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This study aimed to explore the socio-economic inequalities in physical activity (PA) based on domains of daily life, such as work, transport, recreation and sedentary life, among Japanese adults during the COVID-19 pandemic.This was a cross-sectional study.This study used data from the 2020 National Sport and Lifestyle Survey, conducted by the Sasakawa Sports Foundation. Data of 2,296 (1,103 women) participants were analysed. PAs were assessed using the Global Physical Activity Questionnaire. Educational level and household income were used as indicators of socio-economic status. We calculated the slope index of inequality (SII) and relative index of inequality (RII).We detected absolute and relative inequalities for household income in all PA domains, except for work-related PA. The higher the participants' income, the longer they engaged in transport- and recreation-related PA and sedentary behaviour. Recreation-related PA had a larger disparity than other domains, with SII at 20.8% (95% confidence interval [CI] -28.4 to -13.1) and RII at 0.58 (95% CI 0.47-0.71). At the educational level, each inequality was observed in work- and recreation-related PA and sedentary behaviour. The higher the participants' educational level, the longer they engaged in recreation-related PA and sedentary behaviour. However, work-related PA was longer at lower educational levels, with RII at 1.90 (95% CI 1.48-2.44). The inequality in recreation-related PA was also relatively large (SII 23.3%, 95% CI -30.9 to -15.7; RII 0.54, 95% CI 0.45-0.66).Our study revealed significant socio-economic disparities in each PA domain, particularly in recreational PA. These results suggest a widening gap because of the COVID-19 pandemic.

Objective In Japan, it is mandatory for employers to provide general health checkup opportunities to employees. Although many companies have subsidized checkups for employees' dependent family members, their participation is low. We assessed income-based inequality in the participation of employees’ dependents in the general health checkup. Study design This is a cross-sectional descriptive study. Annual participation rate in general health checkup and various factors including income, age, and sex were collected and analyzed to examine the income-based inequality of participation rate in general health checkup. Methods The data for the present study were sourced from the Fukuoka Branch of the Japan Health Insurance Association, a large medical insurer in Japan. We extracted data of 196,057 dependents aged 40–74 years. We conducted a multiple logistic regression analysis using participation from April 2015 to March 2016 as dependent variable and income category ranging from 1 (lowest) to 4 (highest) between April and June 2015 as independent variable (adjusted for sex and age). We computed slope index of inequality (SII) and relative index of inequality (RII) based on income category. Results Higher the income, the more likely were dependents to participate in the general health checkup. SII for the participation rate of general health checkup ranged between −0.02 (95% confidence interval [CI]: −0.07 to 0.03) and 0.06 (0.03–0.09) for men; 0.03 (0.01–0.06) and 0.10 (0.09–0.11) for women. RII for the participation rate of general health checkup ranged between −0.19 (95% CI: −0.66 to 0.29) and 0.88 (0.15–1.61) for men; 0.22 (0.05–0.39) and 0.68 (0.60–0.76) for women. The highest inequality existed for men in their 50s and 60s and women in their 50s; the lowest inequality was among men and women aged 70–74 years. Conclusion There was income-based inequality in participation in the general health checkup among dependents (family members) of the insured persons. The degree of inequality differed with age group. It cannot be explained solely by financial barrier among low-income group, rather it may reflect Japanese unique context in medical insurance system.

Objectives\ud The COVID-19 pandemic in Wales and the UK has highlighted significant and historic inequalities in health between social groups. To better understand the composition of these inequalities and inform planning after the pandemic, we undertook a decomposition of life expectancy inequalities between the most and least deprived quintiles for men and women by age and cause of death and explored trends between 2002 and 2018.\ud \ud Study design\ud Statistical decomposition of life expectancy inequalities by age and cause of death using routine population mortality datasets.\ud \ud Methods\ud We used routine statistics from the Office for National Statistics for the period 2002–2018 on population and deaths in Wales stratified by age, gender, Welsh Index of Multiple Deprivation (WIMD) 2019 quintile and cause of death, categorised by International Classification of Disease, version 10, code into 15 categories of public health relevance. We aggregated data to 3-year rolling figures to account for low numbers of events in some groups annually. Next, we estimated life expectancy at birth by quintile, gender and period using life table methods. Lastly, we performed a decomposition analysis using the Arriaga method to identify the specific disease categories and ages at which excess deaths occur in more disadvantaged areas to highlight potential areas for action.\ud \ud Results\ud Life expectancy inequalities between the most and least WIMD quintiles rose for both genders between 2002 and 2018: from 4.69 to 6.02 years for women (an increase of 1.33 years) and from 6.34 to 7.42 years for men (an increase of 1.08 years). Exploratory analysis of these trends suggested that the following were most influential for women: respiratory disease (1.50 years), cancers (1.36 years), circulatory disease (1.35 years) and digestive disease (0.51 years). For men, the gap was driven by circulatory disease (2.01 years), cancers (1.39 years), respiratory disease (1.25 years), digestive disease (0.79 years), drug- and alcohol-related conditions (0.54 years) and external causes (0.54 years). Contributions for women from respiratory disease, cancers, dementia and drug- and alcohol-related conditions appeared to be increasing, while among men, there were rising contributions from respiratory, digestive and circulatory disease.\ud \ud Conclusions\ud Life expectancy inequalities in Wales remain wide and have been increasing, particularly among women, with indications of worsening trends since 2010 following the introduction of fiscal austerity. As agencies recover from the pandemic, these findings should be considered alongside any resumption of services in Wales or future health and public policy.

Objectives\ud The aim of the study was to assess the magnitude of wealth inequalities in the development of diarrhoea among under-five children in low- and middle-income countries (LMICs) and to identify and quantify contextual and compositional factors' contribution to the inequalities.\ud \ud Design\ud This is a cross-sectional study.\ud \ud Methods\ud We used cross-sectional data from 57 Demographic and Health Surveys conducted between 2010 and 2018 in LMICs. Descriptive statistics were used to understand the gap in having diarrhoea between the children from poor and non-poor households and across the selected covariates using Fairlie decomposition techniques with multivariable binary logistic regressions at P = 0.05.\ud \ud Results\ud Of the 57 countries, we found a statistically significant pro-poor odds ratio in only 29 countries, 7 countries showed pro-non-poor inequality and others showed no statistically significant inequality. Among the countries with statistically significant pro-poor inequality, the risk difference was largest in Cameroon (94.61/1000), whereas the largest pro-non-poor risk difference in diarrhoea was widest in Timor-Leste (−41.80/1000). Important factors responsible for pro-poor inequality varied across countries. The largest contributors to the pro-poor inequalities in having diarrhoea are maternal education, access to media, neighbourhood socio-economic status, place of residence, birth order and maternal age.\ud \ud Conclusion\ud Diarrhoea remains a major challenge in most LMICs, with a wide range of pro-poor inequalities. These disparities were explained by both compositional and contextual factors, which varied widely across the countries. Thus, multifaceted geographically specific economic alleviation intervention may prove to be a potent approach for addressing the poor and non-poor differentials in the risk of diarrhoea with policies tailored to country-specific risk factors. There is a need for further investigation of factors that drive pro-non-poor inequalities found in 9 of the LMICs.

Objectives The objective of the study is to analyze the mortality trend in indigenous peoples in Brazil. Study design The study design used is an ecological study. Methods A study carried out with data from the indigenous deaths recorded on the Mortality Information System in Brazil between 2000 and 2016. The Prais Winsten regression was used to analyze the trend of overall mortality in the country and in its geopolitical regions, in addition to the trend by sex, age groups, and groups of basic causes of death. Results Of all deaths, 47,806 indigenous deaths were recorded between 2000 and 2016. The majority was male (56.5%) and 27.2% in children aged younger than 5 years. The major groups of causes of death were the circulatory diseases (15.8%) and external causes (14.9%). The affections of the perinatal period (23.7%) and infectious and parasitic diseases (18.5%) were the main causes in children aged younger than 5 years. The indigenous mortality rates showed an increasing trend in the country (annual percent change [APC] = 2.37%). There was growth in both sexes and in most age ranges. Mortality from external causes (APC = 4.71%), neoplasms (APC = 4.67%), and respiratory causes (APC = 4.14%) also presented growth. The infectious and parasitic causes and genitourinary causes showed a stable trend in the studied period. Conclusions The increasing trend of mortality in the analyzed variables showed disparities between indigenous and non-indigenous peoples in Brazil, pointing to the need for greater investment in basic social sectors, such as health, education, housing, and sanitation.

Objectives Sparse evidence is available to explain obesity variations between genders in the Turkish population. To our knowledge, no previous study has analysed the magnitude of gender differences in obesity using common social determinants of health. We aimed to quantify gender inequalities in obesity in terms of education, employment status, occupation and perceived income in a Turkish population. Study design The study design used is a cross-sectional study. Methods Population-based data from the Balcova Heart Study (n = 16,080) were analysed. Logistic regression models were used to calculate the crude and adjusted odds ratios (ORs) when comparing obesity prevalence in women vs men within each category of social determinants. Results Women had a higher risk of being obese than men (adjusted OR [aOR] = 2.04 [95% confidence interval {CI}: 1.7–2.1]). Gender inequality in obesity decreased as the level of education increased, from ‘primary school’ (aOR = 2.5 [95% CI: 2.2–2.8]) to ‘university’ (aOR = 0.9 [95% CI: 0.6–1.1]). Women had a higher risk of obesity within the ‘unemployed’ category compared with men (aOR = 2.2 [95% CI: 1.6–3.0]). Gender inequality in obesity decreased with a higher perception of income, from ‘low’ (aOR = 2.1 [95% CI: 1.6–3.0]) to ‘high’ (aOR = 1.5 [95% CI: 1.2–2.0]). Conclusions These findings highlight the fact that gender inequalities in obesity are greatest within populations of low education, unemployment and lower perception of income. Reduced gender inequality in obesity prevalence was seen for the subpopulation with professional occupations, with women having decreased odds of obesity compared with men. Conversely, unemployed women had increased odds of obesity compared with unemployed men. Increasing the status of women should be prioritised in policies to tackle obesity in the Turkish population and in similar developing populations elsewhere.

