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The Models of Child Health Appraised (MOCHA) project recognises that child health policy is determined to a great extent by national culture; thus, exploring and understanding the cultural influences on national policies are essential to fully appraise the models of primary care. Cultures are created by the population who adopt national rituals, beliefs and code systems and are unique to each country. To understand the effects of culture on public policy, and the resulting primary care services, we explored the socio-cultural background of four components of policy-making: content, actors, contexts and processes. Responses from the MOCHA Country Agents about recent key national concerns and debates about child health and policy were analysed to identify the key factors as determinants of policy. These included awareness, contextual change, freedom, history, lifestyle, religion, societal activation and tolerance. To understand the influence of these factors on policy, we identified important internal and external structural determinants, which we grouped into those identified within the structure of health care policy (internal), and those which are only indirectly correlated with the policy environment (external). An important child-focused cultural determinant of policy is the national attitude to child abuse. We focused on the role of primary care in preventing and identifying abuse of children and young people, and treating its consequences, which can last a lifetime.

The early care and education (ECE) workforce plays a pivotal role in shaping early childhood developmental trajectories and simultaneously experiences significant mental health disparities. The purpose of this study is to investigate how social determinants of health and external stressors are associated with the mental health of ECE staff, which represent a low-resourced segment of the workforce; how psychological capital (psycap) can mitigate these associations.

The authors administered an 89-item survey to 332 ECE staff employed in 42 Head Start centers in the USA. The authors ran three hierarchical linear regression models to analyze associations between social determinants of health, external sources of stress, psycap and potential moderation effects and mental health outcomes.

Individuals experiencing greater finance-related stress reported 0.15 higher scores on the depression scale and 0.20 higher scores on the anxiety scale than those experiencing less finance-related stress (p < 0.05). Individuals experiencing greater work-related stress reported 1.26 more days of poorer mental health in the past month than those experiencing less work-related stress (p < 0.01). After controlling for all sociodemographic variables and sources of stress, psycap was significantly and negatively associated with depressive symptomology (b-weight = −0.02, p < 0.01) and the number of poor mental health days reported in the past month (b-weight = −0.13, p < 0.05). Moderation models suggest that higher levels of psycap may mitigate the association between work-related stress and the number of poor mental health days reported in the past month (b-weight = −0.06, p = 0.02).

The implications of these findings suggest a need for policy change to mitigate social determinants of health and promote pay equity and multi-level interventio ns that target workplace-related stressors and psycap to combat poor mental health of the ECE workforce.

Unequal social conditions that provide people with unequal opportunities to live healthy lives are considered unjust and associated with “health inequity”. Governing power is impacting people's lives through laws, policies and professional decisions, and can be used intentionally to combat health inequity by addressing and changing people's living- and working conditions. Little attention is paid to how these ways of exercising governing power unintentionally can structure further conditions for health inequity. In this paper, the authors coin the term “governance determinants of health” (GDHs). The authors' discussion of GDHs potential impact on health inequity can help avoid the implementation of governing strategies with an adverse impact on health equality. This paper aims to discuss the aforementioned objective.

The authors identify Governance Determinants of Health, the GDHs. GDHs refer to governance strategies that structurally impact healthcare systems and health equality. The authors focus on the unintended, blind sides of GDHs that maintain or reinforce the effects of socioeconomic inequality on health.

The power to organize healthcare is manifested in distinct structural approaches such as juridification, politicalization, bureaucratization and medical standardization. The authors explore the links between different forms of governance and health inequalities.

The authors' discussion in this article is innovative as it seeks to develop a framework that targets power dynamics inherent in GHDs to help identify and avoid GDHs that may promote unequal access to healthcare and prompt health inequity. However, this framework has limitations as the real-world, blurred and intertwined aspects of governing instruments are simplified for analytical purposes. As such, it risks overestimating the boundaries between the separate instruments and reducing the complexity of how the GDHs work in practice. Consequently, this kind of theory-driven framework does not do justice to the myriad of peoples' complex empirical practices where GDHs may overlap and intertwine with each other. Nevertheless, this framework can still help assist governing authorities in imagining a direction for the impacts of GDHs on health equity, so they can take precautionary steps to avoid adverse impacts.

The authors develop and explore – and demonstrate – the relevance of a framework that can assist governing authorities in anticipating the impacts of GDHs on health inequity.

