Contribution of primary care expansion to Sustainable Development Goal 3 for health: a microsimulation of the 15 largest cities in Brazil

ObjectivesAs middle-income countries strive to achieve the Sustainable Development Goals (SDGs), it remains unclear to what degree expanding primary care coverage can help achieve those goals and reduce within-country inequalities in mortality. Our objective was to estimate the potential impact of primary care expansion on cause-specific mortality in the 15 largest Brazilian cities.DesignMicrosimulation model.Setting15 largest cities by population size in Brazil.ParticipantsSimulated populations.InterventionsWe performed survival analysis to estimate HRs of death by cause and by demographic group, from a national administrative database linked to the Estratégia de Saúde da Família (Family Health Strategy, FHS) electronic health and death records among 1.2 million residents of Rio de Janeiro (2010–2016). We incorporated the HRs into a microsimulation to estimate the impact of changing primary care coverage in the 15 largest cities by population size in Brazil.Primary and secondary outcome measuresCrude and age-standardised mortality by cause, infant mortality and under-5 mortality.ResultsIncreased FHS coverage would be expected to reduce inequalities in mortality among cities (from 2.8 to 2.4 deaths per 1000 between the highest-mortality and lowest-mortality city, given a 40 percentage point increase in coverage), between welfare recipients and non-recipients (from 1.3 to 1.0 deaths per 1,000), and among race/ethnic groups (between Black and White Brazilians from 1.0 to 0.8 deaths per 1,000). Even a 40 percentage point increase in coverage, however, would be insufficient to reach SDG targets alone, as it would be expected to reduce premature mortality from non-communicable diseases by 20% (vs the target of 33%), and communicable diseases by 15% (vs 100%).ConclusionsFHS primary care coverage may be critically beneficial to reducing within-country health inequalities, but reaching SDG targets will likely require coordination between primary care and other sectors.

Interrupted time series analyses to assess the impact of alcohol control policy on socioeconomic inequalities in mortality in Lithuania: a study protocol

IntroductionAlcohol use is a major risk factor for mortality. Previous studies suggest that the alcohol-attributable mortality burden is higher in lower socioeconomic strata. This project will test the hypothesis that the 2017 increase of alcohol excise taxes linked to lower all-cause mortality rates in previous analyses will reduce socioeconomic mortality inequalities.Methods and analysisData on all causes of deaths will be obtained from Statistics Lithuania. Record linkage will be implemented using personal identifiers combining data from (1) the 2011 whole-population census, (2) death records between 1 March 2011 (census date) and 31 December 2019, and (3) emigration records, for individuals aged 40–70 years. The analyses will be performed separately for all-cause and for alcohol-attributable deaths. Monthly age-standardised mortality rates will be calculated by sex, education and three measures of socioeconomic status (SES). Inequalities in mortality will be assessed using absolute and relative indicators between low and high SES groups. We will perform interrupted time series analyses, and test the impact of the 2017 rise in alcohol excise taxation using generalised additive mixed models. In these models, we will control for secular trends for economic development.Ethics and disseminationThis work is part of project grant 1R01AA028224-01 by the National Institute on Alcohol Abuse and Alcoholism. It has been granted research ethics approval 050/2020 by Centre for Addiction and Mental Health Research Ethics Board on 17 April 2020, renewed on 30 March 2021. The time series of mortality inequalities as well as the statistical code will be made publicly available, allowing other researchers to adapt the proposed method to other jurisdictions.

Geographical inequalities in the evolution of the COVID-19 pandemic: An ecological study of inequalities in mortality in the first wave and the effects of the first national lockdown in England

Objectives This is the first study to examine how geographical inequalities in COVID–19 mortality rates evolved in England, and whether the first national lockdown modified them. This analysis provides important lessons to inform public health planning to reduce inequalities in any future pandemics. Design Longitudinal ecological study Setting 307 Lower-tier local authorities in England Primary outcome measure Age-standardised COVID–19 mortality rates by local authority and decile of index of multiple deprivation. Results Local authorities that started recording COVID–19 deaths earlier tended to be more deprived, and more deprived authorities saw faster increases in their death rates. By 2020–04–06 (week 15, the time the March 23rd lockdown could have begun affecting deaths) the cumulative death rate in local authorities in the two most deprived deciles of IMD was 54% higher than the rate in the two least deprived deciles. By 2020–07–04 (week 27), this gap had narrowed to 29%. Thus, inequalities in mortality rates by decile of deprivation persisted throughout the first wave, but reduced somewhat during the lockdown. Conclusions This study found significant differences in the dynamics of COVID–19 mortality at the local authority level, resulting in inequalities in cumulative mortality rates during the first wave of the pandemic. The first lockdown in England was fairly strict – and the study found that it particularly benefited those living in the more deprived local authorities. Care should be taken to implement lockdowns early enough, in the right places – and at a sufficiently strict level – to maximally benefit all communities, and reduce inequalities.

Building back fairer in Greater Manchester and the country

A summary of our analyses in Greater Manchester (GM), and the northwest (NW) region, might be: the NW is like England as a whole only more so. The life expectancy drop in England in 2020 was 1.2 years in men and 0.9 years in women—shocking, but not as high as in the NW. COVID-19 mortality rates were high in England; 25% higher in the NW. Inequalities in mortality are high in England; bigger in the NW. The title, Build Back Fairer , is a deliberate echo of the Build Back Better mantra, showing that the levels of social, environmental and economic inequality in society are damaging health and well-being. As the UK emerges from the pandemic, it would be a tragic mistake to re-establish the status quo that existed pre-pandemic—a status quo marked in England, over the decade from 2010, by a stagnation of health improvement that was more marked than in any rich country other than Iceland and the USA; by widening health inequalities; and by a fall in life expectancy in the most deprived 10% of areas outside London. That stagnation, those social and regional inequalities, and deterioration in health for the most deprived people are markers of a society that is not meeting the needs of its members.

The potential impact of co-residence structures on socio-demographic inequalities in COVID-19 mortality

During the COVID-19 pandemic, confinement measures were adopted across the world to limit the spread of the virus. In France, these measures were applied between March 17 and May 10. Using high-quality population census data and focusing on co-residence structures on French territory, this article analyzes how co-residence patterns unevenly put different socio-demographic groups at risk of being infected and dying from COVID-19. The research ambition is to quantify the possible impact of co-residence structures heterogeneity on socio-economic inequalities in mortality stemming from within-household transmission of the virus. Using a simulation approach, the article highlights the existence of theoretical pronounced inequalities of vulnerability to COVID-19 related to cohabitation structures as well as a reversal of the social gradient of vulnerability when the age of the infected person increases. