Improving health equity through health care systems research

Objective

To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes.

Data Sources and Study Setting

This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government.

Study Design

Expert group consensus, informed by stakeholder engagement and targeted evidence review.

Data Collection/Extraction Methods

Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus.

Principal Findings

Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines.

Conclusions

As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.     

公共卫生和公共卫生突发事件

该文从理论角度阐述什么是现代公共卫生观念 ,公共卫生应在公共卫生突发事件处理中发挥什么作用和怎样发挥作用 ,希望对确定我国现代公共卫生理论体系有所启发     

Progressive segmented health insurance: Colombian health reform and access to health services

Equal access for poor populations to health services is a comprehensive objective for any health reform. The Colombian health reform addressed this issue through a segmented progressive social health insurance approach. The strategy was to assure universal coverage expanding the population covered through payroll linked insurance, and implementing a subsidized insurance program for the poorest populations, those not affiliated through formal employment. A prospective study was performed to follow-up health service utilization and out-of-pocket expenses using a cohort design. It was representative of four Colombian cities (Cendex Health Services Use and Expenditure Study, 2001). A four part econometric model was applied. The model related medical service utilization and medication with different socioeconomic, geographic, and risk associated variables. Results showed that subsidized health insurance improves health service utilization and reduces the financial burden for the poorest, as compared to those non-insured. Other social health insurance schemes preserved high utilization with variable out-of-pocket expenditures. Family and age conditions have significant effect on medical service utilization. Geographic variables play a significant role in hospital inpatient service utilization. Both, geographic and income variables also have significant impact on out-of-pocket expenses. Projected utilization rates and a simulation favor a dual policy for two-stage income segmented insurance to progress towards the universal insurance goal.     

Understanding population health terminology

Population health is a relatively new term, with no agreement about whether it refers to a concept of health or a field of study of health determinants. There is debate, sometimes heated, about whether population health and public health are identical or different. Discussions of population health involve many terms, such as outcomes, disparities, determinants, and risk factors, which may be used imprecisely, particularly across different disciplines, such as medicine, epidemiology, economics, and sociology. Nonetheless, thinking and communicating clearly about population health concepts are essential for public and private policymakers to improve the population's health and reduce disparities. This article defines and discusses many of the terms and concepts characterizing this emerging field.     

Schools, health literacy and public health: possibilities and challenges

Health literacy is a concept that can be widely embraced by schools. Schools throughout the world contribute to the achievement of public health goals in conjunction with their educational commitments. In this paper, the interface between a school's core business of education and public health goals is identified, and examples provided in the area of nutrition demonstrating how these links can operate at school level. The structure and function of the health promoting school is described and the author proposes that there is a very close connection between the health promoting school and the enabling factors necessary in achieving health literacy. Major findings in the literature that provide evidence of good practices in school health education and promotion initiatives are described. Also, those factors that make schools effective and which facilitate learning for students are identified. There is a substantial overlap between the successful components of a health promoting school and effective schools. This enables schools to potentially achieve all three levels of health literacy, including level 3-critical health literacy. However, there are three challenges that must be addressed to enable schools to achieve this level: the traditional structure and function of schools, teachers practices and skills, and time and resources. Strategies are proposed to address all three areas and to reduce the impediments to achieving the goals of health literacy and public health using the school as a setting.     

“新医改”应致力于公众健康管理

医药卫生体制改革已进入＂深水区＂,在取得一定成果的基础上更应该看到慢性病＂井喷＂、人口老龄化加速等亟待解决的问题,以此入手,合理配置医疗卫生资源、转变卫生服务模式、调整卫生服务重心来保障公众健康,通过走中国特色的健康管理之路来实现人人享有基本医疗卫生服务的目标。     

论农村卫生事业的发展与卫生政治学

卫生工作具有政治性,发展卫生事业必须讲政治。一个国家整个人群的健康不是取决于单个的公民或医生,而是取决于社会制度和社会关系。只有通过政治才能改变社会制度和社会关系。解放后我国农村卫生事业取得了令国际社会赞赏的辉煌成就,根本原因在于中国共产党注重从政治的高度认识并开展农村卫生工作。市场经济条件下,我国农村卫生事业发展遇到了挫折,需要我们重新审视农村卫生与政治的关系,探索建立卫生政治学新学科,为农村卫生工作提供理论指导。     

妊娠期妇女的口腔卫生预防保健

目的 调查妊娠期妇女的口腔健康状况及口腔健康教育状况.方法 对500例孕妇患龋率、牙周病及自我保健意识进行调查分析.结果 妊娠期龋齿及牙龈炎患病率分别为49.67%和75.68%, 软垢及牙石发生率分别为86.87%和52.41%,而龋齿和牙龈炎就诊率仅为3.38%,92.32%的孕妇未接受过口腔健康教育.结论 缺乏口腔保健意识和不良口腔卫生习惯是影响孕妇口腔健康状况的主要原因.     

The association between health risk status and health care costs among the membership of an Australian health plan

Health promotion in Australia has developed into an accepted strategy for solving public health problems and promoting the health of its citizens. However, there are few evidence-based research studies in Australia that measure health risk status or track health changes over time with defined cost outcome measures. Those individuals with more high-risk lifestyle behaviors have been associated with higher costs compared with those with low-risk behaviors. Although intuitively it was believed that the health promotion programs had a positive impact on health behaviors and consequently on health care costs, the relationship between health risk status and health care costs had yet to be tested in the Australian population. Consequently, a verification study was initiated by the Australian Health Management Group (AHMG) to confirm that those relationships between health risks and medical costs that had been published would also hold in the Australian population using Australian private health care costs as the outcome measure. Eight health risks were defined using a Health Risk Appraisal (HRA) to determine the health risk status of participants. Consistent with previous studies, low-risk participants were associated with the lowest health care costs (377 Australian dollars) compared with medium- (484 Australian dollars) or high-risk (661 Australian dollars) participants and non-participants (438 Australian dollars). If the health care costs of those at low risk were considered as the baseline costs, excess health care costs associated with excess health risks in this population were calculated at 13.5% of total expenditures. Health risk reduction and low-risk maintenance can provide important strategies for improving/maintaining the health and well-being of the membership and for potential savings in health care costs.     

