Monitoring equity in health and healthcare: a conceptual framework

This paper aims at articulating a conceptual framework for monitoring equity in health and healthcare. The focus is on four main questions: What is health equity? What is monitoring? What are the essential components of a system for monitoring health equity? and Why monitor health equity? Monitoring equity in health and healthcare requires comparing indicators of health and its social determinants among social groups with different levels of underlying social advantage, i.e. groups who occupy different positions in a social hierarchy. A framework is presented for formulating the key questions, defining the social groups to be compared, and selecting the health indicators and measures of disparity that are fundamental to monitoring health equity. Although monitoring health equity is a scientific endeavour, its fundamental objective is guided by values; technical challenges should be addressed as part of a broader strategy to confront the political obstacles to greater equity.     

Large employers' selection criteria in purchasing behavioral health benefits

To determine the criteria other than cost large employers use in selecting and monitoring behavioral health benefits, this study interviewed 31 of 44 (70.4%) randomly selected corporations employing at least 5,000 workers. While more than 60% of employers considered administrative efficiency and provider access to be very influential in their selection of behavioral health benefits, only 12.9% (95% confidence interval 0.7%–25.1%) considered clinical outcomes. Employers who considered clinical outcomes in their purchasing decision reported significantly greater satisfaction with the quality and cost of their behavioral health benefits. Following selection, 38.7% of corporations used employee complaints to monitor quality problems in their behavioral health benefits; 3.2% used clinical outcomes. If society expects employers to purchase behavioral health care on the basis of quality as well as cost, more employers need better indicators of quality.     

A life-course approach to measuring socioeconomic position in population health surveillance systems

Measuring socioeconomic position (SEP) in population chronic disease and risk factor surveillance systems is essential for monitoring socioeconomic inequalities in health over time. Life-course measures are an innovative way to supplement other SEP indicators in surveillance systems. A literature review examined the indicators of early-life SEP that could potentially be used in population health surveillance systems. The criteria of validity, relevance, reliability and deconstruction were used to determine the value of potential indicators. Early-life SEP indicators used in cross-sectional and longitudinal studies included education level, income, occupation, living conditions, family structure and residential mobility. Indicators of early-life SEP should be used in routine population health surveillance to monitor trends in the health and SEP of populations over time, and to analyse long-term effects of policies on the changing health of populations. However, these indicators need to be feasible to measure retrospectively, and relevant to the historical, geographical and sociocultural context in which the surveillance system is operating.     

Mortality amenable to health care in the United States: the roles of demographics and health systems performance

This article examines associations of socio-demographic and health-care indicators, and the statistic 'mortality amenable to health care' (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of 'uninsurance' and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.     

Surveillance for characteristics of health education among secondary schools--school health education profiles, 1998.

PROBLEM/CONDITION: School health education (e.g., classroom instruction) is an essential component of school health programs; such education promotes the health of youth and improves overall public health. REPORTING PERIOD: February-May 1998. DESCRIPTION OF SYSTEM: The School Health Education Profiles monitor characteristics of health education in middle or junior high schools and senior high schools in the United States. The Profiles are school-based surveys conducted by state and local education agencies. This report summarizes results from 36 state surveys and 10 local surveys conducted among representative samples of school principals and lead health education teachers. The lead health education teacher coordinates health education policies and programs within a middle/junior high school or senior high school. RESULTS: During the study period, most schools in states and cities that conducted Profiles required health education in grades 6-12. Of these, a median of 91.0% of schools in states and 86.2% of schools in cities taught a separate health education course. The median percentage of schools in each state and city that tried to increase student knowledge in selected topics (i.e., prevention of tobacco use, alcohol and other drug use, pregnancy, human immunodeficiency virus [HIV] infection, other sexually transmitted diseases, violence, or suicide; dietary behaviors and nutrition; and physical activity and fitness) was >73% for each of these topics. The median percentage of schools with a health education teacher who coordinated health education was 38.7% across states and 37.6% across cities. A median of 41.8% of schools across states and a median of 31.0% of schools across cities had a lead health education teacher with professional preparation in health and physical education, whereas a median of 6.0% of schools across states and a median of 5.5% of schools across cities had a lead health education teacher with professional preparation in health education only. A median of 19.3% of schools across states and 21.2% of schools across cities had a school health advisory council. The median percentage of schools with a written school or school district policy on HIV-infected students or school staff members was 69.7% across states and 84.4% across cities. INTERPRETATION: Many middle/junior high schools and senior high schools require health education to help provide students with knowledge and skills needed for adoption of a healthy lifestyle. However, these schools might not be covering all important topic areas or skills sufficiently. The number of lead health education teachers who are academically prepared in health education and the number of schools with school health advisory councils needs to increase. PUBLIC HEALTH ACTION: The Profiles data are used by state and local education officials to improve school health education.     

