The globalization of the nursing workforce: implications for education.

More than the sum of its parts

Women hold up half the sky

BackgroundInterest in applying a complex systems approach to understanding socioeconomic inequalities in health is growing, but an overview of existing research on this topic is lacking. In this systematic scoping review, we summarize the current state of the literature, identify shared drivers of multiple health and health behavior outcomes, and highlight areas ripe for future research.MethodsSCOPUS, Web of Science, and PubMed databases were searched in April 2023 for peer-reviewed, English-language studies in high-income OECD countries containing a conceptual systems model or simulation model of socioeconomic inequalities in health or health behavior in the adult general population. Two independent reviewers screened abstracts and full texts. Data on study aim, type of model, all model elements, and all relationships were extracted. Model elements were categorized based on the Commission on Social Determinants of Health framework, and relationships between grouped elements were visualized in a summary conceptual systems map.ResultsA total of 42 publications were included; 18 only contained a simulation model, 20 only contained a conceptual model, and 4 contained both types of models. General health outcomes (e.g., health status, well-being) were modeled more often than specific outcomes like obesity. Dietary behavior and physical activity were by far the most commonly modeled health behaviors. Intermediary determinants of health (e.g., material circumstances, social cohesion) were included in nearly all models, whereas structural determinants (e.g., policies, societal values) were included in about a third of models. Using the summary conceptual systems map, we identified 15 shared drivers of socioeconomic inequalities in multiple health and health behavior outcomes.ConclusionsThe interconnectedness of socioeconomic position, multiple health and health behavior outcomes, and determinants of socioeconomic inequalities in health is clear from this review. Factors central to the complex system as it is currently understood in the literature (e.g., financial strain) may be both efficient and effective policy levers, and factors less well represented in the literature (e.g., sleep, structural determinants) may warrant more research. Our systematic, comprehensive synthesis of the literature may serve as a basis for, among other things, a complex systems framework for socioeconomic inequalities in health.

This article examines the measurement of the success of the redistributive function describing strategies used for measuring the inequality of the outcomes of a health care system in terms of the use of care. The discussion of inequalities can be divided into health, health care, and health care payments. This article is concerned with the association between income, on the one hand, and health and health care, on the other. It further discusses the potential underlying causal pathways of this association. It explains in detail that a significant association or causal effect is a necessary but not sufficient condition for the presence of inequalities. Finally, it reviews the economics approaches of measuring socioeconomic inequalities in health and health care that are applied in the empirical literature. The measurement tools developed and used by health economists to analyze socioeconomic inequalities in health and health care are also discussed.

BackgroundSocioeconomic inequalities in adolescent health predict future inequalities in adult health. Subjective measures of socioeconomic status (SES) may contribute with an increased understanding of these inequalities. The aim of this study was to investigate socioeconomic health inequalities using both a subjective and an objective measure of SES among Swedish adolescents.MethodCross-sectional HBSC-data from 2002 to 2014 was used with a total sample of 23,088 adolescents aged 11–15 years. Three measures of self-rated health (dependent variables) were assessed: multiple health complaints, life satisfaction and health perception. SES was measured objectively by the Family Affluence Scale (FAS) and subjectively by “perceived family wealth” (independent variables). The trend for health inequalities was investigated descriptively with independent t-tests and the relationship between independent and dependent variables was investigated with multiple logistic regression analysis. Gender, age and survey year was considered as possible confounders.ResultsSubjective SES was more strongly related to health outcomes than the objective measure (FAS). Also, the relation between FAS and health was weakened and even reversed (for multiple health complaints) when subjective SES was tested simultaneously in regression models (FAS OR: 1.03, CI: 1.00;1.06 and subjective SES OR: 0.66, CI: 0.63;0.68).ConclusionsThe level of socioeconomic inequalities in adolescent health varied depending on which measure that was used to define SES. When focusing on adolescents, the subjective appraisals of SES is important to consider because they seem to provide a stronger tool for identifying inequalities in health for this group. This finding is important for policy makers to consider given the persistence of health inequalities in Sweden and other high-income countries.