Culture and rural health

This paper considers the role of culture in rural health, suggesting that the concept and its impacts are insufficiently understood and studied. It reviews some of the ways that culture has been considered in (rural) health, and states that culture is either used ambiguously and broadly – for example, suggesting that there is a rural culture, or narrowly – indeed perhaps interchangeably with ethnicity, for example Aboriginal culture as a unity. The paper notes that, although culture is a dynamic social concept, it has been adopted into a biomedical research paradigm as though it is fixed. Culture is often treated as though it is something that can be addressed simplistically, for example, through cultural sensitivity education. Authors suggest that culture is an unaddressed ‘elephant in the room’ in rural health, and that exploring cultural differences and beliefs and facing up to cultural differences are vital in understanding and addressing rural health and health system challenges.     

Promoting health literacy through the health education assessment project

BACKGROUND: The Council of Chief State School Officers' State Collaborative on Assessment and Student Standards Health Education Assessment Project (SCASS-HEAP) allows states to pool financial and human resources to develop effective ready-to-use health education assessment resources through a collaborative process. The purpose of this article is to describe the extensive ongoing development of the SCASS-HEAP and its benefits for important stakeholders in health and education. METHODS: A review of the products from the first decade of the SCASS-HEAP was undertaken. RESULTS: The SCASS-HEAP supports a comprehensive systems approach to helping educators focus effectively on the most important skills and issues in child and adolescent health and gives health education a place at the school reform table, providing visibility and credibility and promoting the essential links between health and learning. CONCLUSION: State education agencies and school districts can use SCASS-HEAP materials for assessment and, perhaps more importantly, to help teachers modify and improve instruction at the classroom level for increased student learning.     

Social health insurance in Nepal: A health system departure toward the universal health coverage

The World Health Organization has identified universal health coverage (UHC) as a key approach in reducing equity gaps in a country, and the social health insurance (SHI) has been recommended as an important strategy toward it. This article aims to analyze the design, expected benefits and challenges of realizing the goals of UHC through the recently launched SHI in Nepal. On top of the earlier free health‐care policy and several other vertical schemes, the SHI scheme was implemented in 2016 and has reached population coverage of 5% in the implemented districts in just within a year of implementation. However, to achieve UHC in Nepal, in addition to operationalizing the scheme, several other requirements must be dealt simultaneously such as efficient health‐care delivery system, adequate human resources for health, a strong information system, improved transparency and accountability, and a balanced mix of the preventive, health promotion, curative, and rehabilitative services including actions to address the social determinants of health. The article notes that strong political commitment and persistent efforts are the key lessons learnt from countries achieving progressive UHC through SHI.     

The search for theory in health behaviour and health promotion

Health promotion is often viewed as based in experience; theoryis seemingly at a more abstract level. The reasons for thisare many. This paper explores some theoretical perspectiveswhich are relevant to health promotion. In particular, it considersa collective approach to the making of theory and what the componentsof a health behaviour and health promotion theory might include.     

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.     

经济学评价方法现状及在公共卫生领域的应用

通过文献回顾,介绍了卫生经济学评价的常用的4种方法 ：成本最小化分析,成本效果分析,成本效用分析和成本效益分析,指出卫生经济学评价的9个步骤和常用的收益指标,并综述了其在公共卫生领域的应用。     

Occupational health in health care workers

Since the second half of the 20th century occupational health in health care workers is a well-established part of occupational medicine. Identification of environmental, biological, chemical, physical, and psychosocial hazards has lead to a number of preventive measures: Technical (e.g. use of safe instruments and double gloving as protection) and immunological (vaccinations) measures against biological hazards), and technical (lifting aides) and personal (back-schools) intervention to prevent musculoskeletal disorders are well-designed examples.     

Women's health, men's health, and gender and health: implications of intersectionality

Although intersectionality is now recognized in the context of women's health, men's health, and gender and health, its full implications for research, policy, and practice have not yet been interrogated. This paper investigates, from an intersectionality perspective, the common struggles within each field to confront the complex interplay of factors that shape health inequities. Drawing on developments within intersectionality scholarship and various sources of research and policy evidence (including examples from the field of HIV/AIDS), the paper demonstrates the methodological feasibility of intersectionality and in particular, the wide-ranging benefits of de-centering gender through intersectional analyses.     

The productivity of health care and health production functions

This paper derives a necessary and sufficient condition under which increased health care productivity must lead to decreased (increased) demand for health care as long as the demand for health care is inelastic (elastic). It is shown that this condition identifies a class of health production functions, which may provide useful guidance to empirical studies that depend wholly or partly on the correct specification of a health production function. As an illustration, it is demonstrated that this class of production functions may be useful for empirical studies that test the hypothesis that schooling, increasing the efficiency of health production, leads to a larger health output from a given set of health inputs. The paper also offers broader classes of production functions that would enable one to test this relationship between the demand elasticity and the effect of health care productivity on health care demand.