Solving poverty or tackling healthcare inequalities? Qualitative study exploring local interpretations of national policy on health inequalities under new NHS reforms in England.

OBJECTIVES: Major reforms to the organisation of the National Health Service (NHS) in England established 42 integrated care systems (ICSs) to plan and coordinate local services. The changes are based on the idea that cross-sector collaboration is needed to improve health and reduce health inequalities-and similar policy changes are happening elsewhere in the UK and internationally. We explored local interpretations of national policy objectives on reducing health inequalities among senior leaders working in three ICSs. DESIGN: We carried out qualitative research based on semistructured interviews with NHS, public health, social care and other leaders in three ICSs in England. SETTING AND PARTICIPANTS: We selected three ICSs with varied characteristics all experiencing high levels of socioeconomic deprivation. We conducted 32 in-depth interviews with senior leaders of NHS, local government and other organisations involved in the ICS's work on health inequalities. Our interviewees comprised 17 leaders from NHS organisations and 15 leaders from other sectors. RESULTS: Local interpretations of national policy objectives on health inequalities varied, and local leaders had contrasting-sometimes conflicting-perceptions of the boundaries of ICS action on reducing health inequalities. Translating national objectives into local priorities was often a challenge, and clarity from national policy-makers was frequently perceived as limited or lacking. Across the three ICSs, local leaders worried that objectives on tackling health inequalities were being crowded out by other short-term policy priorities, such as reducing pressures on NHS hospitals. The behaviour of national policy-makers appeared to undermine their stated priorities to reduce health inequalities. CONCLUSIONS: Varied and vague interpretations of NHS policy on health inequalities are not new, but lack of clarity among local health leaders brings major risks-including interventions being poorly targeted or inadvertently widening inequalities. Greater conceptual clarity is likely needed to guide ICS action in future.

Reducing health inequalities through general practice: a realist review and action framework.

Background: Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities. Objectives: We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice. Design: Realist review. Main outcome measures: Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. Review methods: Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. Results: Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships. Limitations: The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care. Conclusions: Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred. Future work: Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice. Study registration: This trial is registered as PROSPERO CRD42020217871. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Health inequalities are unfair differences in health across different groups of the population. In the United Kingdom, the health inequality gap in life expectancy between the richest and poorest is increasing and is caused mostly by differences in long-term conditions like cancer and cardiovascular disease and respiratory conditions, such as chronic obstructive pulmonary disease. Partly National Health Service inequalities arise in delays in seeing a doctor and care provided through doctors' surgery, such as delays in getting tests. This study explored how general practice services can increase or decrease inequalities in cancer, cardiovascular disease, diabetes and chronic obstructive pulmonary disease, under what circumstances and for whom. It also produced guidance for general practice, both local general practices and the wider general practice system, to reduce inequalities. We reviewed existing studies using a realist methodology. This methodology helps us understand the different contexts in which interventions work or not. We found that inequalities in general practice result from complex processes across different areas. These include funding and workforce, perceptions about health and disease among patients and healthcare staff, everyday procedures involved in care delivery, and relationships among individuals and communities. To reduce inequalities in general practice, action should be taken in all these areas and services need to be connected (i.e. linked and coordinated across the sector), intersectional (i.e. accounting for the fact that people's experience is affected by many of their characteristics like their gender and socio-economic position), flexible (i.e. meeting patients' different needs and preferences), inclusive (i.e. not excluding people because of who they are) and community-centred (i.e. working with the people who will receive care when designing and providing it). There is no one single intervention that will make general practice more equitable, rather it requires long-term organisational change based on these principles.

Using simulation modelling to transform hospital planning and management to address health inequalities.

