Disproportionate infection, hospitalisation and death from COVID-19 in ethnic minority groups and Indigenous Peoples: an application of the Priority Public Health Conditions analytical framework.

The COVID-19 pandemic has resulted in disproportionate consequences for ethnic minority groups and Indigenous Peoples. We present an application of the Priority Public Health Conditions (PPHC) framework from the World Health Organisation (WHO), to explicitly address COVID-19 and other respiratory viruses of pandemic potential. This application is supported by evidence that ethnic minority groups were more likely to be infected, implying differential exposure (PPHC level two), be more vulnerable to severe disease once infected (PPHC level three) and have poorer health outcomes following infection (PPHC level four). These inequities are driven by various interconnected dimensions of racism, that compounds with socioeconomic context and position (PPHC level one). We show that, for respiratory viruses, it is important to stratify levels of the PPHC framework by infection status and by societal, community, and individual factors to develop optimal interventions to reduce inequity from COVID-19 and future infectious diseases outbreaks.

Underlying pathways of social inequality in tooth loss: the mediating role of sugary beverages and diabetes.

BACKGROUND: Previous studies show social inequality in tooth loss, but the underlying pathways are not well understood. The aim was to investigate the mediated proportion of sugary beverages (SBs) and diabetes and the association between educational level and tooth loss, and to investigate whether the indirect effect of SBs and diabetes varied between educational groups in relation to tooth loss. METHODS: Data from 47,109 Danish men and women aged 50 years or older included in the Danish Diet, Cancer and Health Study was combined with data from Danish registers. Using natural effect models, SBs and diabetes were considered as mediators, and tooth loss was defined as having <15 teeth present. RESULTS: In total, 10,648 participants had tooth loss. The analyses showed that 3% (95% confidence interval 2-4%) of the social inequality in tooth loss was mediated through SBs and diabetes. The mediated proportion was mainly due to differential exposure to SBs and diabetes among lower educational groups. CONCLUSIONS: The findings show that SBs and diabetes to a minor degree contribute to tooth-loss inequalities. The explanation indicates that individuals in lower educational groups have higher consumption of SBs and more often suffer from diabetes than higher educational groups.

Agribusiness and the COVID-19 syndemic: The unsustainable pathways.

It has been suggested that it would be more appropriate to term the COVID-19 pandemic a syndemic, as the infection interacts synergistically with pre-existing chronic conditions such as obesity. Both conditions occur with steep socio-economic inequalities, and Brazil is suffering a heavy burden from both. What and who drives the clustering and interaction of these disorders? In this commentary, we examine the pathways leading to the COVID-19 syndemic. Deforestation, declining biodiversity and factory farming are promoting the emergence of new pathogens. Widespread use of pesticides influences immune, endocrine and metabolic systems. The ingestion of ultra-processed food promotes malnutrition and obesity in a country where at the same time poverty and food insecurity is rising. Brazilian agribusiness is focused on the production and global export of agricultural commodities, mainly for animal food and meat production. It is made possible through a combination of expanded land use, with deforestation in Amazonas and other Brazilian biomes, and the intensification of land use and cultivation of genetically modified crops with fertilizers and pesticides. This development is not sustainable for either population health or the environment.

Gunnar Inghe: A founding father of Scandinavian social medicine and still highly relevant.

Gunnar Inghe (1910-1977) was a founding father of Scandinavian social medicine and the first editor of the Scandinavian Journal of Social Medicine. He worked as a physician for social care clients in Stockholm from 1944 to 1961 and was professor in social medicine from 1961 to 1975. We (F.D. and U.J.) were his last two PhD students. As we were recollecting the 50-year history of the Scandinavian Journal of Public Health in 2022, it became evident to us how relevant Gunnar Inghe's work, 45 years after his death, still is for today's social medicine, population health research and policy in Scandinavia. We shall explain why with five examples of Inghe's work: reproductive health, health of paupers, foundation of the discipline, international solidarity and collaboration between medical and social care.