Purpose This study aims to estimate the degree and nature of socioeconomic-related inequalities in sexual and reproductive health in Ghana and further assesses causes of these inequalities using decomposition technique. The authors assess the contribution of personal characteristics of the woman including access to health information and health seeking behaviours, household and locational characteristics to inequalities in sexual and reproductive health in Ghana. The study uses data from the three rounds of the Ghana Demographic and Health Survey conducted in 2003, 2008 and 2014. Design/methodology/approach Two indicators – use of modern contraceptives and intention to use modern contraceptives – are used to measure sexual and reproductive health of sexually active women. A wealth index, based on household ownership of assets, consumer goods and living conditions, is used as a measure of socioeconomic status. The paper estimates a concentration index to the relationship between cumulative health and socioeconomic rank. Paper procedures to apply decomposition techniques to determine the causes of socioeconomic inequalities in health based on a linear health regression model. Findings The study finds evidence of varying degrees of socioeconomic-related inequalities in sexual and reproductive health indicators. Specifically, the study finds that whilst use of modern contraceptives was concentrated among women in households with high socioeconomic status in 2003 and 2008, modern contraceptive use was prevalent among women in low socioeconomic status households in 2014. Equally, the study finds significant pro-poor inequalities in the intentions to use modern contraceptives in 2003 and 2014. The degree of socioeconomic inequalities in the intentions to use modern contraceptives increased between 2003 and 2014. Originality/value There is the lack of evidence on the degree, nature and causes of socioeconomic-related inequalities, which in tend impedes the design and implementation of sexual and reproductive health policies targeted at vulnerable and under-served populations. In addition, there is the need to study inequalities in health over time to monitor progress of health delivery systems towards equitable and universal coverage and understand the evolution of the determinants.

Mental Health Care Reforms in Latin America: Child and Adolescent Mental Health Services in Mexico

STUDY OBJECTIVE: To examine the contribution of childhood health to the explanation of socioeconomic inequalities in health in early adult life. DESIGN: Retrospective data were used, which were obtained from...

An econometric analysis of three health economic issues in China

Social Disparities In Health: An Anglo-European Perspective

One of the challenges in international health care policy is the reduction of health inequalities. We study the case of a recent health care reform in Ecuador, based on a revised model of public provision and financing of comprehensive care. The policy challenged not only the health care system but also key determinants of health, seeking to grant access and reduce persistent inequalities in utilization of health care services. This study evaluates the progress made on the socioeconomic health inequalities before and after reforms, between 2006 and 2014. The Living Standards Measurement Survey 2006 and 2014 are used to examine trends in inequality of two health dimensions: health status and health care utilization in Ecuador. The analysis includes the estimation and decomposition of the concentration index of health care utilization variables to understand which the most important contributors to inequality are, and how they change during the period analyzed. Health inequality reduced after the public health system reform in Ecuador. The utilization of curative visits shows a pro-rich bias, which significantly reduced over the period of analysis. The use of a public facility for a doctor visit also shows a moderate reduction in socioeconomic inequality; although concentrated among the poor, the findings confirm an increase in the utilization of public health facilities by all socioeconomic groups. The decomposition analysis concludes that the most relevant determinants of the inequality in health care utilization variables are income, family size and education. Moreover, the contribution of income decreased dramatically in the utilization of curative visits after the reforms. This is the first study that assesses the inequality implications of recent policies targeted at guaranteeing the right to health, equity and social protection of the Ecuadorian population. We provide evidence of a significant reduction of health care inequality, following a well-rounded set of public interventions and investments to attack health and inequality determinants. Yet policies aimed at improving the distribution of education and income are necessary to further reduce health inequalities.

