Accounting for health inequities in the design of contact tracing interventions: a rapid review

ContextContact tracing has been a central COVID-19 transmission control measure. However, without the consideration of the needs of specific populations, public health interventions can exacerbate health inequities.PurposeThe purpose of this rapid review was to determine if and how health inequities were included in the design of contact tracing interventions in epidemic settings.MethodWe conducted a search of the electronic databases MEDLINE and Web of Science. Our inclusion criteria included articles that: (i) described the design of contact tracing interventions, (ii) have been published between 2013 and 2020 in English, French, Spanish, Chinese, or Portuguese, (iii) and included at least 50% of empiricism, according to the Automated Classifier of Texts on Scientific Studies (ATCER) tool. We relied on various tools to extract data.ResultFollowing the titles and abstracts screening of 230 articles, 39 articles met the inclusion criteria. Only seven references were retained after full text review. None of the selected studies considered health inequities in the design of contact tracing interventions.ConclusionThe use of tools/concepts for incorporating health inequities, such as the REFLEX-ISS tool, and “proportionate universalism” when designing contact tracing interventions, would enable practitioners, decision makers, and researchers to better consider health inequities.

Proportionate Universalism and Public Health : An Analysis of WRR Policy Brief From Disparity to Potential

The article analyses the public health policy brief From Disparity to Potential by the Dutch Scientific Council for Government Policy (WRR). It argues that the WRR brief presents a distinctive and novel brand of proportionate universalism, a theory proposed by Sir Michael Marmot (2010). The article situates the brief in the wider debate on proportionate universalism and offers an evaluation from an ethical perspective. It argues that the WRR’s version of proportionate universalism exhibits three flaws: (1) the definition of socio-economic status is unduly focused on education levels and thus ignores important, health-relevant disparities; (2) whilst the policy brief endorses subsidiarity, it remains focused on governmental and economic actors, ignoring the importance of voluntary associations such as churches and faith-based organizations; (3) the focus of proportionate universalism is quantitative and needs supplementing with theories of the good life, typically associated with theological and philosophical forms of ethics originating in the premodern era.

An intersectional analysis providing more precise information on inequities in self-rated health

Background Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages. Methods We analyzed participants (n=133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004–2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status. Results The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14–7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67). Conclusions The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.

Blending an implementation science framework with principles of proportionate universalism to support physical activity promotion in primary healthcare while addressing health inequities

Globally, insufficient physical activity (PA) is one of the main risk factors for premature mortality. Although insufficient PA is prevalent in nearly every demographic, people with socio-economic disadvantage participate in lower levels of PA than those who are more affluent, and this contributes to widening health inequities. PA promotion interventions in primary healthcare are effective and cost effective, however they are not widely implemented in practice. Further, current approaches that adopt a ‘universal’ approach to PA promotion do not consider or address the additional barriers experienced by people who experience socioeconomic disadvantages. To address the research to policy and practice gap, and taking Australia as a case study, this commentary proposes a novel model which blends an implementation science framework with the principles of proportionate universalism. Proportionate universalism is a principle suggesting that health interventions and policies need to be universal, not targeted, but with intensity and scale proportionate to the level of social need and/or disadvantage. Within this model, we propose interrelated and multi-level evidence-based policies and strategies to support PA promotion in primary healthcare while addressing health inequities. The principles outlined in the new model which blends proportionate (Pro) universalism principles and Practical, Robust Implementation and Sustainability Model (PRISM), ‘ProPRISM’ can be applied to the implementation of PA promotion interventions in health care settings in other high-income countries. Future studies should test the model and provide evidence of its effectiveness in improving implementation and patient health outcomes and cost-effectiveness. There is potential to expand the proposed model to other health sectors (e.g., secondary and tertiary care) and to address other chronic disease risk factors such as unhealthy diet, smoking, and alcohol consumption. Therefore, this approach has the potential to transform the delivery of health care to a prevention-focused health service model, which could reduce the prevalence and burden of chronic disease and health care costs in high-income countries.

An Intersectional Analysis Providing More Precise Information on Inequities in Self-Rated Health

Background: Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages. Methods: We analyzed participants (n=133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004-2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status. Results: The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14-7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67). Conclusions: The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.

An Intersectional Analysis Providing More Precise Information on Inequities in Self-Rated Health

Background: Intersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables the application of proportionate universalism for resource allocation in public health. Analyzing self-rated health (SRH) in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages.Methods: We analyzed participants (n=133,244) in 14 consecutive National Public Health Surveys conducted in Sweden in 2004-2016 and 2018. Applying AIHDA, we investigated the risk of bad SRH across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated odds ratios (with 95% confidence intervals) to evaluate between-strata differences, using native-born men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AU-ROC) to evaluate the discriminatory accuracy of the intersectional strata for identifying individuals according to their SRH status.Results: The analysis of intersectional strata showed clear average differences in the risk of bad SRH. For instance, the risk was seven times higher for immigrated women with low income (OR 7.00 [95% CI 6.14-7.97]) than for native men with high income. However, the discriminatory accuracy of the intersectional strata was small (AU-ROC=0.67).Conclusions: The intersectional AIHDA approach provides more precise information on the existence (or the absence) of health inequalities, and can guide public health interventions according to the principle of proportionate universalism. The low discriminatory accuracy of the intersectional strata found in this study warrants universal interventions rather than interventions exclusively focused on strata with a higher average risk of bad SRH.