Monitoring health reform: a report card approach

During the past several years, budget cuts have forced hospitals in several countries to change the way they deliver care. Gilson (Gilson, L. (1998). Discussion: In defence and pursuit of equity. Social Science & Medicine, 47(12), 1891-1896) has argued that, while health reforms are designed to improve efficiency, they have considerable potential to harm equity in the delivery of health care services. It is essential to monitor the impact of health reforms, not only to ensure the balance between equity and efficiency, but also to determine the effect of reforms on such things as access to care and the quality of care delivered. This paper proposes a framework for monitoring these and other indicators that may be affected by health care reform. Application of this framework is illustrated with data from Winnipeg, Manitoba, Canada. Despite the closure of almost 24% of the hospital beds in Winnipeg between 1992 and 1996, access to care and quality of care remained generally unchanged. Improvements in efficiency occurred without harming the equitable delivery of health care services. Given our increasing understanding of the weak links between health care and health, improving efficiency within the health care system may actually be a prerequisite for addressing equity issues in health.     

What do health authorities think of population based health outcome indicators?

OBJECTIVES: To determine the role of population based indicators of health outcome in local health outcome assessments; the constraints of using such indicators; how they could be made more useful; and whether health authorities had developed their own indicators of health outcome. DESIGN: A structured telephone interview with representatives of 91 of the 100 English health authorities. RESULTS: Interviewees, asked to give details on two clinical areas in which population health outcome assessments had been of most value, nominated 147 examples in over 30 clinical areas. They chose 50 (34%) of the examples because of an outlying national indicator, and 20 (14%) because of local variations in a national indicator. The main perceived constraints in the use of population based indicators of health outcome were: data validity and timeliness; the attributability of these health outcomes to the quality of health care; the difficulties of changing clinical behavior; and organisational change within health authorities. To make these indicators more useful interviewees wanted an increased use of process indicators as proxies for health outcome, indicator trend data, and indicator comparisons of districts with similar population structures. Some recent publications have started to consider some of these issues. 27 (30%) health authorities had developed their own indicators, mostly provider based process indicators. 10 of these used their own indicators to manage the performance of local provider units. CONCLUSIONS: Population based indicators of health outcome had an important role in prompting districts to undertake population health outcome assessments. Health authorities also used these indicators to examine local variations in health outcome. They helped to highlight areas for further investigation, initiated data validation, and enabled the monitoring of changes to services. Comparative population based indicators of health outcome may have an increasing part to play in assessing the performance of health authorities.     

Issues in the development of health promotion indicators

The rapid adoption of the concept of health promotion in recentyears, with the corresponding need to monitor health promotionendeavours, raises issues for the development of valid indicatorsof progress. A first step in such development is the differentiationof health promotion indicators from indicators of health status.The former constitute the means or methods to achieve the goalof enhancing health. The two types of indicators should be conceptuallydistinguished. Indicators must be refined, to tap the relevantdimensions of influences on health. Another major issue in thedevelopment of health promotion indicators is the excessivefocus on indicators of personal behaviour. Meaningful indicatorsare needed of the cultural, structural and situational processesthat affect health.     

Surveillance of preconception health indicators among women delivering live-born infants--Oklahoma, 2000-2003

Promoting preconception health of women is a key public health strategy in the United States to decrease morbidity and mortality associated with adverse maternal and infant outcomes. In 2006, CDC published 10 recommendations for improving the health of women before pregnancy; one recommendation proposed maximizing public health surveillance to monitor preconception health. Toward this end, data collected in Oklahoma (the only state to develop a detailed survey question on preconception health) during 2000-2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed to 1) estimate the prevalence of women who did not report three selected preconception health indicators, (i.e., pre-pregnancy awareness of folic acid benefits, multivitamin consumption, and receipt of health-care counseling) and 2) identify those subpopulations of women who were more likely not to report these indicators. Results of this analysis indicated that 21.5% of Oklahoma women with a recent live birth were not aware of folic acid benefits before they became pregnant, 73.5% did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8% did not receive preconception counseling from a health-care provider. Subpopulations of women with characteristics (at the time of conception) significantly associated (p<0.05) with not reporting at least two of the three indicators included those who were younger, were unmarried, had < or =12 years of education, had no health insurance, had an unintended pregnancy, or had a previous live birth. Other states might use this analysis to help develop preconception health questions to be included in their own PRAMS surveys; Oklahoma state and local health officials can use the results to help prioritize preconception health objectives and identify subpopulations of women in need of targeted programs.     