Policies on integrated care have waxed and waned over time in the English health and care sectors, culminating in the creation of 42 integrated care systems (ICSs) which were confirmed in law in July 2022. One of the four fundamental purposes of ICSs is to tackle health inequalities. This paper reports on the content of the overarching ICS plans in order to explore how they focus on health inequalities and the strategies they intend to employ to make progress. It explores how the integrated approach of ICSs may help to facilitate progress on equity.

The analysis is based on a sample of 23 ICS strategic plans using a framework to extract relevant information on health inequalities.

The place-based nature of ICSs and the focus on working across traditional health and care boundaries with non-health partners gives the potential for them to tackle not only the inequalities in access to healthcare services, but also to address health behaviours and the wider social determinants of health inequalities. The plans reveal a commitment to addressing all three of these issues, although there is variation in their approach to tackling the wider social determinants of health and inequalities.

This study adds to our knowledge of the strategic importance assigned by the new ICSs to tackling health inequalities and illustrates the ways in which features of integrated care can facilitate progress in an area of prime importance to society.

Equity is an issue that pervades all aspects of primary care provision for children and as such is a recurring theme in the Models of Child Health Appraised project. All European Union member states agree to address inequalities in health outcomes and include policies to address the gradient of health across society and target particularly vulnerable population groups. The project sought to understand the contribution of primary care services to reducing inequity in health outcomes for children. We focused on some key features of inequity as they affect children, such as the importance of good health services in early childhood, and the effects of inequity on children, such as the higher health needs of underprivileged groups, but their generally lower access to health services. This indicates that health services have an important role in buffering the effects of social determinants of health by providing effective treatment that can improve the health and quality of life for children with chronic disorders. We identified common risk factors for inequity, such as gender, family situation, socio-economic status (SES), migrant or minority status and regional differences in healthcare provision, and attempted to measure inequity of service provision. We did this by analysing routine data of universal primary care procedures, such as vaccination, age at diagnosis of autism or emergency hospital admission for conditions that can be generally treated in primary care, against variables of inequity, such as indicators of SES, migrant/ethnicity or urban/rural residency. In addition, we focused on the experiences of child population groups particularly at risk of inequity of primary care provision: migrant children and children in the state care system.

The differences in the distribution of factors associated with under-five mortality (UFM) can help explain the rural-urban inequities in UFM. The determinants contributing to UFM in rural and urban areas have not been previously explored in Bhutan. This study examined the factors associated with UFM in rural and urban Bhutan and the role of the factors in explaining UFM disparity.

The dataset of 6,398 single births (4,999 in rural and 1,399 in urban areas) from the 2012 Bhutan National Health Survey was analyzed. Logistic regression analysis accounting for the complex survey design was performed to investigate the determinants.

The UFM rate was 2.75 times higher in rural than in urban Bhutan. In rural communities, children of younger mothers, born in households without safe sanitation and electricity, and central and eastern regions had increased UFM odds. Whereas, children born to working mothers and educated fathers, and born in households with non-working household heads had lower UFM odds in urban areas. A higher number of births and smaller household size was associated with an increased UFM odds irrespective of rural-urban residence. Environmental factors were attributable for the largest portion of rural UFM disadvantage.

This study helps to understand the rural-urban differences in the factors influencing UFM in Bhutan. The findings suggest that policies aimed to improve environmental and socioeconomic conditions, women empowerment, and those aimed to enhance health utilization can help reduce the rural-urban child survival disparity and accelerate the achievement of the Sustainable Development Goal target.

Homelessness is a colossal issue, precipitated by a wide array of social determinants, and mirrored in substantial health disparities and a revolving hospital door. Connecting people to safe and secure housing needs to be part of the health system response. The paper aims to discuss these issues.

This mixed-methods paper presents emerging findings from the collaboration between an inner city hospital, a specialist homeless medicine GP service and Western Australia’s inaugural Housing First collective impact project (50 Lives 50 Homes) in Perth. This paper draws on data from hospitals, homelessness community services and general practice.

This collaboration has facilitated hospital identification and referral of vulnerable rough sleepers to the Housing First project, and connected those housed to a GP and after hours nursing support. For a cohort (n=44) housed now for at least 12 months, significant reductions in hospital use and associated costs were observed.

While the observed reductions in hospital use in the year following housing are based on a small cohort, this data and the case studies presented demonstrate the power of care coordinated across hospital and community in this complex cohort.

This model of collaboration between a hospital and a Housing First project can not only improve discharge outcomes and re-admission in the shorter term, but can also contribute to ending homelessness which is itself, a social determinant of poor health.

