Equity in Health

Climate risks in urban areas
Humphreys G: Bulletin of the World Health Organisation 1:102(2), 90-91, 2024

Engaging with communities in informal settlements presents opportunities to mitigate the health impacts of climate change, but government investment is also needed. Around one third of the estimated 4.5 billion urban dwellers worldwide use pit toilets or septic tanks, which are normally the first to be overwhelmed in floods, spreading excrement and the pathogens it carries into the environment. Climate change is likely to exacerbate the challenges faced in cities. According to UN-Habitat, “cities are growing faster than governments can build the necessary institutional capacity to better plan and manage urban growth." in the absence of progress on urban investment, planning and management, one suggested way of addressing inequitable exposure to climate risk is to engage with the communities most affected. Not only are community members motivated to initiate risk mitigation measures, they also typically have the best understanding of their surroundings, including the makeup of the local population, and areas most likely to flood.

Global health inequities: more challenges, some solutions
Tangcharoensathien V, Lekagul A, Teo Y-Y: Bulletin of the World Health Organisation 102, 86–86A, 2024

This theme issue of the Bulletin of the World Health Organization shows how health inequities affect many areas, both at national and global scale. The papers discuss health inequity and its root causes, and offer promising solutions. Challenges include national statistics not capturing health inequity among vulnerable populations such as Indigenous people, refugees and migrant workers, including migrant health workforce. However, good practices exist. For example on paper reports on local Indigenous communities successfully managing primary health-care clinics, that can be scaled up and replicated. Overall, the issue editors observe that rectifying global health inequity requires multidimensional interventions and decisive government leadership at the macro-policy level, collaboration with affected populations at the micro-operational level and accelerating progress towards UHC.

The role of the social sciences and humanities in pandemic preparedness responses: insights gained from COVID-19, HIV and AIDS and related epidemics
Govender K, King J, Nyamaruze P, et al: African Journal of AIDS Research, 22(4), 269–27, 2023

The COVID-19 pandemic, particularly from 2020 to mid-2022, debilitated the management of the HIV epidemic in Africa. The multiple effects included well-documented HIV service interruptions, curtailment of HIV prevention programmes, the associated marked increase in both the risk for HIV infection among key populations and vulnerability of sub-populations. As importantly but less well documented were the diverse negative socio-economic effects that accentuate HIV risk and vulnerability generally (e.g. loss of earnings, gender-based violence, stigma, police harassment of people during lockdowns. The global biomedical response to COVID-19 was necessary and remarkable for mitigating the bio-physical impacts of the pandemic. However, this article suggests that key lessons learnt during the HIV and AIDS and other pandemics were ignored, at least during the early stages of COVID-19. The authors critique is that better integration of the social sciences and humanities in responses to pandemics can counter the reflex tendency to uncritically adopt a biomedical paradigm and, more importantly, to enable consideration of the social determinants of health in pandemic responses.

Elevated blood pressure among adolescents in sub-Saharan Africa: a systematic review and meta-analysis
Chen A, Waite L, Mocumbi A, et al: The Lancet Global Health 11:8; E1238-E1248, 2023

More people from sub-Saharan Africa aged between 20 years and 60 years are affected by end-organ damage due to underlying hypertension than people in high-income countries, but we lack data on the pattern of elevated blood pressure among adolescents aged 10–19 years in sub-Saharan Africa. This study aimed to fill this gap, through systematic review and meta-analysis of studies published from Jan 2010, to Dec 2021. 36 studies comprising 37 926 participants aged 10–19 years from sub-Saharan African countries were eligible. A pooled sample of 29 696 adolescents informed meta-analyses of elevated blood pressure and 27 155 adolescents informed meta-analyses of mean blood pressure. The reported prevalence of elevated blood pressure ranged from 0·2% to 25·1% of adolescents. with 13·4% of male participants compared with 11·9% of female participants having elevated blood pressure, Although many low-income countries were not represented in the study, the findings suggest that approximately one in ten adolescents have elevated blood pressure across sub-Saharan Africa. The authors observe that there is an urgent need to improve preventive heart-health programmes in the region.

Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys
Daca CSL, San Sebastian M, Arnaldo C, et al. BMC Public Health. 23:1007 https://doi.org/10.1186/s12889-023-15988-y, 2023

Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed. This study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique. The study was based on analysis of measures from repeated cross-sectional surveys from nationally representative sample surveys. The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. The authors observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. They suggest that decision-makers target underserved populations, specifically non-educated, poor people and rural women, to address inequalities in health care coverage.

Individual and area-level socioeconomic correlates of hypertension prevalence, awareness, treatment, and control in uMgungundlovu, KwaZulu-Natal, South Africa
Madela S L M, Harriman N W, Sewpaul R et al. BMC Public Health 23:417; 1-15, 2023

This analysis explores the relationship between individual and area-level socioeconomic status and hypertension prevalence, awareness, treatment, and control within a sample of 7,303 Black South Africans in three municipalities of the uMgungundlovu district in KwaZulu-Natal province. The prevalence of hypertension in the sample was 44% (n = 3,240). Of those, 2,324 were aware of their diagnosis, 1,928 were receiving treatment, and 1,051 had their hypertension controlled. Educational attainment was negatively associated with hypertension prevalence and positively associated with its control. Employment status was negatively associated with hypertension control. Black South Africans living in more deprived wards had higher odds of being hypertensive and lower odds of having their hypertension controlled. Potential interventions proposed by the authors include community-based programs that deliver medication to households, workplaces, or community centers.

Emigration as a social and economic determinant of health in low-income urban Zimbabwe
Chigariro, TC and Mhloyi, MM:. Journal of Health, Population and Nutrition 41(49), 1-10, 2022

This study compared socio-economic characteristics, including health, of emigrants’ households with those of non-emigrants’ households in an urban setting in Harare, Zimbabwe. A cross-sectional survey and focus group discussions were used to collect quantitative and qualitative data, respectively. Concurrent and retrospective data were collected using an interviewer-administered questionnaire with 268 de facto heads of the respective households, the. majority of whom were female. Emigrants’ households were more likely to access private compared to government health care facilities, than non-emigrants’ households. Emigrants' households were also more likely to report higher incomes than non-emigrants’ households and were having more meals per day and better access to education. Emigrants' households were also more likely to report positive lifestyles than non-emigrants’ households. Only 13.8% of emigrants' households reported a negative shift in lifestyle, compared to 25.2% non-emigrants' households. Emigration was found to have a positive relationship with health seeking, income, education, and number of meals a household had. The authors argue that it is clear from the findings that emigration during the hard economic times in Zimbabwe is beneficial; it cushions households from the ravages of poverty. Yet emigration robs the nation of its professional able-bodied people. They recommend that government optimise the reported positive effects, whilst improving the economy to reverse out-migration.

Multimorbidity and its socio-economic associations in community-dwelling older adults in rural Tanzania; a cross-sectional study
Lewis E G; Gray W L; Walker R; et al: BMC Public Health 22(1918), 1-12, 2022

The authors describe the prevalence and socio-economic conditions associated with multimorbidity in 235 community-dwelling older people ( ≥ 60 years) living in rural Tanzania, using a history and focused clinical examination. Multimorbidity was defined as having two or more conditions. The median age was 74 years and 136 were women. Adjusting for frailty-weighting, the prevalence of self-reported multimorbidity was 26%, and by clinical assessment/screening was 67%. Adjusting for age, sex, education and frailty status, multimorbidity by self-report increased the odds of being financially dependent on others threefold, and of a household member reducing their paid employment nearly fourfold. Multimorbidity is prevalent in this rural lower-income African setting and is associated with evidence of household financial strain. Multimorbidity prevalence is higher when not reliant on self-reported methods, revealing that many conditions are underdiagnosed and undertreated.

Under-five mortality in the Democratic Republic of the Congo: secondary analyses of survey and conflict data by province
Schedwin M; Furaha A B; Kapend R; Akilimali P; et al: Bulletin of the World Health Organisation 100(7), 422–435, 2022

This study compared coverage of key child health policy indicators across provinces and to explore their association with under-five mortality and level of conflict in the Democratic Republic of the Congo. A secondary analysis of nationally representative data was implemented from 1380 health facilities and 20 792 households in 2017–2018 was done. All grouped coverage scores demonstrated large ranges across the 26 provinces: newborn health: 20% to 61%; pneumonia: 26% to 86%; diarrhoea: 25% to 63%; malaria: 22% to 53%; and safe environment: 4% to 53%. The diarrhoea score demonstrated the strongest association with under-five mortality. Child mortality and the odds of coverage were higher in conflict-affected provinces for 13 out of 23 indicators. However, the authors also noted that children in unaffected provinces should not be neglected while addressing the needs of the most vulnerable in conflict settings. They notes that prevent, protect and treat strategies for diarrhoeal disease could help improve equity in child survival.

Tackling health inequities in indigenous communities
World Health Organisation: WHO, Geneva, 2022

There are currently 476 million indigenous people globally who experience structural racial and ethnicity-based discrimination, higher rates of health risks and poorer health outcomes. Their leadership and participation in public health is argued to be central to understand and address their health issues. In May 2022, WHO hosted a side event at the 21st session of the UN Permanent Forum under the theme “indigenous peoples, business, autonomy and the human rights principles of due diligence including free, prior and informed consent." The session explored the ‘causes of the causes’ of these health inequities and considered measures to tackle them, with members of indigenous communities speaking out on health systems strengthening, restorative justice, racism and discrimination, traditional medicine and health practices, access to water and social determinants of health like housing and education.