Theoretical and practical challenges of proportionate universalism: a review

Objective. In 2010, the principle of proportionate universalism (PU) has been proposed as a solution to reduce health inequalities. It had a great resonance but does not seem to have been widely applied and no guidelines exist on how to implement it. The two specific objectives of this scoping review were: (1) to describe the theoretical context in which PU was established, (2) to describe how researchers apply PU and related methodological issues. Methods. We searched for all articles published until 6th of February 2020, mentioning “Proportionate Universalism” or its synonyms “Targeted universalism” OR “Progressive Universalism” as a topic in all Web of Science databases. Results. This review of 55 articles allowed us a global vision around the question of PU regarding its theoretical foundations and practical implementation. PU principle is rooted in the social theories of universalism and targeting. It proposes to link these two aspects in order to achieve an effective reduction of health inequalities. Regarding practical implementation, PU interventions were rare and led to different interpretations. There are still many methodological and ethical challenges regarding conception and evaluation of PU interventions, including how to apply proportionality, and identification of needs. Conclusion. This review mapped available scientific literature on PU and its related concepts. PU principle originates from social theories. As highlighted by authors who implemented PU interventions, application raises many challenges from design to evaluation. Analysis of PU applications provided in this review answered to some of them but remaining methodological challenges could be addressed in further research.

Health promotion in Swiss municipalities: towards proportionate universalism

Background Health promotion goes beyond the health sector. Municipalities, the local public authorities in Switzerland, have a crucial role to promote population health in all their decisions. Initially developed by Promotion Santé Valais, the label “Healthy municipality” exists in the canton of Vaud since 2015. The label takes stock of existing measures in health promotion and prevention in all sectors and incentivise new interventions. The labelling process respects different criteria and is validated by an external committee. It is voluntarist, free of charge for the municipality but requires time and intersectoral communication. This abstract explores equity in the uptake of the label. Results In Vaud, 17 municipalities have been labelled “healthy”. Two external evaluations by Swiss universities highlighted that small villages are less involved in the label than urban areas. To achieve health equity, we need to identify and approach municipalities with limited human and financial resources, that might be less active in health promotion and/or whose population is socioeconomically disadvantaged. Preliminary results indicate that municipalities below 1000 inhabitants, in rural areas, should be targeted first. We are currently investigating the barriers and facilitators for them to enrol in the label. Lessons As labels rewarding healthy cities are expanding worldwide, it is important to document and reflect on who benefits from them, and who does not. Our practice is now focusing more on villages in rural areas, with less resources than urban settings. We investigate their needs regarding the type of support that we, public health professionals, can provide. Proportionate universalism principles should also apply to advocacy for health promotion, at the municipality level. Key messages To achieve health in all policies, the role of municipalities is essential. More efforts in health promotion should target specifically small and rural municipalities, with limited resources.

An Intersectional Analysis Providing More Precise Information on Inequities in Self-Rated General Health

BackgroundIntersectionality theory combined with an analysis of individual heterogeneity and discriminatory accuracy (AIHDA) can facilitate our understanding of health disparities. This enables a more precise application of proportionate universalism for resource allocation in public health. Analyzing self-rated general health in Sweden, we show how an intersectional perspective allows for a detailed mapping of health inequalities while avoiding simplification and stigmatization based on indiscriminate interpretations of differences between group averages. MethodsWe analyzed responses (n=133,244) to 14 consecutive National Public Health Surveys conducted in Sweden in 2004–2016 and 2018. Applying AIHDA, we investigated the risk of bad self-rated general health across 12 intersectional strata defined by gender, income and migration status, adjusted by age and survey year. We calculated prevalence ratios (with 99% confidence intervals) to evaluate between-strata differences, using native men with high income as the comparison reference. We calculated the area under the receiver operating characteristic curve (AUC) to evaluate the discriminatory accuracy of the intersectional strata. ResultsThe analysis of intersectional strata showed a clear social gradient where the risk of bad self-rated health among immigrated women with low income was six times higher (PR 6.01 [99% CI 5.32–6.79]) than that of native men with high income. A large degree of heterogeneity was present, however, as the discriminatory accuracy of the intersectional strata for identifying individuals according to their self-assessed general health status was relatively low (AUC=0.674).ConclusionsAn intersectional AIHDA approach provides more precise information on the distribution of bad self-assessed general health in the population and could thus guide public health interventions according to the principle of proportionate universalism.