This toolkit brings together those with first-hand experience of designing, delivering, evaluating and participating in a Longitudinal Integrated Clerkship (LIC) within a UK Higher Education Institution and those working closely on programmes focussing on Health Education England (HEE)'s and NHS England's national priorities. In August 2022, a collaborative workshop was held for students and tutors participating in a London-based LIC in 2021–2022, faculty with prior experience in running LICs, and HEE representatives. The aim of the workshop was to co-produce a toolkit to guide undergraduate institutions, who may wish to introduce an LIC within their medical school curriculum that aligns to these national priorities. Although this toolkit primarily focuses on a UK audience, we anticipate that other health systems facing a need for similar educational reform may also find use for this toolkit. The NHS Long Term Plan,1 the HEE Future Doctor Report2 and The Enhance Programme3 have outlined key national priorities for the future of health and social care (Figure 1), including how we can train our workforce to deliver these aims. These priorities include embedding generalist skills in early career doctors, so they can better provide person-centred care in the context of complex multi-morbidity, while considering the impact of deep-rooted health inequity and social determinants of health. They can better provide person-centred care in the context of complex multi-morbidity, while considering the impact of deep-rooted health inequity and social determinants of health. This toolkit has been written for medical schools but may also be beneficial for other undergraduate and postgraduate health educators, who are considering setting up longitudinal educational programmes to meet their local and national health and workforce priorities. This document may also enable health and social care providers and third sector organisations, who are partnering up to support educational programmes, to better understand how longitudinal courses may benefit their health priorities. Currently, undergraduate and postgraduate training is fragmented in its provision of educational supervision and patient care. The lack of continuity of relationships with patients, supervisors and peers, can make it harder to effectively address the increasing complexity of multi-morbidity at an individual and population level. Because this fragmentation continues in the educational experience of postgraduates, it has a domino effect on undergraduates placed within those fragmented clinical settings—it becomes easy to see how this cyclical lack of continuity could perpetuate workforce burnout and poor retention.4, 5 This cyclical lack of continuity could perpetuate workforce burnout and poor retention. There is also a need for the future workforce to better understand the effects of health inequity, both at an individual and community level. It is well-recognised that certain groups of patients have poorer health outcomes than others.6 However, a deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time. A deeper understanding of local population health priorities is difficult to achieve within our current, fragmented teaching and training programmes and instead requires being embedded into a community over a period of time. LICs (Figure 2) are an ideal educational model to address the issues of fragmentation of the student experience, and the need for students to have a better grasp of local population health. LICs place a greater emphasis on continuity for students and patients,7 greater responsibility for patient care, with more rewarding outcomes for students/trainees, and their patients and communities.8 Furthermore, many of the LICs in the United Kingdom are based in primary care,9 which provides a fertile ground for students to develop meaningful longitudinal patient relationships, and allows students to be embedded within a local community. The discussions within our workshop were informed by the existing literature on LICs which provides an international lens on how to develop LICs, what benefit they can provide, and their pitfalls.10-12 This toolkit builds on this literature with our lived experience within a UK health care and higher education environment, and aims to re-frame the importance of LICs as an educational model that better aligns to new integrated care priorities in the United Kingdom. For consistency in this toolkit, we use the term 'Longitudinal Integrated Clerkship' as it is most commonly known within the literature. However, there is debate about whether this term is relevant to the UK context and whether a more general term such as 'longitudinal placement' would better capture what currently exists and is achievable within the UK landscape.13 Design & Development of an LIC Evaluation and Research of an LIC To ensure an LIC that is sustainable, it is important to identify and consult with key stakeholders from the outset. Consideration of your institution's culture will also be important to ensure the success of an LIC, particularly with regard to the assessment process and how the LIC will be perceived within the hidden curriculum.14 A co-created mission statement for your LIC can help to ensure that all stakeholders are on the same trajectory. The overarching aim of your LIC is likely to depend on your local context. For example, in your local area, a main driver may be the need to address workforce recruitment and retention. Alternatively, addressing health inequity within underserved communities in the local area may be your main driver. When considering learning outcomes for your LIC, these can be considered under the headings of educational and health outcomes to ensure mutual benefit for those served by health systems and educational institutions. Similarly to a programme's mission statement, LIC outcomes are best defined with input from educational, health and community stakeholders. Investment at this stage from all stakeholders will be important as there may be conflicting priorities that will need to be worked through. Educational outcomes should align with the broader priorities and values of your institution, as well as national priorities, such as the Medical Licencing Assessment and those from HEE. Creation of a curriculum blueprint will be useful at this stage. Health outcomes would consider NHS policy documents (such as the Five Year Forward view), as well as local policies relevant to health context. The success of an LIC will depend on how the principles of the longitudinal model are adapted to fit with existing educational and service delivery models in your institution and local area. While there are existing frameworks of what an LIC might look like, these are based on the international literature, and local context should be considered for the successful delivery of an LIC. For example, from current literature, an LIC should be long enough for students to establish meaningful relationships, and Worley et al. suggest that an appropriate length of time should be from 6 to 12 months.15 We would suggest the length of time should be conducive to students having repeated encounters with the same