Coordinated care between hospitals and programmes to house people who are homeless can significantly reduce hospital use and healthcare costs, and provides hospitals with the opportunity to contribute to more systemic solutions to ending homelessness.

This paper aims to investigate the extent to which three subgroups – people with mental health conditions, people belonging to sexual minority and gender groups and Indigenous peoples – have been “left behind” by countries implementing the World Health Organization’s Framework Convention on Tobacco Control.

A general review of electronic bibliographical databases to provide an overview of smoking prevalence among the three groups and interventions designed specifically to reduce their smoking rates.

Although explanations and specific rates differ, two trends are consistent across all three groups. First, information reported in the past two decades suggests that smoking prevalence is disproportionately high among people with mental health conditions, and in the rainbow and indigenous communities. Second, most cessation programmes are targeted at majority politically dominant groups, missing opportunities to reduce smoking rates in these minority communities.

There is a general dearth of data preventing detailed analysis. Better data collection efforts are required. Trials to identify effective smoking reduction interventions for marginalised groups are needed.

It is socially unjust that these groups are being systematically ignored by tobacco control initiatives. A failure to equitably reduce tobacco harms among all groups across society has contributed to the perceived concentration of smoking in some subgroups. The increasing stigmatisation of people who smoke then adds a marginality, compounding the negative effects associated with belonging to a marginalised group. Ongoing marginalisation of these groups is an important determinant of smoking.

Cross-case analysis of neglected subgroups with disproportionately high smoking rates suggests social marginalisation is a shared and important determinant of smoking prevalence.

This study aims at evaluating the technical efficiency (TE) of healthcare systems in the Arab region and exploring the key factors that affect the efficiency performance.

The study applies a two-stage Data Envelopment Analysis (DEA) approach to a sample of 20 Arab countries. In the first stage, a DEA model is used to calculate the TE scores of the examined healthcare systems in 2019 and 2010, following both the output and input orientations of efficiency. In the second stage, a censored Tobit model is estimated to investigate the determinants of healthcare efficiency.

DEA results of 2019 indicate that achievable efficiency gains of the Arab countries range from 0.4% to 16% under the output and input orientations, respectively. Six countries are efficient under both orientations. Although the average efficiency scores of the Arab countries have deteriorated between 2010 and 2019, Djibouti and Sudan had the greatest efficiency improvements between the two years. Bahrain, Mauritania, Morocco and Qatar proved to be efficient in 2010 and 2019 under the two orientations of efficiency and according to the two DEA specifications followed. The Tobit model reveals that corruption and government health expenditure tend to have an adverse impact on healthcare efficiency.

The author evaluates healthcare efficiency and healthcare's efficiency determinants in the Arab countries. Regardless Arab countries' diversity, these countries are facing common health challenges, including diminishing role of governments in healthcare financing; increased out-of-pocket healthcare spending; poor healthcare outputs and prevalence of health inequities resulting from weak governance institutions. Comparing the efficiency of healthcare systems between 2010 and 2019 gives insights on the potential impact of the Arab spring uprisings on healthcare efficiency. Moreover, examining the determinants of healthcare efficiency allows for better understanding of how to improve the efficiency of healthcare systems in the region.

Young prisoners are one of the most vulnerable groups in society for mental health problems and ill-being. Therefore, there is a crucial need to understand their physical, psychological and social situations. This study aims to explore young Cambodian prisoners’ experiences and perceptions of mental health and well-being, their determinants and their coping strategies.

Six focus group discussions were carried out in three prisons with a total of 48 young prisoners between the ages of 15 and 24 years (50% women, 50% men). Semi-structured questions guided the discussions, and thematic analysis was applied to analyse the data.

Young prisoners reported multifaceted experiences of mental health and well-being. The majority described adverse mental health experiences, while some revealed better well-being, partly influenced by the socio-economic support from outside the prisons and previous involvement or not in drug abuse. The experience of physical overcrowding without emotional attachment among the fellow prisoners was perceived as the overarching determinant of loneliness and mental health problems, while socio-emotional support and rituals were described as the most important coping mechanisms.

This pioneering study from Cambodia gives young prisoners an opportunity to voice their experiences and perceptions of mental health and well-being in the prison setting. The findings in this study underline the importance of prison authorities tackling overcrowding to promote well-being and reduce mental health problems. Also, the coping mechanisms outlined by the participants should be considered when planning psychosocial interventions.