feedback' and 'awareness of legal implications'.

Conclusions: This study highlights the importance of cultural sensitivity, community engagement, and reflexivity in research design and implementation. The findings emphasize the need for innovative strategies to navigate legal, social, and logistical barriers that researchers and participants face. Despite these challenges, the study demonstrates that meaningful collaboration with community members and building trust can significantly enhance the research process and outcomes. Future research should continue to explore these strategies while addressing ethical and safety concerns.

Background: Colombia, which hosts over 3 million of the Venezuelan diaspora, is lauded for its progressive approach to social integration, including providing migrants access to its universal health coverage system. However, barriers to healthcare persist for both migrant and host populations, with poorly understood disparities in healthcare-seeking behaviors and associated costs. This is the first study to link healthcare-seeking behaviors with costs for Venezuelan migrants in Colombia, encompassing costs of missing work or usual activities due to healthcare events.

Methods: We use self-reported survey data from Venezuelan migrants and Colombians living in Colombia (September-November 2020) to compare healthcare-seeking behaviors and cost variables by nationality using two-sampled t-tests or Chi-square tests (X²). The International Classification of Diseases was used to compare reported household illnesses for both populations. Average health service direct costs were estimated using the Colombian Government's Suficiencia database and self-reported out-of-pocket (OOP) payments for laboratory and pharmacy services. Indirect costs were calculated by multiplying self-reported days of missed work or usual activities with estimated income levels, derived by matching characteristics using the Gran Enquesta Integrada de Hogares database. We calculate economic burdens for both populations, combining self-reported healthcare-seeking behaviors and estimated healthcare service unit costs across six healthcare-seeking behavior categories.

Results: Despite similar disease profiles, Venezuelan migrants are 21.3% more likely to forego formal care than Colombians, with 746.3% more Venezuelans reporting lack of health insurance as their primary reason. Venezuelan women and uninsured report the greatest difficulties in accessing health services, with accessing medications becoming more difficult for Venezuelan women during the COVID-19 pandemic. Colombians cost the health system more per treated illness event (US$40) than Venezuelans (US$26) in our sample, over a thirty-day period. Venezuelans incur higher costs for emergency department visits (123.5% more) and laboratory/ pharmacy OOP payments (24.7% more).

Conclusions: While Colombians and Venezuelans share similar disease burdens, significant differences exist in access, cost, and health-seeking behaviors. Increasing Venezuelan health insurance enrollment and tackling accessibility barriers are crucial for ensuring healthcare equity and effectively integrating the migrant population. Findings suggest that improving migrant access to primary healthcare would produce savings in Colombian healthcare expenditures.

Background: Discrimination may further impede access to medical care for individuals in socially disadvantaged positions. Sociodemographic information and perceived discrimination intersect and define multiple contexts or strata that condition the risk of refraining from seeking physician's care. By applying analysis of individual heterogeneity and discriminatory accuracy (AIHDA) we aimed to improve the mapping of risk by considering both strata average risk differences and the accuracy of such strata risks for distinguishing between individuals who did or did not refrain from seeking physician's care.

Methods: We analysed nine annual National Public Health Surveys (2004, 2007-2014) in Sweden including 73,815 participants. We investigated the risk of refraining from seeking physician's care across 64 intersectional strata defined by sex, education, age, country of birth, and perceived discrimination. We calculated strata-specific prevalences and prevalence ratios (PR) with 95% confidence intervals (CI), and the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy (DA).

Results: Discriminated foreign-born women aged 35-49 with a low educational level show a six times higher risk (PR = 6.07, 95% CI 5.05-7.30) than non-discriminated native men with a high educational level aged 35-49. However, the DA of the intersectional strata was small (AUC = 0.64). Overall, discrimination increased the absolute risk of refraining from seeking physician's care, over and above age, sex, and educational level.

Conclusions: AIHDA disclosed complex intersectional inequalities in the average risk of refraining from seeking physician's care. This risk was rather high in some strata, which is relevant from an individual perspective. However, from a population perspective, the low DA of the intersectional strata suggests that potential interventions to reduce such inequalities should be universal but tailored to the specific contextual characteristics of the strata. Discrimination impairs access to healthcare.

Background: The period of early childhood bears significant importance from the lifespan perspective. Children from marginalized Roma communities face several risk factors that endanger their early development. Based on the gaps in available evidence, the aim of the RomaREACH research project (Research on Early Childhood in marginalized Roma communities) is, therefore, to explore the complex mechanisms influencing psychomotor development in the first 3 years of a child's life in marginalized Roma communities, and to translate and adapt instruments for measuring development and parenting in marginalized Roma communities and assess their psychometric qualities and suitability METHODS: The project comprises two parts. The first part is a validation study of the translated Caregiver-Reported Early Development Instrument (CREDI) and the Comprehensive Early Childhood Parenting Questionnaire (CECPAQ), tools for the assessment of early development and of parenting strategies and practices. The second part is a longitudinal cohort study, in which the relationships of risk and protective factors with development are explored.

Discussion: The RomaREACH project is a multicomponent study of social determinants of health and development in early childhood that can provide new evidence on the relationship of risk and protective factors with early development. Such young children from difficult-to-reach marginalized Roma communities are rarely included in research, and information about the scope and the extent of inequities in health and development in the period of early childhood is scarce. The expected results of the RomaREACH project have the potential to influence policy and practice by providing validated tools and evidence-based insights that can help mitigate the developmental risks faced by children in marginalized Roma communities and contribute to improving developmental outcomes and equity.

Background: Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes.

Methods: We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics.

Results: Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree.

Conclusions: Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.