Facilitators and Barriers to the Application of Health Equity Planning and Assessment Tools

Abstract

Methods A total of 15 832 (74% men) participants of the GAZEL cohort, employees of the French National Gas and Electricity Company, aged 35-50 years in 1989 were included. Mental disorder status was defined based on sick leave spells from 1989 to 2000. Hospitalizations for: all-cause (except psychiatric reasons), myocardial infarction (MI), stroke and cancer were recorded yearly from 2001 to 2011. Negative binomial regression models were used to estimate hospitalization rates over the follow-up among participants with and without any mental disorder. Results After controlling for baseline sociodemographic factors, health-related behaviours, and self-rated health, participants with any mental disorder had significantly higher rates of hospitalization for all-cause [Rate ratio, RR = 1.20 (95%, 1.14-1.26), p < 0.001], myocardial infarction (MI) [RR = 1.50 (95%, 1.19-2.47), p = 0.001] but not for stroke [RR = 1.32 (95%, 0.93-1.88), p = 0.12] and cancer [RR = 1.01 (95%,0.87-1.18), p = 0.86]. A similar trend was observed when diagnostic categories were considered, even though the magnitude of the associations was much stronger, particularly for hospitalization for MI and stroke. Conclusions In this prospective cohort study, we found that participants with mental disorders had higher rates of non-psychiatric-hospitalizations, particularly for myocardial infarction and stroke. This may indicate both a higher prevalence of chronic physical comorbidities, as well as less access to effective management of these comorbidities and their risk factors at primary and specialized care settings. Key message Higher rates of non-psychiatric hospitalizations for individuals with mental disorders might indicate a poorer access to effective management of their physical medical comorbidities. Loss and psycho-social factors as determinants of quality of life among survivors of the 1988 Armenian earthquake: a 23-year follow-up study Background Disaster related experiences and health consequences have been found to be among factors associated with lower quality of life (QOL). However, long-term QOL outcomes and their determinants among disaster exposed populations are understudied. Methods This study explored the association of psycho-social variables on QOL among a cohort of 725 individuals exposed to the 1988 Armenian earthquake. A wide range of socio-demographic characteristics, earthquake related experiences, and mental and physical health measures were collected during four phases of this longitudinal study conducted between 1990 and 2012. Linear and ordinal logistic regression models were fitted to evaluate the associations of these variables with QOL and its underlying five domains (mobility, self-care, usual activity, pain/discomfort and anxiety/depression). Results Compared to those individuals with no/minimum earthquake related loss, those with severe losses had higher odds to have problems with mobility (OR = 1.86, p < 0.05), self-care (OR = 2.85, p < 0.01), and anxiety/depression (OR = 2.70, p < 0.01) domains of QOL, 23 years after the earthquake. Post-earthquake financial/material aid provided to those with severe loss was associated with lower odds of problems on self-care (OR = 0.20, p < 0.01), usual activity (OR = 0.40, p < 0.05), and anxiety/depression (OR = 0.48, p < 0.05) domains of QOL. Every unit increase in social support score was associated with 6-10% lower odds of self-reported problems on various domains of QOL. There was no statistically significant association between the 1991 baseline psychopathology and current 2012 QOL; however, current depression, post-traumatic stress disorder and anxiety were negatively associated with most QOL domains (OR range = 1.46-3.52). Conclusions These findings highlight the importance of post-disaster financial/material aid in improving QOL of survivors with severe loss. Promotion and improvement in social network is another strategy that can benefit the QOL of disaster survivors. These findings also show the magnitude of adverse effects of mental illnesses on the QOL of survivors, suggesting that prevention and/or treatment of mental conditions might have a significant impact on improving the QOL of survivors. Key messages Even more than 2 decades after the 1988 Armenian earthquake, those survivors with severe earthquake related material loss had statistically significantly lower quality of life outcomes. Post-earthquake financial/material aid to survivors with earthquake related severe losses showed a significant positive impact on their quality of life outcomes measured 23 years after the disaster. Objectives To identify factors that facilitates or hinders the application and evaluation of health equity planning and assessment tools. Methods Published and grey literature from Western jurisdictions was reviewed. Key informants who designed and applied the tools in Canada, Australia and New Zealand were interviewed to share their experiences. Thematic analysis was used to analyze the qualitative data. Results We identified facilitators and barriers to both: 1) the application/use of health equity impact assessment and other health equity planning and assessment tools; as well as 2) the adoption of recommendations coming from the use of the tools. Three levels of facilitators and barriers were identified: system, organizational and operational. System level facilita-tors included leadership support, mandates to use health equity focused tools, and organizational performance management incentives. Organizational level facilitators included organizational commitment and readiness, and buy-in from top management. Facilitators at the operational level included having a clearly defined approach to the application of these tools, staff training and access to technical support. Involvement of stakeholders and application of the health equity focused tool in the project planning phase facilitated the adoption of recommendations arising from the use of the tool. Operational level barriers included lack of resources, limited capacity within the health care system for this work, subjectivity introduced during the equity analysis, and lack of data and literature on equity outcomes. Evaluation efforts were largely descriptive, focusing on the process of applying the tools, rather than outcomes and impacts. Challenges to evaluation included difficulties in measuring the impact of recommendations arising from the use of the tools and assessing indirect impacts such as increasing awareness of health equity issues and partnership building. Conclusions The application and evaluation of health equity planning and assessment tools could be strengthened by including both process and outcome evaluation, broader adoption of a standardized reporting framework for case studies, and facilitated information sharing. Key messages Three levels of facilitators and barriers were identified for the application of health equity impact assessment tools: system, organizational and operational. Assessment and prioritization of these facilitators and barriers for action will help in wider application of the tools. Equity in access to healthcare in two different health systems: a study in municipalities of central Colombia and northeastern Brazil Introduction Most studies examining inequities in access to health care in Colombia and Brazil consider the country as a whole, despite the existing internal inequalities; moreover, they do not distinguish between levels of the continuum of care. The aim is to analyze, in a comparative way, the degree of inequity in access to the different levels of the continuum of care in Colombia and Brazil. Methods Cross-sectional study by means of a questionnaire among people who have had at least one health problem in the past three months. Areas of study were two municipalities in each country. Multistage sampling: primary (census section)