Health inequalities are a perennial concern for policymakers and in service delivery to ensure fair and equitable access and outcomes. As health inequalities are socially influenced by employment, income, and education, this impacts healthcare services among socio-economically disadvantaged groups, making it a pertinent area for investigation in seeking to promote equitable access. Researchers widely acknowledge that health equity is a multi-faceted problem requiring approaches to understand the complexity and interconnections in hospital planning as a precursor to healthcare delivery. Operations research offers the potential to develop analytical models and frameworks to aid in complex decision-making that has both a strategic and operational function in problem-solving. This paper develops a simulation-based modelling framework (SimulEQUITY) to model the complexities in addressing health inequalities at a hospital level. The model encompasses an entire hospital operation (including inpatient, outpatient, and emergency department services) using the discrete-event simulation method to simulate the behaviour and performance of real-world systems, processes, or organisations. The paper makes a sustained contribution to knowledge by challenging the existing population-level planning approaches in healthcare that often overlook individual patient needs, especially within disadvantaged groups. By holistically modelling an entire hospital, socio-economic variations in patients' pathways are developed by incorporating individual patient attributes and variables. This innovative framework facilitates the exploration of diverse scenarios, from processes to resources and environmental factors, enabling key decision-makers to evaluate what intervention strategies to adopt as well as the likely scenarios for future patterns of healthcare inequality. The paper outlines the decision-support toolkit developed and the practical application of the SimulEQUITY model through to implementation within a hospital in the UK. This moves hospital management and strategic planning to a more dynamic position where a software-based approach, incorporating complexity, is implicit in the modelling rather than simplification and generalisation arising from the use of population-based models.

Health promotion: reconfiguring nurses' practice to reduce social inequalities.

Inequalities in people's health due to economic or social circumstances remain a persistent challenge in the UK, with people from disadvantaged communities disproportionately likely to die earlier and experience more health issues than the general population. Health promotion has a vital role in reversing health inequalities and requires a focus on structural and political-level determinants of health, rather than individuals' lifestyle choices. However, while health promotion is a significant aspect of nurse education curricula, individual nurses may experience role confusion regarding the application of health promotion in their practice. Therefore, a shift is required in nurse education and training on health promotion, as well as its practical implementation. This article suggests some approaches that could be taken to reconfigure the role of nurses in health promotion.

The physician's role in reducing health disparities for persons with epilepsy and intellectual disability: "it's not just epilepsy you really have to take a deeper dive."

Epilepsy affects approximately 25 % of people with intellectual disability (ID). Despite this high prevalence, evidence of health disparity exists in healthcare access and health outcomes for this population. Patients with ID experience additional challenges in accessing appropriate epilepsy care, and are at greater risk of experiencing inappropriate prescribing, polypharmacy and misdiagnosis compared with the general population. The expectations, attitudes and actions of physicians are key in addressing health inequalities, particularly those which disproportionately impact a specific group of patients, such as patients with ID and epilepsy. This qualitative study aimed to explore the views of specialist physicians as to why they believe this patient group are at a disadvantage when it comes to accessing appropriate epilepsy care, and how physicians can intervene to ensure that patients with ID are given equal access to suitable epilepsy care, and equal opportunity to achieve the best possible treatment outcomes. Semi-structured interviews were carried out with six physicians, located in six countries, who specialise in the care of persons with ID who have epilepsy. Interviews sought views on prognostic expectations, experiences of disparities in epilepsy care, and suggestions for advocacy interventions. Interviews were analysed using reflexive thematic analysis. Three core themes and nine subthemes were identified. Core themes included (1) 'Nervousness in care and treatment,' which reflected participants' descriptions of a nervousness by colleagues when treating epilepsy in patients with ID. (2) 'Taking a deeper dive' captured the harmful effects of accepting "common dogma," as well as the issue of a lack of clarity around treatment pathways for patients with epilepsy and ID. (3) 'Teach me' illustrated the importance of shared expertise, reflective practice and continued research and advocacy. Findings reflected participants' recommendations to address disparities in epilepsy care for patients with ID. These recommendations highlighted education and training, taking time to learn how to communicate in different ways, and regular reflection on personal assumptions and biases as important contributors to addressing inequalities in epilepsy care for patients with ID. It is hoped that findings will prompt those providing epilepsy care to reflect on their own practice and identify ways in which they might intervene to minimise inadvertent harm and reduce health disparities in epilepsy care for patients with ID.

Social Determinants of Health and Disparities in Thyroid Care.