patients, educators and peers to maximise relationships. There is no formal consensus on how 'repeated encounters' should be defined but the aim is for students to experience patient care over time in different settings with different health care practitioners. Facilitating sustained patient–student partnerships across the course of an LIC lies at the heart of this educational model. It is through these partnerships that mutual benefit can be garnered. The aim is for students to experience patient care over time in different settings with different health care practitioners. Table 1 outlines some important factors to consider during the design of your LIC. Consider the overarching outcomes of your LIC. Use this to decide what stage of medical school it is best delivered in. Early years E.g., Key LIC outcome = deeper understanding of the health inequity and preventative care for your population. You may wish to introduce these foundational concepts via an LIC at an early stage of clinical training, when there may be more curriculum space to dedicate to these concepts, and students are establishing their values around health equity. Later years E.g., Key LIC outcome = enhancing preparation for practice in line with national priorities In this case, the LIC may be better suited for those who are about to graduate New medical schools or those undergoing curriculum review may wish to implement an LIC for an entire cohort Medical schools with an established curriculum could pilot an LIC with a small group of students, with a phased roll-out in future years, allowing for improvements in your model if you fully roll out. Or there are many LICs that are small cohort student-selected programmes. If do you choose to run a pilot LIC, consider how you will advertise and recruit prospective students. The format of an LIC can vary internationally. Within the United Kingdom, LIC structure can range from a full time LIC to 1 day a week. Also consider the balance between Consider if your original LIC outcomes can be achieved in your chosen format and whether you can evaluate and assess these outcomes (see below for evaluation and assessment) within the constraints of your given structure. LICs can take place in a variety of settings with one setting usually acting as the main base for student learning Adequate supervision ensures clinical and educational safety for students and the patients they care for. This is an important consideration across all clinical settings. Also consider how undergraduates and postgraduates, and students from different health professions within the same learning environment can be brought together to enhance learning for both groups, e.g., through group supervision, tutorials or patient care. Assessment should be considered from the outset of LIC planning to ensure there is alignment with learning outcomes, as well as medical school and national assessments. Consider How and when these assessments will be reviewed should also be factored into the timetable for students and supervisors. LICs are likely to require a shift in mindset and logistics from the existing culture of learning at your institution, not only from the perspective of students, but also placement supervisors and central faculty. Adequate support for all relevant groups will help to identify early teething problems and ensure smoother transitions during implementation (see Table 2). With any educational intervention, particularly one that is new to an institution, there will be multiple reasons to collect data. For future iterations of the course, it is important to establish what worked well and what could be improved. Broadly, this type of data would be regarded as evaluation. Additionally, different stakeholder groups will have particular outcomes they are interested in, and these data might fall under the category of research. When deciding what data to collect, it is worth looking back at the primary LIC objectives, and planning from the outset how evaluation will be conducted and data collected, alongside the design and development of the overall LIC. This will help make early decisions regarding why the data are being collected, when and from whom, and ensures timely ethics and funding applications. Reviewing the existing literature at this stage will help shape both the LIC and your evaluation and research questions. Kirkpatrick's hierarchy can be a useful heuristic when considering what type of data to collect—for example, collecting qualitative data from different stakeholders on their perceptions and experience of the LIC. You may also choose to collect specific quantitative student or patient outcome data. When deciding who to collect data from, consider the whole range of stakeholders. For example, if a key aim of your LIC is to improve patient access to health care in your local area, it would be important to hear from patients themselves on their experiences. When deciding who to collect data from, consider the whole range of stakeholders. While data are often collected to look at what additional value an intervention provided, it is equally important to ensure no harm has inadvertently been inflicted on stakeholder groups in the process. This is also something to consider when deciding what parameters should be evaluated. The timeframe of data collection is also an important consideration. In keeping with a longitudinal process, some research questions may be better answered by looking at different points across the course, to capture how data change over time. When writing up and presenting data, consider involving all stakeholders in this process. It would be worth looking at presenting and publishing avenues that reach a broad audience—for example, health care arenas, patient and community facing publications, and medical educators. The future health workforce will require new complex skills to manage increasingly complex population needs. Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care landscape. An LIC places continuity and integration at its core and is an ideal educational model to embed these key skills within the curriculum. This, in turn, could help prepare our future workforce in providing person-centred integrated care that meets population need. This toolkit can be used to guide those considering educational reform in line with population need. Finally, it is the collaborative partnerships with students, policy makers, educators, and health and social care providers that will help ensure alignment between population priorities, workforce needs and medical education. Current undergraduate training needs to consider how it is preparing future graduates to develop the skills needed to adapt to the rapidly changing health care landscape. We would like to thank Mohammed-Hareef Asunramu, one of our LIC students, and Monika Gupta from Health Education England's London Enhancing Generalist Skills Team for their contribution to this work. The authors have no conflict of interest to disclose. No data have been used in this submission that would require formal ethical approval. All participants of our workshop have been listed as authors and have contributed and consented to the work.

The GLOBE study is a prospective cohort study specifically aimed at the explanation of socio-economic inequalities in health in the Netherlands. The returns of the study are reviewed after ten years of follow-up, and the studies' contribution to the development of policy measures to reduce inequalities in health in the Netherlands are described. The study started in 1991 with a baseline postal survey (response rate 70.1% or n=18973, 15-74 years of age). Two sub-samples of respondents to this survey were subsequently interviewed in 1991 (response 79.4% and 72.3%, n=5667). Baseline data collection included measures of socio-economic position, health and possible explanatory factors. Follow-up involved repeated postal surveys and interviews, and routinely collected data on hospital admissions, cancer incidence and mortality by cause of death. Compared with higher socio-economic groups, lower socio-economic groups showed higher prevalence rates of poor self-reported health (perceived general health, health complaints, chronic conditions, disabilities), higher incidence rates of specific conditions (myocardial infarction) and higher rates of all-cause mortality. The higher prevalence of adverse material circumstances, unhealthy behaviour, adverse psychosocial characteristics, and adverse childhood circumstances in the lower socio-economic groups was important in the explanation of socio-economic inequalities in health. Socio-economic differences in health care utilization did not contribute to the explanation. The GLOBE study contributed significantly to the understanding of the explanation of socio-economic inequalities in health in the Netherlands. Study results were a main source of information in the development of policy measures aimed at the reduction of socio-economic inequalities in health in the Netherlands.

BackgroundIn order to support the case for inter-sectoral policies to tackle health inequalities, the authors explored the economic costs of socioeconomic inequalities in health in the European Union (EU).MethodsUsing recent...

America, all things not being equal