Indicators for Occupational Health Reference Centers: proposal of a system for monitoring health services

This research proposes a framework of indicators to monitor the activities of the Occupational Health Reference Centers (CEREST). CEREST are structural elements of the National Network of Comprehensive Attention to Workers' Health (RENAST) and are coordinated by the General Coordination of Occupational Health of the Ministry of Health (CGSAT). In order to build this framework, we first elaborated a list of indicators based on the norms that govern CEREST's responsibilities. As a strategy to build a participative approach, a Likert scale questionnaire was sent to 173 CEREST coordinators, who were asked to evaluate this preliminary list of indicators. After the return of the questionnaires (48,6%), the answers were analyzed, considering the CEREST scope (State or Regional), date of accreditation and location. Indicators with approval rate higher than 75% were included in the proposed framework. This instrument consisted in 12 indicators for State CEREST and 13 indicators for Regional CEREST. It is expected that the procedures proposed in this research and the framework itself might encourage the government to create a monitoring system for RENAST as well as for health services in general.     

A summary measure of health disparity

OBJECTIVES: Eliminating health disparities is a goal of Healthy People 2010. In order to track progress toward this goal, we need improved methods for measuring disparity. The authors present the Index of Disparity (ID) as a summary measure of disparity. METHODS: The ID, a modified coefficient of variation, was used to measure disparity across populations defined on the basis of race/ethnicity, income, education, and gender. Disparity was also assessed for a diverse range of health indicators and over time to monitor trends. RESULTS: Disparity in cardiovascular disease deaths decreased based on gender from 1989 to 1998 but was largely unchanged based on race/ethnicity. The magnitude of disparities in cervical cancer and cholesterol screening, smoking, exercise, and health insurance ranged from 1.9% to 78.6%. The largest disparities for health indicators were not associated with any particular population classification, whether defined on the basis of race/ethnicity, education, or income. CONCLUSIONS: To eliminate disparities, we need a means to assess disparities across many types of health indicators. Furthermore, for a given health indicator, disparities may differ for populations defined on the basis of race/ethnicity, education, income, and so on. The ID is a simple method for summarizing disparities across groups within a population that can be applied across health indicators regardless of magnitude, over time to monitor trends, and across different populations.     

The health status of Kerala

This paper presents the 1998 report of the Task Force of Kerala, which describes the status of sanitation, nutrition, health and health infrastructure in Kerala, India. It is noted that the report characterizes environmental sanitation in the State as dismal, with sanitation coverage in Kerala as only 51%. In terms of availability of safe drinking water, the report indicated that only 19% of the rural households are consuming piped water despite claims of the government that 37% of the rural and 70% of the urban population have access to piped water supply schemes. In the area of nutrition, food consumption in Kerala is reported to be below the recommended level and was ranked second lowest in consumption of nutrients among the eight states studied in 1990. Although Kerala seem to have achieved the "Health For All" goal, as per conventional health indicators, the people still suffer more episodes of diseases, which arise out of poverty and deprivation. Moreover, the utilization rate of health services is low, in that government health services are used by only one-fourth of the population and the rest use the private sector health system.     

Monitoring pesticide use and associated health hazards in Central America

We established methods for monitoring pesticide use and associated health hazards in Central America. With import data from Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama for 2000-2004, we constructed quantitative indicators (kg active ingredient) for general pesticide use, associated health hazards, and compliance with international regulations. Central America imported 33 million kg active ingredient per year. Imports increased 33% during 2000-2004. Of 403 pesticides, 13 comprised 77% of the total pesticides imported. High volumes of hazardous pesticides are used; 22% highly/extremely acutely toxic, 33% moderately/severely irritant or sensitizing, and 30% had multiple chronic toxicities. Of the 41 pesticides included in the Stockholm Convention on Persistent Organic Pollutants (POPs), the Rotterdam Convention on Prior Informed Consent (PIC), the Montreal Protocol on Substances that Deplete the Ozone Layer, the Pesticide Action Network (PAN) Dirty Dozen, and the Central American Dirty Dozen, 16 (17% total volume) were imported, four being among the 13 most imported pesticides. Costa Rica is by far the biggest consumer. Pesticide import data are good indicators of use trends and an informative source to monitor hazards and, potentially, the effectiveness of interventions.     

Soil enzyme activities as biological indicators of soil health

Soil health can be defined as the continued capacity of a specific kind of soil to function as a vital living system, within natural or managed ecosystem boundaries, to sustain plant and animal productivity, to maintain or enhance the quality of air and water environments, and to support human health and habitation. Because of the conflicting pressures increasingly applied to the soil, it is clear that relevant indicators are urgently needed to assess and monitor soil health. Biological indicators of soil health offer certain advantages over physicochemical methods. Among the various biological indicators that have been proposed to monitor soil health, soil enzyme activities have great potential to provide a unique integrative biological assessment of soils and the possibility of assessing the health of the soil biota. Besides, soil enzyme activities provide an easy, relatively rapid, and low cost procedure to monitor soil health. Nevertheless, soil enzyme activities also present some limitations and must always be considered in conjunction with other biological and physicochemicals measurements if we are to diagnose soil health correctly.     