BACKGROUND: There have been documented racial and ethnic disparities in the care and clinical outcomes of patients with thyroid disease. CONTEXT: Key to improving disparities in thyroid care is understanding the context for racial and ethnic disparities, which includes acknowledging and addressing social determinants of health. Thyroid disease diagnosis, treatment, and survivorship care are impacted by patient- and system-level factors, including socioeconomic status and economic stability, language, education, health literacy, and health care systems and health policy. The relationship between these factors and downstream clinical outcomes is intricate and complex, underscoring the need for a multifaceted approach to mitigate these disparities. CONCLUSION: Understanding the factors that contribute to disparities in thyroid disease is critically important. There is a need for future targeted and multilevel interventions to address these disparities, while considering societal, health care, clinician, and patient perspectives.

Health inequalities in the geographic distribution of dental practitioners in Costa Rica: An ecological study.

OBJECTIVE: The uneven distribution of dental health services in a territory can cause an imbalance in accessibility, increasing health inequalities. This study aimed to describe the geographical distribution of dental health practitioners according to urbanicity and area-level socio-economic status in Costa Rica. METHODS: A National Dentist Survey was developed to identify employment status, number of working hours, address and list of the working clinics. Data was completed using information from the national College of Surgeons, including all Costa Rican dentists. The Minimal Geographic Units (MGU) allowed for aggregating the population's individual level socio-economic position. Local Potential Accessibility (LPA) calculated the density of full-time hour's equivalents around each MGU using floating sectors. Clinics were geocoded using Geographic Information Systems, creating 2853 clinical points. Distance between each MGU and the nearest accessible clinics considering full-time working hours equivalents was estimated. MGU were divided into six categories: 'No accessibility', 'Very low accessibility', 'Low accessibility', 'Good accessibility' 'High accessibility' and 'Very high accessibility'. RESULTS: Mean national LPA was 6.5 full-time equivalents per 10 000 inhabitants, 3.4% of the Costa Rican population had no access to dentist; 12.9% had very low accessibility, 22.7% had low accessibility, 35.0% had good accessibility, 16.2% had high accessibility, and 9.8% had very high accessibility. Overall, 39% of the population has a rather low accessibility. LPA was higher in urban districts compared to rural districts and in wealthiest districts compared to most disadvantaged districts. Within districts, after adjustment for district's characteristics, LPA was higher in urban MGU compared to rural MGU and in wealthiest MGU compared to most disadvantaged MGU. CONCLUSIONS: This study found that despite having a high number of dentists, their numbers are small in many areas, increasing inequalities in access to health care. The dentist's free establishment, where they can decide to provide private services within a community, creates zones with very high densities, in particular in the wealthiest urban areas, and others with very low densities, in particular the poorest rural areas. The lack of territorial planning has been one of the reasons that has encouraged an imbalance in the availability of dental human resources. To achieve effective universal health coverage, public institutions should focus their efforts on improving access to dental services in underserved areas.

Health inequality and health insurance coverage: The United States and China compared.

We study inequality in the distribution of self-assessed health (SAH) in the United States and China, two large countries that have expanded their insurance provisions in recent decades, but that lack universal coverage and differ in other social determinants of health. Using comparable health survey data from China and the United States, we compare health inequality trends throughout the period covering the public health insurance coverage expansions in the two countries. We find that whether SAH inequality is greater in the US or in China depends on the concept of status and the inequality-sensitivity parameter used; however, the regional pattern of SAH inequality is clearly associated with health-insurance coverage expansions in the US but not significant in China.

What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND: There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown. OBJECTIVES: The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use. DESIGN: Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool. RESULTS: The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities. CONCLUSIONS: Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

Reducing intervention- and research-induced inequalities to tackle the digital divide in health promotion.

Social inequalities are an important contributor to the global burden of disease within and between countries. Using digital technology in health promotion and healthcare is seen by some as a potential lever to reduce these inequalities; however, research suggests that digital technology risks re-enacting or evening widening disparities. Most research on this digital health divide focuses on a small number of social inequality indicators and stems from Western, educated, industrialized, rich, and democratic (WEIRD) countries. There is a need for systematic, international, and interdisciplinary contextualized research on the impact of social inequality indicators in digital health as well as the underlying mechanisms of this digital divide across the globe to reduce health disparities. In June 2023, eighteen multi-disciplinary researchers representing thirteen countries from six continents came together to discuss current issues in the field of digital health promotion and healthcare contributing to the digital divide. Ways that current practices in research contribute to the digital health divide were explored, including intervention development, testing, and implementation. Based on the dialogue, we provide suggestions for overcoming barriers and improving practices across disciplines, countries, and sectors. The research community must actively advocate for system-level changes regarding policy and research to reduce the digital divide and so improve digital health for all.