Objectives Recent research by Public Health has redefined harmful gambling, shifting the focus from problematic people with irresponsible behaviour to ‘gamblogenic’ environments. The aim of this research was to support this alternative perspective with concrete ecological tools for characterizing harmful environments. Studies that analyse the spatial distribution of gambling show that people living in the most disadvantaged areas have greater access to gambling and are more affected by the harms of gambling. Despite their quality methodology and usefulness, the scope of geographic access measures has been partially limited. These measures have been mostly structured around a single form of gambling, focus on only one dimension of accessibility (density or proximity) and few of them take into account the risks associated with each type of the game. The main goal of our research was to propose an innovative method to characterize gambling environments in Quebec and address social inequality with respect to gambling exposure. This article more specifically describes the method we used to address the aforementioned shortcomings by developing the gambling exposure index (GEI), a more comprehensive ecological index of all games—weighted by their relative level of risk—to which populations are exposed. Study design The study design is a cross-sectional ecological study. Methods The methodological approach was carried out in three stages. A GEI was operationalized and is composed of three dimensions: A dimension of spatial accessibility to gambling sites, a dimension of density of gambling places and a dimension of relative risk associated with different types of game. The two-step floating catchment area (2SFCA) method was used to combine these three dimensions into an overall GEI index. Data were retrieved from a geocoded directory of all gambling sites from Loto-Quebec and other commercial databases. The relative risk of each type of game has been expressed by prevalence rates for those specific games in a Quebec population prevalence survey. A vulnerability to gambling index (VGI) was produced based on 6 socio-economic proxies of problem gambling from the 2016 Canadian census. The six variables were weighted and aggregated at the dissemination area (DA) level. Spatial and descriptive statistical analyses were conducted to explore the relationship between VGI and GEI and to identify areas that are highly vulnerable and have a high gambling exposure. Results The findings of our analysis reveal widespread geographic exposure to gambling and a significant positive linear relationship between the GEI and the VGI. In many areas, increased accessibility to gambling is significantly associated with a higher vulnerability to gambling. Our findings demonstrate that in 1328 DAs in Quebec, there is a particularly unequal and potentially harmful geographical distribution of gambling, exposing 9% of the population which are theoretically vulnerable to gambling to an increased presence of gambling. Conclusion This research applied a spatial analytical approach to assess the association between environments, gambling and vulnerability. The GEI and VGI at the DA level can serve as a monitoring tool for policy-makers regarding gambling exposure in the most vulnerable sectors and contribute to prevention and intervention strategies better adapted to the population. The general findings raise the ethical implications of increased marketing development in vulnerable neighbourhoods. As the GEI takes into account both the environmental determinants and the relative risk of games, it is in contributing to the shift in public and scientific discourse, redefining the subject from problematic people to problematic games and environments.

Objectives To examine self-rated health (SRH) trajectories by age, period and cohort in the dynamic environment of China and to focus on sex, educational, family economic status (FES) and regional disparities in these temporal trajectories. Study design Repeated cross-sectional data from the World Value Survey from 1990 to 2012 (n = 7731) were used. Methods An age-period-cohort (APC) model with an intrinsic estimator method was applied, using SRH as a continuous variable to analyse SRH trajectories by age, period and cohort in different groups in China. Robust analyses were conducted using SRH as a binary variable and a hierarchical APC cross-classified random effects model. Results SRH was adversely associated with age, and a global trend of declining SRH was observed between 1990 and 2012; however, SRH generally increased across successive cohorts in China. SRH was better in males, individuals from the eastern region, and in those with higher levels of education and higher FES. Regional and FES disparities in SRH increased with age and across successive cohorts; however, educational disparities in SRH first decreased and then increased with age and across successive cohorts, and sex disparities in SRH decreased across successive cohorts, in general. Conclusions A well-performing social environment is related to better population health. The cumulative disadvantage in health among individuals from underprivileged regions/families with less education should be the focus of social transition in China.

Objectives The literature suggests that sexual minority young people (SMYP) use alcohol at disproportionate levels when compared with their heterosexual counterparts. Little is known about alcohol dependency symptoms and correlations between high-risk alcohol use/dependency symptoms and minority stress in this population in general and between subgroups. Study design Cross-sectional study. Methods Descriptive statistics, adjusted odds ratios, and analysis of covariance were used to determine high-risk alcohol use, dependency symptoms, differences between subgroups, and correlations between alcohol use, dependency symptoms, and minority stress. Results A total of 1556 Australian SMYPs aged 18 to 35 years completed the survey. Fifty percent of the participants reported high-risk alcohol consumption with significant differences between subgroups. Typical dependency symptoms such as ‘health, social, legal or financial problems due to alcohol consumption’ (16.8%, n = 247) were identified in large parts of the sample. High-risk consumption and dependency symptoms were significantly correlated with minority stress. Conclusion High levels of high-risk alcohol use and dependency symptoms were found, largely consistent with existing literature. However, disparities are not distributed equally in this population, suggesting that future health promotion interventions should focus on SMYP subgroups. Significant correlations between minority stress and dependency symptoms/high-risk use suggest a potential route for future interventions in these populations.

Objectives China is currently facing an unprecedented complex health demand from a rapidly aging population. Based on multidimensional health, this study aimed to identify heterogeneous latent health classes for older Chinese people, and assess regional disparities and associated sociodemographic factors. Study design Chinese Longitudinal Healthy Longevity Survey in 2014 was adopted. Methods For 2886 participants aged 65 years and more without missing health indicators in physical, psychological, and social dimensions, latent class analysis was used to identify heterogeneous health. For 2128 participants with complete information, logistic regressions were used to examine how regional divisions and sociodemographic factors impact each identified class. Results Four classes were identified and labeled as ‘Lacking Socialization’ (17.4%), ‘High Comorbidity’ (13.7%), ‘Functional Impairment’ (7.1%), and ‘Relative Health’ (61.8%). When the Relative Health class was the reference, the likelihoods of the High Comorbidity and Functional Impairment classes were higher for older adults in eastern and central regions than in western regions. Those in eastern regions also tended to be in the Lacking Socialization class than in western regions. The effects of regional divisions on the different classes were significantly impacted by sociodemographic characteristics. Conclusions Four health classes identified by multidimensional health have enhanced our understanding of heterogeneity among older Chinese people. By examining regional disparities in China, our study provided evidence for health policies addressing the issue of aging with respect to regional disparities.