Planning for health equity in the crossfire between science and policy.

The persistence of health inequalities means that many public health professionals face an ongoing task to develop and update policies to tackle them. However, although the inequalities might be unchanged, the political priorities in the many policy areas involved are changing and the ambition to reduce the health divide is constantly facing strong forces pushing in the opposite direction. Recent proposals to re-think health inequalities need to be treated with caution because they are disconnected from what is needed for policy-making in this area. From our experience of 35 years in developing strategies to tackle health inequalities, we still see many entry points with space for local and national improvements, but it is crucial to ask the right questions. The aim of this Commentary is to present a new framework of eight questions that might provide a helpful structure for the necessary dialogue between researchers and policy-makers. Even if answers are not yet available for all of them, we believe that discussing them for a specific population in a specific political context will be fruitful to inform policy on the ground.

Mediating role of multimorbidity in inequality in mortality: a register study on the Danish population.

BACKGROUND: The social inequality in mortality is due to differential incidence of several disorders and injury types, as well as differential survival. The resulting clustering and possible interaction in disadvantaged groups of several disorders make multimorbidity a potentially important component in the health divide. This study decomposes the effect of education on mortality into a direct effect, a pure indirect effect mediated by multimorbidity and a mediated interaction between education and multimorbidity. METHODS: The study uses the Danish population registers on the total Danish population aged 45-69 years. A multimorbidity index based on all somatic and psychiatric hospital contacts as well as prescribed medicines includes 22 diagnostic groups weighted together by their 5 years mortality risk as weight. The Aalen additive hazard model is used to estimate and decompose the 5 years risk difference in absolute numbers of deaths according to educational status. RESULTS: Most (69%-79%) of the effect is direct not involving multimorbidity, and the mediated effect is for low educated women 155 per 100 000 of which 87 is an effect of mediated interaction. For low educated men, the mediated effect is 250 per 100 000 of which 93 is mediated interaction. CONCLUSION: Multimorbidity plays an important role in the social inequality in mortality among middle aged in Denmark and mediated interaction represents 5%-17%. As multimorbidity is a growing challenge in specialised health systems, the mediated interaction might be a relevant indicator of inequities in care of multimorbid patients.

Roles of allostatic load, lifestyle and clinical risk factors in mediating the association between education and coronary heart disease risk in Europe.

BACKGROUND: Previous studies have shown that differential exposure to lifestyle factors may mediate the association between education and coronary heart diseases (CHD). However, few studies have examined the potential roles of allostatic load (AL) or differential susceptibility. METHODS: 25 310 men and 26 018 women aged 35-74 and CHD free at baseline were identified from 21 European cohorts and followed for a median of 10 years, to investigate the mediating role of AL, as well as of smoking, alcohol use and body mass index (BMI), on educational differences in CHD incidence, applying marginal structural models and three-way decomposition. RESULTS: AL is a mediator of the association between educational status and CHD incidence, with the highest proportion mediated observed among women and largely attributable to differential exposure, (28% (95% CI 19% to 44%)), with 8% (95% CI 0% to 16%) attributable to differential susceptibility. The mediating effects of smoking, alcohol and BMI, compared with AL, were relatively small for both men and women. CONCLUSION: Overall, the educational inequalities in CHD incidence were partially mediated through differential exposure to AL. By contrast, the mediation of the educational gradient in CHD by investigated lifestyle risk factors was limited. As differential susceptibility in men was found to have a predominant role in the accumulation of AL in low educational classes, the investigation of AL-related risk factors is warranted.

Unequal impact of the COVID-19 crisis on minority ethnic groups: a framework for understanding and addressing inequalities.