Healthcare bias and health inequalities towards displaced Syrians in Lebanon: a qualitative study.

Introduction: According to Lebanese official data, Lebanon hosts over 1.5 million displaced Syrians (DS). Research shows that migrants encounter barriers when accessing healthcare. The social determinants of health (SDOH) related to migration are an additional challenge for DS in Lebanon, though bias plays a significant factor in exacerbating health inequalities. This study aims to identify DS perception of healthcare biases in the Lebanese healthcare system, and its consequences on DS' accessing and receiving quality healthcare in Lebanon. Methods: A qualitative analysis using in-depth, semi-structured interviews was utilized. 28 semi-structured interviews were conducted with doctors (n = 12) and nurses (n = 16) in 2021. Six group interviews were conducted with DS (n = 22) in Lebanese healthcare facilities. The recruitment of participants relied on reasoned and targeted sampling. Thematic analysis was performed to identify common themes in participants' experiences with DS accessing Lebanese healthcare. Results: The findings indicated that there were barriers to accessing healthcare related to the SDOH, such as transportation and financial resources. The results also suggested that DS perceived health biases, including discriminatory behavior from Lebanese healthcare providers, stereotypes and racism leading to health inequalities. Conclusion: Based on the perceptions and experiences reported by participants, the underlying causes of biases are due to the fragility of the Lebanese healthcare system when facing a humanitarian crisis as well as a collapsing infrastructure torn by past wars and the current socio-political and financial crises in the country. Global initiatives are required to provide the necessary resources needed for offering equitable health services. Such initiatives involve addressing biases, health inequities, discrimination, and the lack of a Lebanese infrastructure system for the provision of healthcare. Addressing health inequalities remains a major health objective in achieving health equity on the micro level (cultural awareness and competencies) and macro level (equitable distribution of resources, implementation of a universal health coverage) in order to guarantee quality healthcare services to DS.

A scoping review exploring oral health inequalities in India: a call for action to reform policy, practice and research.

INTRODUCTION: Reduction in health inequalities and providing universal access to health care have been identified as two important global milestones by the World Health Organization for countries to achieve by 2030. Therefore, recognizing the magnitude of oral health inequalities in India has become a pressing priority to improve access to dental care within the country. This scoping review was conducted with the aim of reviewing, collating and analysing the current knowledge base on oral health inequalities in India. METHODOLOGY: The scoping review followed Arksey and O'Malley's approach, and reporting was performed in accordance with the PRISMA-ScR guidelines. A systematic search was conducted on Scopus, PubMed, Web of Science, and EMBASE to identify literature addressing one or more dimensions of oral health inequalities in India, published in English between January 2002 and April 2022. The data were charted, and qualitative analysis was performed to derive themes, highlighting the key concepts emerging from this review. RESULTS: In accordance with the eligibility criteria, a total of 71 articles retrieved through database search and backward citation search were included in this scoping review. The major themes ranged from individual to diverse sociodemographic factors acting as barriers to and facilitators of access to dental care. Deficiencies in human resources for oral health, along with a wide diversity in dental service provision and dental education were other major themes contributing to inequality. Subsequently, this has resulted in recommendations on restructuring the dental workforce and their development and modifications in oral health care policies and practices. The qualitative synthesis demonstrates the intertwined nature of the multiple factors that influence the goal of achieving an affordable, accessible, extensive and inclusive oral healthcare system in India. CONCLUSIONS: This comprehensive review provides a broad perspective on oral health inequalities in India, providing valuable insights for both researchers and policymakers in this area and guiding their efforts towards achieving universal oral health coverage in the Indian context.

What health inequalities exist in access to, outcomes from and experience of treatment for lung cancer? A scoping review.

OBJECTIVES: Lung cancer (LC) continues to be the leading cause of cancer-related deaths and while there have been significant improvements in overall survival, this gain is not equally distributed. To address health inequalities (HIs), it is vital to identify whether and where they exist. This paper reviews existing literature on what HIs impact LC care and where these manifest on the care pathway. DESIGN: A systematic scoping review based on Arksey and O'Malley's five-stage framework. DATA SOURCES: Multiple databases (EMBASE, HMIC, Medline, PsycINFO, PubMed) were used to retrieve articles. ELIGIBILITY CRITERIA: Search limits were set to retrieve articles published between January 2012 and April 2022. Papers examining LC along with domains of HI were included. Two authors screened papers and independently assessed full texts. DATA EXTRACTION AND SYNTHESIS: HIs were categorised according to: (a) HI domains: Protected Characteristics (PC); Socioeconomic and Deprivation Factors (SDF); Geographical Region (GR); Vulnerable or Socially Excluded Groups (VSG); and (b) where on the LC pathway (access to, outcomes from, experience of care) inequalities manifest. Data were extracted by two authors and collated in a spreadsheet for structured analysis and interpretation. RESULTS: 41 papers were included. The most studied domain was PC (32/41), followed by SDF (19/41), GR (18/41) and VSG (13/41). Most studies investigated differences in access (31/41) or outcomes (27/41), with few (4/41) exploring experience inequalities. Evidence showed race, rural residence and being part of a VSG impacted the access to LC diagnosis, treatment and supportive care. Additionally, rural residence, older age or male sex negatively impacted survival and mortality. The relationship between outcomes and other factors (eg, race, deprivation) showed mixed results. CONCLUSIONS: Findings offer an opportunity to reflect on the understanding of HIs in LC care and provide a platform to consider targeted efforts to improve equity of access, outcomes and experience for patients.

A holistic model of health inequalities for health policy and state administration: a case study in the regions of the Czech Republic.

BACKGROUND: Health inequities exist within and between societies at different hierarchical levels. Despite overall improvements in health status in European Union countries, disparities persist among socially, economically, and societally disadvantaged individuals. This study aims to develop a holistic model of health determinants, examining the complex relationship between various determinants of health inequalities and their association with health condition. METHODS: Health inequalities and conditions were assessed at the territorial level of Local Administrative Units (LAU1) in the Czech Republic. A dataset of 57 indicators was created, categorized into seven determinants of health and one health condition category. The necessary data were obtained from publicly available databases. Comparisons were made between 2001-2003 and 2016-2019. Various methods were employed, including composite indicator creation, correlation analysis, the Wilcoxon test, aggregate index calculation, cluster analysis, and data visualization using the LISA method. RESULTS: The correlation matrix revealed strong relationships between health inequality categories in both periods. The most significant associations were observed between Economic status and social protection and Education in the first period. However, dependencies weakened in the later period, approaching values of approximately 0.50. The Wilcoxon test confirmed variations in determinant values over time, except for three specific determinants. Data visualization identified persistently adverse or worsening health inequalities in specific LAU1, focusing on categories such as Economic status and social protection, Education, Demographic situation, Environmental status, Individual living status, and Road safety and crime. The health condition indices showed no significant change over time, while the aggregate index of health inequalities improved with widened differences. CONCLUSION: Spatial inequalities in health persist in the Czech Republic, influenced by economic, social, demographic, and environmental factors, as well as local healthcare accessibility. Both inner and outer peripheries exhibit poor health outcomes, challenging the assumption that urban areas fare better. The combination of poverty and vulnerabilities exacerbates these inequalities. Despite the low rates of social exclusion and poverty, regional health inequalities persist in the long term. Effectively addressing health inequalities requires interdisciplinary collaboration and evidence-based policy interventions. Efforts should focus on creating supportive social and physical environments, strengthening the healthcare system, and fostering cooperation with non-medical disciplines.

Culture, religion and gender: considerations in facing migration related health inequalities in Italy.

BACKGROUND: The presence in Italy of a significant foreign population (5-6 million including both formally residents and not officially registered ones) introduces significant transformations in the Italian demography with important challenges on ensuring fundamental rights including work, education and above all, health. Access to healthcare. Issues common to the entire migrant population concern the difficulty of accessing the health system of the host country due to the lack of knowledge of its rules and its functioning, the linguistic and cultural barriers and the distrust towards a system that is not recognized as his own, as well as the difficulties and misunderstandings encountered in the relationship with health professionals. Religion, culture and gender may even increase these difficulties. Conlusion and future perspective. Culture and religion should be taken into account when designing and implementing healthcare services and healthcare workers need to be trained in acknowledging these challenges. The National Health Service should become more sensitive to the increasing cultural and religious pluralism of patients starting with investing more in the training of health professionals.