Adverse drug reaction monitoring in Mississippi home health care agencies

A statewide survey of home health care agency directors in Mississippi was conducted to determine the extent of Adverse Drug Reaction (ADR) monitoring and reporting by health care professionals. A 24-item questionnaire was sent to agency directors eliciting responses on agency characteristics, rate of occurrence of ADRs, and attitudes toward responsibility for monitoring ADRs. A total of 77 questionnaires were returned yielding a response rate of 48%. The average program enrolled 104 patients with 3.5 ADRs reported by health care professionals per year (range 0-65). Agency directors reported that physicians, nurses, pharmacists, and members of the pharmacy and therapeutics committee should monitor ADRs. Results indicated a need for all health-care professional involved in home health care to increase their ADR monitoring and reporting activities.     

Comparing indicators of health or nutritional status

The performance of an indicator of health or nutritional status depends on its sensitivity and specificity properties over a range of cut-offs. Frequently, it is of interest to compare indicators to pick the best for a given purpose, such as screening for disease or monitoring to detect changes in prevalence of inadequate nutriture. Relative operating characteristic (ROC) analysis provides an objective method for making this comparison, but the application of this methodology as described for epidemiologists in this Journal is now outdated for most indicators. Recent developments are noted and an alternative analysis for use with continuous Gaussian data is presented here. The estimators and statistical test procedures proposed here are compared with the previously described methods, by means of a computer simulation study. The new procedures are found to be superior for continuous Gaussian data, and have the practical advantage that they do not require use of a specialized computer program. The implications of these results for comparing indicators to be used to monitor population prevalences are discussed.     

Year 2000 health status indicators: a profile of California.

OBJECTIVES: To examine the health status of Californians using a set of 18 health status indicators (HSIs) corresponding to goals set forth in Healthy People 2000 and to develop a health status profile for use in research and surveillance, policy development program planning, and program evaluation. METHODS: Federal, state, and county data were used to evaluate California''s performance on 18 indicators of health status related to mortality, disease incidence, and health risks. RESULTS: By 1994, California had achieved Year 2000 objectives associated with seven HSIs and significant declines in mortality associated with two other HSIs. Nationally, California was ranked among the states with the lowest rates for infant mortality, lung cancer, female breast cancer, and syphilis but among states with the highest rates for homicide, AIDS, measles, tuberculosis, late prenatal care, childhood poverty, and poor air quality. CONCLUSIONS: California''s experience may provide a useful model for other state and local health agencies monitoring the health status of populations using HSIs associated with Year 2000 objectives.     

Validation of a screening survey to assess local public health performance.

The study seeks to validate an abbreviated protocol for measuring local public health performance. Primary data were collected during 1993 on a series of indicators keyed to defined public health core functions and their associated practices. The data were obtained from responses provided by local health department directors and were reviewed for accuracy by respective state health department personnel. All local public health jurisdictions (370) in six states were surveyed with a screening protocol. A sample of 36 of these jurisdictions was then resurveyed by means of a full-length protocol using 84 different indicators of public health performance. Correlations between scores obtained from the screening survey and those from the reference survey were high for overall public health performance, for each of the three functions, and for some of the ten practices. A group of only four queries was shown to predict reliably the overall scores. Findings support the conclusion that public health practice can be defined, measured, and monitored. A proposed surveillance system is feasible.     

我国环境健康综合监测指标体系建立的初步研究

目的通过梳理国内外环境健康指标,初步建立我国环境健康综合监测指标体系,探索国内外环境健康监测指标差异,以期为开展环境健康综合监测工作提供依据。方法对国外环境健康综合监测网站平台和国内环境健康数据资源开展调研,归纳总结出国内监测指标中的不足,在此基础上初步建立我国的环境健康综合监测指标体系。结果本研究初步整理的环境健康指标监测体系分为环境类、健康效应类和人口与社会经济学因素类,环境类包括空气、气象、土壤和饮用水监测数据;健康效应类包括慢性病监测、医院监测、死亡监测、高温中暑、出生监测和地方疾病监测数据;人口与社会经济学类包括人口、社会经济、空间数据和生活方式等数据。基于国内外监测指标对比,发现我国目前缺乏对婴儿死亡率、吸烟率、期望寿命和空调拥有率等指标的全国性综合监测。结论通过对国内外环境健康指标的调研,初步建立了我国环境健康指标综合监测体系,探讨了国内外环境健康指标的差别,为进一步完善指标监测体系和为开展综合监测工作提供依据。