Minority ethnic groups have been disproportionately affected by the COVID-19 pandemic. While the exact reasons for this remain unclear, they are likely due to a complex interplay of factors rather than a single cause. Reducing these inequalities requires a greater understanding of the causes. Research to date, however, has been hampered by a lack of theoretical understanding of the meaning of 'ethnicity' (or race) and the potential pathways leading to inequalities. In particular, quantitative analyses have often adjusted away the pathways through which inequalities actually arise (ie, mediators for the effect of interest), leading to the effects of social processes, and particularly structural racism, becoming hidden. In this paper, we describe a framework for understanding the pathways that have generated ethnic (and racial) inequalities in COVID-19. We suggest that differences in health outcomes due to the pandemic could arise through six pathways: (1) differential exposure to the virus; (2) differential vulnerability to infection/disease; (3) differential health consequences of the disease; (4) differential social consequences of the disease; (5) differential effectiveness of pandemic control measures and (6) differential adverse consequences of control measures. Current research provides only a partial understanding of some of these pathways. Future research and action will require a clearer understanding of the multiple dimensions of ethnicity and an appreciation of the complex interplay of social and biological pathways through which ethnic inequalities arise. Our framework highlights the gaps in the current evidence and pathways that need further investigation in research that aims to address these inequalities.

How did Sweden Fail the Pandemic?

Sweden has since the start of the pandemic a COVID-19 mortality rate that is 4 to 10 times higher than in the other Nordic countries. Also, measured as age-standardized all-cause excess mortality in the first half of 2020 compared to previous years Sweden failed in comparison with the other Nordic countries, but only among the elderly. Sweden has large socioeconomic and ethnic inequalities in COVID-19 mortality. Geographical, ethnic, and socioeconomic inequalities in mortality can be due to differential exposure to the virus, differential immunity, and differential survival. Most of the country differences are due to differential exposure, but the socioeconomic disparities are mainly driven by differential survival due to an unequal burden of comorbidity. Sweden suffered from an unfortunate timing of tourists returning from virus hotspots in the Alps and Sweden's government response came later and was much more limited than elsewhere. The government had an explicit priority to protect the elderly in nursing and care homes but failed to do so. The staff in elderly care are less qualified and have harder working conditions in Sweden, and they lacked adequate care for the clients. Sweden has in recent years diverged from the Scandinavian welfare model by strong commercialization of primary care and elderly care.

A health inequality impact assessment from reduction in overweight and obesity.

BACKGROUND: In recent years, social differences in overweight and obesity (OWOB) have become more pronounced. Health impact assessments provide population-level scenario evaluations of changes in disease prevalence and risk factors. The objective of this study was to simulate the health effects of reducing the prevalence of overweight and obesity in populations with short and medium education. METHODS: The DYNAMO-HIA tool was used to conduct a health inequality impact assessment of the future reduced disease prevalence (ischemic heart disease (IHD), diabetes, stroke, and multi-morbidity) and changes in life expectancy for the 2040-population of Copenhagen, Denmark (n = 742,130). We simulated an equalized weight scenario where the prevalence of OWOB in the population with short and medium education was reduced to the levels of the population with long education. RESULTS: A higher proportion of the population with short and medium education were OWOB relative to the population with long education. They also had a higher prevalence of cardiometabolic diseases. In the equalized weight scenario, the prevalence of diabetes in the population with short education was reduced by 8-10% for men and 12-13% for women. Life expectancy increased by one year among women with short education. Only small changes in prevalence and life expectancy related to stroke and IHD were observed. CONCLUSION: Reducing the prevalence of OWOB in populations with short and medium education will reduce the future prevalence of cardiometabolic diseases, increase life expectancy, and reduce the social inequality in health. These simulations serve as reference points for public health debates.

Inequalities in extending working lives beyond age 60 in Canada, Denmark, Sweden and England-By gender, level of education and health.