Mediating and Moderating Effects of Internet Use on Urban-Rural Disparities in Health Among Older Adults: Nationally Representative Cross-Sectional Survey in China.

BACKGROUND: The urban-rural disparities in health outcomes in China are remarkable. The internet has shown the potential to reduce the likelihood of contracting a disease by increasing disease knowledge. However, little is known about the effects of internet use in alleviating health inequities between urban and rural areas. OBJECTIVE: This study aimed to examine the mediation and moderation of health disparities between urban and rural older adults through internet use. METHODS: A total of 8223 respondents were selected from the China Health and Retirement Longitudinal Study 2018 data set. Basic activities of daily living, a brief Community Screening Instrument for Dementia, and the Centre for Epidemiologic Studies Depression Scale were used to measure functional disability, cognitive function, and depressive symptoms, respectively. Logistic regressions testing "internet use×urban-rural status" interactions for moderation and Karlson-Holm-Breen decomposition for mediation were performed. RESULTS: Internet use moderated the urban-rural disparities in cognitive function (odds ratio 7.327, 95% CI 3.011-17.832) and depressive symptoms (odds ratio 1.070, 95% CI 1.037-1.787), but the moderating effects were significant only for those using the internet daily. Karlson-Holm-Breen results showed the suppression effects of using the internet daily (ß=.012, 95% CI .002-.021) on the association between urban-rural status and cognitive function. The urban-rural inequality in depressive symptoms was partially attributed to the disparity in internet use (ß=-.027, 95% CI -.043 to -.009). CONCLUSIONS: The urban-rural inequalities in mental health are partially attributable to disparities in the prevalence of internet use between the 2 groups. However, using the internet is more beneficial for the psychological health of rural users, thereby alleviating the urban-rural disparities in health. Providing convenient channels for rural older adults to use the internet, improving the ability of rural users to effectively use the internet, and promoting internet popularity in rural areas are effective approaches to reducing urban-rural health inequalities.

Socioeconomic inequalities in health outcomes among Thai older population in the era of Universal Health Coverage: trends and decomposition analysis.

BACKGROUND: Thailand's Universal Health Coverage (UHC) has been achieved since 2002 when the entire population are covered by three main public health security schemes: (1) Civil Servant Medical Benefit Scheme (CSMBS); (2) Social Security Scheme (SSS); and (3) Universal Coverage Scheme (UCS). Citizens have access to healthcare services at all life stages and are protected from catastrophic expenditure and medical impoverishment. However, there are health inequalities in both health outcomes and access to healthcare among older Thais. This study aims to: (1) assess the degrees of socioeconomic inequalities in health outcomes among the older Thai population during the period of Thailand's UHC implementation (2003-2019), and (2) explain socioeconomic inequalities in health outcomes through decomposition of the contributions made by Thailand's UHC policy and other health determinants. METHODS: Data sets come from a four-year series of the National Health and Welfare Survey (HWS) between 2003 and 2019. The health outcome of interest was obtained from the Thai EQ-5D index. The Erreygers' concentration index (CI) was used to calculate the socioeconomic inequality in health outcomes. Multivariate methods were employed to decompose inequalities. RESULTS: Findings indicated Thai older adults (aged 50 and older) are healthier during the UHC implementation. Better health outcomes remain concentrated among the wealthier groups (pro-rich inequality). However, the degree of socioeconomic inequalities in health outcomes significantly declined by almost a factor-of-three (from CI = 0.061 in 2003 to CI = 0.024 in 2019) after the roll-out of the UHC. Decomposed results reported that Thailand's UHC, urban residence, and household wealth were major contributors in explaining pro-rich inequalities in health outcomes among Thai older adults. CONCLUSIONS: Older persons in Thailand have better health while health inequalities between the rich and the poor have substantially decreased. However, there is inequalities in health outcomes within all three national health security schemes in Thailand. Minimizing differences between schemes continues to be a crucial cornerstone to tackling health inequalities among the older population. At the same time, making Thailand's UHC sustainable is necessary through preparing financial sustainability and developing health resources to better serve an ageing society.