Objectives Sociodemographic disparities in the incidence and mortality of human papillomavirus (HPV)–associated conditions have been well documented in the pre-HPV vaccine era. It is still unknown if the introduction of routine vaccination has been effective in reducing these prevaccine era inequalities. The purpose of this review was to determine the utilization of sociodemographic variables to assess for disparities in population-level HPV vaccine impact research and to evaluate the current evidence for disparities in the reduction of HPV-associated conditions after vaccine introduction in the United States (US). Study design A systematic review of the literature from January 2007 through March 2018 was carried out to identify studies evaluating the impact HPV vaccines have had on the rates of HPV infection, genital warts, and cervical dysplasia (cervical intraepithelial neoplasia grades 1+) in the US. An in-depth review was then performed to synthesize these data and to assess the way prior studies have reported and evaluated for potential disparities in the vaccine's impact within various racial, ethnic, and/or socio-economic subgroups of the population. Methods Vaccine impact studies measure the change in the population-level burden of disease prelicensure versus postlicensure of the vaccine. We systematically searched PubMed/Medline and Embase, combining search terms related to the HPV vaccine, sentinel surveillance, and HPV-associated conditions. Eligible studies were those with population-level, postvaccine introduction data that were conducted in the US. Finally, a cited reference search was conducted for all included articles using the Web of Science platform that accesses three major citation indexes: Science Citation Index, Social Sciences Citation Index, and Arts and Humanities Citation Index. This allowed us to screen not only the articles that were cited by our final collection of studies but also the articles that used our selected studies as one of their references. The study protocol is registered in PROSPERO (#CRD42018107579). Results Overall, 23 of the 4139 references retrieved assessed the population-level impact of HPV vaccines between January 1, 2007, and March 29, 2018. Among these, 13 (57%) reported sociodemographic data. Only two articles reported stratified results by sociodemographic factors, thereby allowing assessment for potential disparate impact. One of these studies described differences in the impact of the vaccine by race, ethnicity, and income. Conclusion Although approximately half of the studies that assessed the impact of the HPV vaccine measured sociodemographic characteristics, few presented results in a way that allowed for the identification of potential differences in impact between the relevant subgroups of the population. Determining to what extent, if any, vaccines are reducing known sociodemographic disparities is an important public health priority and an essential step in developing immunization strategies that are beneficial for all.

Policy recommendations, which aim to reduce health inequalities in society, often focus upon improving the incomes, working conditions and physical environments of the most deprived groups. We agree with these recommendations but argue that they are insufficient to reduce health inequalities because they fail to address the economic relationships between social groups that lead to health inequalities and which perpetuate them over time. A comprehensive programme to reduce health inequalities will require policies that address the numerous ways in which economic resources flow from poorer groups to richer groups through the design of the economy. In this commentary we describe key economic relationships between social groups that lead to inequalities, namely rent, interest, capital gains, profit, monopoly and speculation. Addressing these causes of economic inequality in recommendations to reduce health inequalities should be considered by future research in this area.

This year marks the 30th anniversary of the Dahlgren and Whitehead model of the main determinants of health, sometimes known as 'The Rainbow Model'. In this article, we reflect on developments over those thirty years before going on to look to the future. We start by telling the story of our model's idiosyncratic journey from initial rejection to worldwide acclaim. We reflect on the many ways in which the model has been used over the years and why it has proved illuminating for people in so many different positions. It is equally important to understand what it does not do and what it was never intended to do, as sometimes the conceptual debate gets side-tracked by mistaken assumptions. We take some space to outline how we ourselves use the model with the complementary Diderichsen Framework to explain the pathways and mechanisms by which the known determinants of health bring about the social gradients in health that are observed within countries. We conclude by looking to the future and what further needs to be done to capture insights for action on the determinants and drivers of health and of growing inequalities in the post-pandemic world.

Objectives The primary objective of this study was to work with tribal communities to define and develop their own healthcare services and strategies for positive change regarding injection drug use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infection. The secondary objective of this study was to incorporate community capacity building strategies to develop and sustain programming and resources to optimize tribal communities’ responsiveness to reduce health disparities. Study design Semi-structured qualitative interviews. Methods Interviews were guided by community-based participatory research (CBPR) principles to create programs, projects, and policy recommendations meaningful to American Indian and Alaska Native (AI/AN) people. Results The study generated a formative understanding of the context of AI/AN people who inject drugs (PWID) in three distinct AI/AN communities as well as developed local capacity for future programming, projects, and policy. Conclusions This study confirms CBPR methods should be part of an iterative cycle to inform policy and programs. CBPR has helped strengthen local research capacity and has formed ongoing relationships between study investigators, local liaisons, and the community that will be essential for next phases of program design and policy implementation. This cycle of CBPR could be replicated in other tribal communities to bring awareness of the opioid epidemic and its effects and to prioritize local indigenous and community-led responses.

Objectives Progress on health equity will require a robust metric. The aim of this article is to propose a new health equity metric that is distinct from existing measures and that allows meaningful comparisons across time and place, is calculable using health data typically available, and measures health equity across all major forms of social exclusion. Study design A cross-sectional study. Methods The new health equity measure was calculated using data included from all 50 states and the District of Columbia in the 2017 Behavioral Risk Factor Surveillance Survey, collected by the US Centers for Disease Control and Prevention. The total sample size was 287,602. State-specific sample sizes ranged from 2269 (Alaska) to 14,685 (Kansas) with a median of 4452. A Healthy Days measure was calculated as the mean number of days that the respondents reported being physically healthy and mentally healthy out of the previous 30 days. The proposed measure defines individual health disutility as the distastefulness associated with one's health falling short of optimal achievable health, instrumentalized as the median health of the most socially privileged category, that of upper-income white men. The value of the health equity metric in a population is the mean value of this distastefulness over the entire population and has a theoretical range of -∞ to 1. Results There is substantial variation across states (mean: 0.13; standard deviation: 0.15), with the District of Columbia (0.48), Minnesota (0.37), and Connecticut (0.30) showing the greatest health equity, and West Virginia (−0.26), Arkansas (−0.18), and Kentucky (−0.13) exhibiting the least. Across states, the value of the health equity metric is not correlated with the size of black-white health disparities. Conclusions It is feasible to use a single health equity metric for consistent and objective measurement of health equity. Doing so may facilitate more rapid progress toward health equity.

Objective The overarching goal of the Swedish public health policy is to create the right societal conditions for good and equitable health throughout the population and to reduce avoidable health inequalities within a generation. The objective of this article is to highlight the main findings of the Open Comparisons in Public Health (OCPH) 2019 study. Study design The OCPH is a longitudinal indicator-based comparative study, encompassing 39 public health indicators with results from Sweden's 21 regions and 290 municipalities. Methods Descriptive statistics and 95% confidence intervals were used to compare results between municipalities, regions and time points. Correlation analysis was used to study the strength of the relationship between the results of municipalities and their socio-economic conditions. Results Across the population, levels of health are good and have, in some areas, improved over recent decades. However, some significant health disparities remain according to neighbourhood, sex, age and educational background. Health disparities related to the level of education are often larger than those between women and men, and there are larger differences within a region than between regions. Health disparities have, in some cases, increased, such as for life expectancy. Conclusion If health equity is to be achieved, leaders at all levels must collaborate and advocate for political action and local efficient public health interventions to eliminate health disparities as a result of neighbourhood and social conditions.

Objectives Ethno-national approaches to research public health and migrant outcomes have dominated for decades but lack efficacy in a globalised world and in view of the intractable nature of health outcome inequalities for migrant and minority groups. This article highlights some of the challenges and opportunities associated with a superdiversity perspective in public health research. Superdiversity and ethno-national approaches Migration patterns have changed with more people arriving from more places and the diversification of diversity meaning that the ethno-national categories utilised in public health research have reduced explanatory potential. The example of maternal and perinatal mortality in the United Kingdom Adjusting UK perinatal mortality rates by five ethnic groups based on assumptions of relationships between high levels of risk and ethnic groups masks the scale of inequality faced by groups wherein mortality rates are increasing and highlights some of the difficulties associated with using ethno-national classifications. A superdiversity perspective A superdiversity approach moves beyond ethno-nationalism to socially locate groups focussing on commonalities and differences across spaces and characteristics and employing intracategorical or anticategorical approaches. Conclusions Superdiversity brings new levels of demographic complexity and fluidity. Greater reflexivity is needed in diversity research with justification of classifications used for analysis necessary when research questions are developed.

The health of Māori, the Indigenous peoples of Aotearoa, New Zealand, like that of almost all Indigenous peoples worldwide, is characterised by systematic inequities in health outcomes, differential exposure to the determinants of health, inequitable access to and through health and social systems, disproportionate marginalisation and inadequate representation in the health workforce. As health providers, we are often taught that ‘taking a history’ is a critical component of a patient consultation to ensure that the underlying conditions are treated rather than the often superficial presenting symptoms. In the same way, attempts to make sense of the health and well-being of Indigenous peoples is inadequate unless health providers engage critically with the history of their respective nations and any subsequent patterns of privilege or disadvantage. Understanding this history, within the framework of western imperialism and other similar colonial projects, allows us to make sense of international patterns of Indigenous health status. While health commentators acknowledge the unequal health outcomes of Indigenous people, and an increasing number also link these inequities to Indigenous marginalisation resulting from historic events, very few go further and expose the deep relationship between racism and coloniality and how these continue to be the basic determinants of Indigenous health today. This work includes honest examination of the role that science and the health disciplines have played historically in colonisation through the subjugation of Indigenous ways of knowing and knowledge production, as well as being complicit in the creation and maintenance of a fabricated hierarchy of humankind. Despite the ‘science’ of this racial hierarchy being discredited, it retains a false validity in our societies. As long as oppressive systems that continue to re-inscribe racism and white privilege remain in communities, including our academic communities, coloniality continues its discrimination. Indigenous voices on migration, ethnicity, racism a and health will always demand the elimination of inequities in health but to do so will require a parallel commitment to critically interrogating all of our histories and our disciplines, as well as examining how our practice, including research, disrupts or maintains global systems of racism and coloniality.

Objectives: \ud To examine existing definitions of health and health inequalities and to synthesise the most useful of these using explicit rationale and the most parsimonious text.\ud \ud Study design: \ud Literature review and synthesis.\ud \ud Methods: \ud Existing definitions of health and health inequalities were identified, and their normative properties were extracted and then critically appraised. Using explicit reasoning, new definitions, synthesising the most useful aspects of existing definitions, were created.\ud \ud Results: \ud A definition of health as a structural, functional and emotional state that is compatible with effective life as an individual and as a member of society and a definition of health inequalities as the systematic, avoidable and unfair differences in health outcomes that can be observed between populations, between social groups within the same population or as a gradient across a population ranked by social position are proposed. Population health is a less commonly used term but can usefully be defined to encompass the average, distribution and inequalities in health within a society.\ud \ud Conclusions: \ud Clarifying what is meant by the terms health and health inequalities, and the assumptions, emphasis and values that different definitions contain, is important for public health research, practice and policy.

Objective: Adolescents are at risk of developing detrimental health behaviours that will affect their adult health. The aim was to estimate prevalence of health risk behaviours (HRB), comparing young people (12–18 years old)in Wiltshire (UK)who are vulnerable (looked after children, special education needs and disabilities, young carers and military dependents)to those who are not vulnerable and assess whether these behaviours are associated with protective factors (e.g. friendship groups). Study design: Secondary analysis of cross-sectional survey data (n = 4129). Methods: In total, 900 vulnerable young people were compared with 3229 non-vulnerable young people. Differences between the two groups were assessed using Chi-squared tests, and associations with possible protective factors were assessed using logistic regression (adjusting for confounding factors). Results: Vulnerable young people have a higher prevalence of smoking tobacco (15% vs 9%, P < 0.001), using cannabis (7% vs 5%, P = 0.03)and self-harming (16% vs 9%, P < 0.001)monthly or more compared with the rest of the Wiltshire adolescent population. Whilst vulnerable young people have many shared protective factors with non-vulnerable young people, there are also differences between the two groups. Conclusions: There are shared protective factors across HRB that can build on the resilience of a young person, impacting their current and future health. Therefore, we should focus our attention on developing protective factors that promote health and well-being, not solely delivering specialist interventions targeted at specific risks. Further consideration should be given to identifying and promoting protective factors specifically for vulnerable people as they have higher levels of HRB and experience protective factors differently.

Pressures on the health system are intense. Prevention is often seen as a sustainable way to manage these pressures. However, the impact of prevention on the demand for health and social care is not fully understood. It will reflect the balance of opposing forces: reduced needs for health and social care because of improving health and increased needs associated with increasing life expectancy and the diseases of old age, mediated by how the system manages the resulting pressures. This article illustrates how some of these factors are playing out in Scotland. The article also highlights the substantial growth in the evidence base on the economics of prevention and identifies policy developments with the potential to support a shift to prevention that might help move towards more sustainable demands on the health and social care system. These include recognition of the importance of the social determinants of health, the integration of health and social care and 'realistic medicine'. The article suggests that more use needs to be made of available evidence on the economics of prevention and that all stakeholders need to be engaged in tackling the technical and political challenges posed by the shift to prevention.

Objectives This study assesses the change in premature mortality and in morbidity under the scenario of meeting the World Health Organization (WHO) global targets for non-communicable disease (NCD) risk factors (RFs) by 2025 in France. It also estimates medical expenditure savings because of the reduction of NCD burden. Study design A microsimulation model is used to predict the future health and economic outcomes in France. Methods A ‘RF targets’ scenario, assuming the achievement of the six targets on RFs by 2025, is compared to a counterfactual scenario with respect to disability-adjusted life years and healthcare costs differences. Results The achievement of the RFs targets by 2025 would save about 25,300 (and 75,500) life years in good health in the population aged 25–64 (respectively 65+) years on average every year and would help to reduce healthcare costs by about €660 million on average per year, which represents 0.35% of the current annual healthcare spending in France. Such a reduction in RFs (net of the natural decreasing trend in mortality) would contribute to achieving about half of the 2030 NCD premature mortality target in France. Conclusions The achievement of the RF targets would lead France to save life years and life years in good health in both working-age and retired people and would modestly reduce healthcare expenditures. To achieve RFs targets and to curb the growing burden of NCDs, France has to strengthen existing and implement new policy interventions.

Objective Explore the factors that could explain the differences of fatality rates among indigenous groups with COVID-19 diagnosis compared to the rest of the population in Mexico. Study design We analyzed the public data of COVID-19 surveillance, of the Mexican Ministry of Health, to estimate COVID-19 fatality rates by ethnicity. Methods We explored associated factors using Cox proportional hazards models stratified by outpatient and hospital management at diagnosis; analysis was conducted in three scenarios: national level, states with 89% of indigenous population, and South Pacific region. Results 412,017 COVID-19 cases were included, with 1.1% of indigenous population. Crude fatality rate per 1,000 person-weeks was 64.8% higher among indigenous than in non-indigenous (29.97 vs. 18.18, respectively), and it increased more than twice within outpatients (5.99 vs. 2.64). Cox analysis revealed that indigenous with outpatient management had higher fatality rate compared to non-indigenous outpatients; at national level (HR 1.63 95% CI 1.34-1.98), within the subgroup of 13 states (HR 1.66 95% CI 1.33-2.07), and South Pacific region (HR 2.35 95% CI 1.49-3.69). Factors associated with higher fatality rates among non-indigenous and indigenous outpatients were age, sex and comorbidities. Conclusions COVID-19 fatality is higher among indigenous populations, particularly within cases managed as outpatients., Graphical abstract Image 1

Objectives Identification of racial differences in characteristics and comorbidities in patients hospitalized for COVID-19 and the impact on outcomes. Study design Retrospective observational study. Methods Data for all patients admitted to seven community hospitals in Michigan, United States with polymerase chain reaction confirmed diagnosis of COVID-19 from March 10 to April 15, 2020 was analyzed. The primary outcomes of racial disparity in inpatient mortality and intubation were analyzed using descriptive statistics and multivariate regression models. Results The study included 336 black and 408 white patients. Black patients were younger (62.9 +/- 15.0 years vs 71.8 +/- 16.4, P65, 39.2%) and younger white patients (age, Highlights • This is an observational retrospective study of 799 patients diagnosed with COVID-19 and admitted to seven Trinity Health System hospitals in Michigan, United States. • Black patients had a disproportionately higher rate of COVID-19 hospitalizations. They were younger and presented later. The incidences of diabetes and obesity were different in black patients when compared to white patients and may be the key factors leading to disproportionate hospitalizations. • Overall, we found that although black patients have disproportionately higher hospitalizations, they do not suffer worse outcomes when compared to white patients if provided similar care.

Objectives The aim of this study was to distinguish independent and shared effects of material/structural factors and psychosocial resources in explaining educational inequalities in self-rated health (SRH) by using structural equation modelling. Study design Cross-sectional survey. Methods Data were derived from a questionnaire sent to a random sample of the population in five counties in Sweden in 2008. The study population (aged 25–75 years) included 15,099 men and 17,883 women. Exploratory structural equation modelling was used to analyse the pathways from educational level to SRH. Results The pathway including both material/structural factors (e.g. financial buffer and unemployment) and psychosocial resources (e.g. sense of coherence and social participation) explained about 40% of educational differences in SRH for both men and women. The pathways including only the independent effects of psychosocial resources (14% in men and 20% in women) or material/structural factors (9% and 18%, respectively) explained substantial but smaller proportions of the differences. Conclusions The major pathway explaining educational inequalities in SRH included both material/structural factors and psychosocial resources. Therefore, to reduce educational inequalities in SRH, interventions need to address both material/structural conditions and psychosocial resources across educational groups. Funding agencies: This work was supported by grants from the Centre for Clinical Research Sörmland, Uppsala University and Sörmland County Council, Sweden. The ‘Life and Health’ study was funded by the County Councils of Västmanland, Sörmland, Uppsala, Värmland and Örebro.

Background There is emerging evidence about characteristics that may increase the risk of Covid-19 mortality, but they are highly correlated. Methods An ecological analysis was used to estimate associations between these variables and age-standardised Covid-19 mortality rates at the local authority level. Results Ethnicity, population density and overweight/obesity were all found to have strong independent associations with Covid-19 mortality, at the local authority level. Discussion This analysis provides some preliminary evidence about which variables are independently associated with Covid-19 mortality and suggests that others (deprivation and pollution) are not directly linked. It highlights the importance of multivariate analyses to understand the factors that increase vulnerability to Covid-19., Highlights • A multivariate ecological analysis of Covid-19 mortality by local authority was conducted. • Non-white ethnicity was associated with increased Covid-19 mortality. • Higher population density was associated with increased Covid-19 mortality. • Overweight/obesity was associated with increased Covid-19 mortality. • There was no evidence for an independent effect of pollution.

Objective The objective of the study is to identify the barriers to UK Black, Asian and Minority Ethnic (BAME) women attending breast screening and subsequently, support the growing evidence base providing solutions to the public health problem of ethnic variation within screening attendance. Study design A systematic review and thematic analysis of UK-based, qualitative studies concerning BAME women. Methods The methodology of this review is based on Cochrane guidelines. A search strategy was applied to Embase, PubMed and Medline. Predefined inclusion and exclusion criteria yielded 8 final articles which were appraised and thematically analysed. Results The main findings of the review revealed three overarching themes: knowledge-related, access-related and cultural-related factors. The emphasis of the importance of knowledge was highlighted by all studies identifying a lack of knowledge as a key barrier to screening attendance. Conclusions BAME women have disproportionally lower breast screening attendance and a lack of knowledge is an essential barrier to overcome when addressing this health inequality.

Objectives Socioeconomic inequalities may affect COVID-19 incidence. The goal of the research was to explore the association between deprivation of socioeconomic status (SES) and spatial patterns of COVID-19 incidence in Chennai megacity for unfolding the disease epidemiology. Study design Ecological (or contextual) study for electoral wards (sub-cities) of Chennai megacity. Methods Using data of confirmed COVID-19 cases from May 15, 2020, to May 21, 2020, for 155 electoral wards obtained from the official website of the Chennai municipal corporation, we examined the incidence of COVID-19 diseases using two count regression models namely, Poisson Regression (PR) and Negative Binomial Regression (NBR). As explanatory factors, we considered area-deprivation that represented the deprivation of socioeconomic status (SES). An index of multiple deprivations (IMD) developed to measure the area-deprivation using an advanced local statistic, Geographically Weighted Principal Component Analysis (GWPCA). Based on the availability of appropriately scaled data, five domains (i.e. poor housing condition, low asset possession, poor availability of WaSH services, lack of household amenities and services, and gender disparity) were selected as components of the IMD in this study. Results The Hot-spot analysis revealed that area-deprivation was significantly associated with higher incidences of COVID-19 in Chennai megacity. The high variations (adj. R2: 72.2%) with the lower BIC (124.34) and AIC (112.12) for the NBR compared to PR suggests that the NBR model better explains the relationship between area-deprivation and COVID-19 incidences in Chennai megacity. NBR with two-sided tests, and p, Graphical abstract Image 1, Highlights • The incidence of COVID-19 diseases was modelled using two count regression models namely, Poisson Regression and Negative binomial regression. • An index of multiple deprivation (IMD) was devised using Geographically Weighted Principal Component Analysis. • Area deprivation has both positive and inverse associations with the COVID-19 incidences in Chennai megacity. • Our results can guide COVID-19 control and prevention by considering spatial risk detection through area-deprivation.

Although US-born Hispanics experience infant mortality rates (IMRs) which are lower than the national rate, within the Hispanic population, infants of Puerto Rican origin experience higher IMRs than other Hispanics. We aimed to describe the contribution of deaths among previable live-born infants to disparity in IMRs comparing Puerto Rican infants to infants of other Hispanic origins.Retrospective, descriptive analysis.We analyzed data from the Centers for Disease Control and Prevention (CDC) WONDER online database representing linked US live births and infant deaths from 2005 to 2014. Data were stratified by race and ethnicity as well as by Puerto Rican and non-Puerto Rican Hispanic origin. Live births23 weeks of gestation were classified as previable. Ten-year IMRs were calculated as the number of deaths divided by the number of live births for each group over the entire decade.Puerto Rican IMR of 7.34 (per 1000 live births) was higher than the US rate of 6.34 as well as the non-Puerto Rican Hispanic IMR of 5.15. Approximately 22% of US deaths were attributable to previable live births compared with 27% among Puerto Ricans and 20% among non-Puerto Rican Hispanics. The contribution to IMR of previable births among Puerto Ricans measuring 1.96 per 1000 total live births was 42% higher than the US rate of 1.38 and 90% higher than the non-Puerto Rican Hispanic rate of 1.03.Further research is needed to develop interventions to reduce disparity in previable birth rates, particularly among infants of Puerto Rican origin.

Objectives: Pancreatic cancer has a lower morbidity yet higher case fatality rates (CFRs) compared with other gastrointestinal cancers. The effects of socio-economic components on pancreatic cancer rates have been acknowledged; however, the effects of the Human Development Index (HDI) inequality are not. In this study, we aimed to determine the contribution of important socio-economic components on pancreatic cancer rates using a decomposition approach. Study design: Global ecological study. Methods: Incidence and mortality rates of pancreatic cancer were obtained for 172 countries from GLOBOCAN and the United Nations Development Program. The World Bank database was also used to obtain the HDI and its gradient for 169 countries. Inequality in pancreatic cancer age-specific incidence and mortality rates was calculated according to the HDI using the concentration index (CI). We decomposed the CI to determine main contributors of the inequality. Results: The CI for incidence and mortality of pancreatic cancer in both genders according to the HDI was 0.26 (95 confidence interval: 0.21-0.30) and 0.25 (95 confidence interval: 0.21-0.30), respectively, which indicated more concentrated inequality in advantaged countries. About 80 of the inequality sources were predicted by socio-economic component in both rates of pancreatic cancer. The main contributors to inequality were the mean years of schooling, life expectancy at birth, expected years of schooling, and urbanization. Conclusion: Global inequalities exist in pancreatic cancer incidence and mortality rates according to the HDI; in addition, inequality was more concentrated in countries with higher score of HDI. (c) 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Objectives To investigate the relationship between socio-economic circumstances and cancer incidence in Scotland in recent years. Study design Population-based study using cancer registry data. Methods Data on incident cases of colorectal, lung, female breast, and prostate cancer diagnosed between 2001 and 2012 were obtained from a population-based cancer registry covering a population of approximately 2.5 million people in the West of Scotland. Socio-economic circumstances were assessed based on postcode of residence at diagnosis, using the Scottish Index of Multiple Deprivation (SIMD). For each cancer, crude and age-standardised incidence rates were calculated by quintile of SIMD score, and the number of excess cases associated with socio-economic deprivation was estimated. Results 93,866 cases met inclusion criteria, comprising 21,114 colorectal, 31,761 lung, 23,757 female breast, and 15,314 prostate cancers. Between 2001 and 2006, there was no consistent association between socio-economic circumstances and colorectal cancer incidence, but 2006–2012 saw an emerging deprivation gradient in both sexes. The incidence rate ratio (IRR) for colorectal cancer between most deprived and least deprived increased from 1.03 (95% confidence interval [CI] 0.91–1.16) to 1.24 (95% CI 1.11–1.39) during the study period. The incidence of lung cancer showed the strongest relationship with socio-economic circumstances, with inequalities widening across the study period among women from IRR 2.66 (95% CI 2.33–3.05) to 2.91 (95% CI 2.54–3.33) in 2001–03 and 2010–12, respectively. Breast and prostate cancer showed an inverse relationship with socio-economic circumstances, with lower incidence among people living in more deprived areas. Conclusion Significant socio-economic inequalities remain in cancer incidence in the West of Scotland, and in some cases are increasing. In particular, this study has identified an emerging, previously unreported, socio-economic gradient in colorectal cancer incidence among women as well as men. Actions to prevent, mitigate, and undo health inequalities should be a public health priority., Highlights • There is an emerging social gradient in colorectal cancer incidence in both sexes. • Profound socio-economic inequalities in lung cancer persist. • Breast and prostate cancer remain more common among less deprived populations.

Objectives To measure the ‘best possible health for all’, incorporating sustainability, and to establish the magnitude of global health inequity. Study design Observational, retrospective. Methods We identified countries with three criteria: (1) a healthy population—life expectancy above world average; (2) living conditions feasible to replicate worldwide—per-capita gross domestic product (GDP-pc) below the world average; and (3) sustainability—per-capita carbon dioxide emissions lower than the planetary pollution boundary. Using these healthy, feasible, and sustainable (HFS) countries as the gold standard, we estimated the burden of global health inequity (BGHiE) in terms of excess deaths, analyzing time-trends (1950–2012) by age, sex, and geographic location. Finally, we defined a global income ‘equity zone’ and quantified the economic gap needed to achieve global sustainable health equity. Results A total of 14 countries worldwide met the HFS criteria. Since 1970, there has been a BGHiE of ∼17 million avoidable deaths per year (∼40% of all deaths), with 36 life-years-lost per excess death. Young children and women bore a higher BGHiE, and, in recent years, the highest proportion of avoidable deaths occurred in Africa, India, and the Russian Federation. By 2012, the most efficient HFS countries had a GDP-pc/year of USD$2,165, which we proposed as the lower equity zone threshold. The estimated USD$2.58 trillion economic gap represents 3.6% of the world's GDP—twenty times larger than current total global foreign aid. Conclusions Sustainable health equity metrics provide a benchmark tool to guide efforts toward transforming overall living conditions, as a means to achieve the ‘best possible health for all.’