BACKGROUND: Keeping older workers in employment is critical for societies facing the challenge of an ageing population. This study examined the association between types of health conditions and differentials in the probability of employment by level of education among men and women between 60-69 years of age in Canada, Denmark, Sweden and England. METHODS: Data were drawn from the Canadian Community Health Survey, Survey of Health, Ageing and Retirement in Europe and English Longitudinal Study of Ageing. We combined country data, applied logistic regression, adjusted for educational level, and stratified the analysis by sex to calculate the odds ratio (OR) of employment (>15 hours work per week) for persons with physical health conditions, mental health conditions (depression) and physical-mental health comorbidity. RESULTS: The odds of employment among men and women with physical-mental health comorbidity were lower compared to those with no/other conditions (men: OR 0.32, 95% CI: 0.25-0.42, women: OR 0.38 95% CI: 0.30-0.48). Women with low education had lower odds of employment compared to their counterparts with high education (OR 0.66, 95% CI: 0.57-0.76). The odds of employment at older ages was lower in Canada, Denmark and England compared with Sweden (e.g. English men: OR 0.48 95% CI 0.40-0.58; English women OR 0.33 95% CI 0.27-0.41). CONCLUSIONS: The odds of employment beyond age 60 is lower for groups with low education, particularly women, and those with physical-mental health co-morbidities. As such, policies to extend working lives should not be 'one size fits all' but instead consider subgroups, in particular, these groups that we have shown to be most vulnerable on the labour market.

Simulations of future cardiometabolic disease and life expectancy under counterfactual obesity reduction scenarios.

The aim of this study was to provide decision makers with an assessment of potential future health effects of interventions against overweight and obesity (OWOB). By means of the DYNAMO-HIA tool we conducted a health impact assessment simulating future prevented disease (ischemic heart disease (IHD), diabetes, stroke, and multi morbidity) incidence, prevalence and life expectancy (LE) related to a scenario where OWOB is reduced by 25% and a scenario where obesity is eliminated. The study covered projected number of persons living in Copenhagen, Denmark during year 2014-2040 (n 2040 = 742,129). Reducing the proportion of men/women with OWOB with 25% will increase population LE by 2.4/1.2 months and at the same time decrease LE with diabetes by 3.1/2.2 months. As a result of eliminating obesity, total LE will increase by 6.0/3.6 months and LE with diabetes will decrease with 9.8/10.3 months for men/women. We found no important effects on LE with IHD and stroke. This illustrates that the positive effects of lowering OWOB levels on IHD and stroke incidence is offset due to increasing total LE. Although the population of Copenhagen is relatively lean, reducing obesity levels will result in significant benefits for population cardiometabolic health status and LE. Future public health prevention programs may use the results as reference data for potential impact of reductions in OWOB.

How does socioeconomic development in Brazil shape social inequalities in diabetes?

Many countries, including Brazil, are facing growing social inequalities in diabetes prevalence. The different states in Brazil represent different levels of development and by comparing diabetes inequalities across states we aim to get a better understanding of how educational inequalities in diabetes are linked to social development. We use the latest cross-sectional national health survey of Brazil - PNS-2013 (N = 60,202) and analyse the disparities in diabetes as well as the differential exposure and susceptibility to the effect of obesity across states for men and women. Among women in high-HDI states the prevalence of diabetes is 11.7 percentage units (CI: 9.3; 14.0) higher among the lowest compared to the highest educated. In less-developed states the disparity is smaller. Among men, there is no social gradient found for diabetes, but obesity is positively associated with education. The association between obesity and diabetes is stronger among the low educated particularly for men in high-HDI states. Here the interaction effect between low education and obesity is 11.7 (CI 8.1; 15.4) percentage units. The fact that economic development is associated with increasingly unequal levels of diabetes and with unequal levels of exposure and susceptibility to obesity indicates that other interacting determinants are important for the development of the diabetes epidemic in Brazil.

The impact of longstanding illness and common mental disorder on competing employment exits routes in older working age: A longitudinal data-linkage study in Sweden.

OBJECTIVES: Comorbidity is prevalent in older working ages and might affect employment exits. This study aimed to 1) assess the associations between comorbidity and different employment exit routes, and 2) examine such associations by gender. METHODS: We used data from employed adults aged 50-62 in the Stockholm Public Health Survey 2002 and 2006, linked to longitudinal administrative income records (N = 10,416). The morbidity measure combined Limiting Longstanding Illness and Common Mental Disorder-captured by the General Health Questionnaire-12 (≥4)-into a categorical variable: 1) No Limiting Longstanding Illness, no Common Mental Disorder, 2) Limiting Longstanding Illness only, 3) Common Mental Disorder only, and 4) comorbid Limiting Longstanding Illness+Common Mental Disorder. Employment status was followed up until 2010, treating early retirement, disability pension and unemployment as employment exits. Competing risk regression analysed the associations between morbidity and employment exit routes, stratifying by gender. RESULTS: Compared to No Limiting Longstanding Illness, no Common Mental Disorder, comorbid Limiting Longstanding Illness+Common Mental Disorder was associated with early retirement in men (subdistribution hazard ratio = 1.73, 95% confidence intervals: 1.08-2.76), but not in women. For men and women, strong associations for disability pension were observed with Limiting Longstanding Illness only (subdistribution hazard ratio = 11.43, 95% confidence intervals: 9.40-13.89) and Limiting Longstanding Illness+Common Mental Disorder (subdistribution hazard ratio = 14.25, 95% confidence intervals: 10.91-18.61), and to a lesser extent Common Mental Disorder only (subdistribution hazard ratio = 2.00, 95% confidence intervals: 1.31-3.05). Women were more likely to exit through disability pension than men (subdistribution hazard ratio = 1.96, 95% confidence intervals: 1.60-2.39). Common Mental Disorder only was the only morbidity category associated with unemployment (subdistribution hazard ratio = 1.70, 95% confidence intervals: 1.36-2.15). CONCLUSIONS: Strong associations were observed between specific morbidity categories with different employment exit routes, which differed by gender. Initiatives to extend working lives should consider older workers' varied health needs to prevent inequalities in older age.

Too sick to work, too healthy to qualify: a cross-country analysis of the effect of changes to disability benefits.

BACKGROUND: Denmark and Sweden have implemented reforms that narrowed disability benefit eligibility criteria. Such reforms in combination with increasing work demands create a pincer movement where in particular those with moderate health problems might be unable to comply with work demands, but still not qualify for permanent disability benefits, ending up with temporary means-tested or no benefits. This paper examines whether this actually happened before and after the reforms. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) study waves 1-2 and 4-6 in Denmark and Sweden for the age group 50-59 years (N=5384) was used to analyse changes in employment rates and benefits among people with different levels of health before, during and after disability benefit reforms. Interaction between time and health in relation to employment versus permanent or temporary benefits was used as a criterion for whether our hypotheses was confirmed. RESULTS: Overall, employment rates have increased in the age group, but only among the healthy. The OR for receiving temporary or no benefits increased from 1.25 (95% CI: 0.81 to 1.90) before to 1.73 (95% CI: 1.14 to 2.61) after policy reforms for the 29% with moderate health problems and from 2.89 (95% CI: 1.66 to 5.03) to 6.71 (95% CI: 3.94 to 11.42) among the 11% with severe health problems. The interaction between time and health was statistically significant (p<0.001). CONCLUSION: People with impaired health and workability are forced into a life with temporary means-tested or no benefits when pressed by rising work demands and stricter disability benefit eligibility criteria.

Social inequality in tooth loss, the mediating role of smoking and alcohol consumption.

OBJECTIVES: The objective of the study was to investigate the mediated proportion of smoking and alcohol consumption in the association between education and tooth loss. Further, the objective was, on the additive scale, to decompose the total effect of education on tooth loss into the direct effect of education, the natural indirect effect through smoking and alcohol consumption (differential exposure) and the mediated interaction between education, smoking and alcohol consumption on tooth loss (differential susceptibility). METHODS: The study was based on data from the Social Inequality in Cancer Cohort (SIC); a cohort constructed by seven pooled cohorts. The total study population comprised of 34 975 participants. With the use of natural effects models, we regarded smoking and alcohol consumption as intermediates; we investigated the role of smoking and alcohol consumption in mediating the effect of education on tooth loss. RESULTS: In total, 4924 participants had tooth loss defined as <15 teeth present. The results of the analyses, on the additive scale, showed 1202 (95% CI: 623-1781) additional persons with tooth loss per 10 000 persons among low compared to highly educated men. Among women, the analyses showed 1159 (95% CI: 959-1359) additional persons with tooth loss per 10 000 persons. The results, on the relative scale, showed that 11% (95% CI: 8%-15%) of the social inequality in tooth loss was jointly mediated by smoking and alcohol consumption among low-educated men. Among women with low education, the mediated proportion was 26% (95% CI: 19%-36%). CONCLUSION: Social inequality in tooth loss seems partly explained by differential exposure and differential susceptibility to smoking and alcohol consumption.

Resource allocation for equity in Brazilian health care: a methodological model / Alocação de recursos para equidade na atenção à saúde no Brasil: um modelo metodológico

ABSTRACT It is a fundamental requirement of governments that they allocate resources to public services among institutions or populations that are potential competitors for funding. In Brazil, a country with clear social inequalities, equitable allocation of resources in the Unified Health System (SUS) poses a particular challenge. The present study proposes an individual-level matrix model for allocating health resources in the SUS based on data from the National Health Survey (PNS) 2013. This model is founded on a matrix of the following variables: age, sex, education, employment and income and the relationships between them. A morbidity score is used to estimate weights for each category. This model provides an opportunity for managers to use objective methods to provide a clear guide for decision-making in accordance with principles laid down in Brazilian law and in a manner based on health needs and epidemiological and demographic factors, in addition to the capacity to offer services.

RESUMO É um requisito fundamental dos governos alocar recursos para serviços públicos entre instituições ou populações que são concorrentes potenciais para financiamento. No Brasil, país com desigualdades sociais claras, alocar recursos no Sistema Único de Saúde (SUS) se torna particularmente desafiador e equitativo. O estudo tem por objetivo apresentar um modelo matricial de nível individual para alocação de recursos em saúde no SUS com base em dados da Pesquisa Nacional de Saúde (PNS) 2013. Este modelo é baseado na matriz de variáveis idade, sexo, educação, emprego e renda e seus relacionamentos. Um escore de morbidade é usado para estimar pesos para cada categoria. Este modelo oferece uma oportunidade para que os gestores utilizem métodos objetivos que auxiliem a tomada de decisão de forma clara e baseada nas leis brasileiras, considerando as necessidades de saúde, aspectos epidemiológicos, demográficos, bem como a capacidade de oferecer serviços.

Differential vulnerability and susceptibility: how to make use of recent development in our understanding of mediation and interaction to tackle health inequalities.

This paper discusses the concepts of vulnerability and susceptibility and their relevance for understanding and tackling health inequalities. Tackling socioeconomic inequalities in health is based on an understanding of how an individual's social position influences disease risk. Conceptually, there are two possible mechanisms (not mutually exclusive): there is either some cause(s) of disease that are unevenly distributed across socioeconomic groups (differential exposure) or the effect of some cause(s) of disease differs across groups (differential effect). Since differential vulnerability and susceptibility are often used to denote the latter, we discuss these concepts and their current use and suggest an epidemiologically relevant distinction. The effect of social position can thus be mediated by causes that are unevenly distributed across social groups and/or interact with social position. Recent improvements in the methodology to estimate mediation and interaction have made it possible to calculate measures of relevance for setting targets and priorities in policy for health equity which include both mechanisms, i.e. equalize exposure or equalize effects. We finally discuss the importance of differential susceptibility and vulnerability for the choice of preventive strategies, including approaches that target high-risk individuals, whole populations and vulnerable groups.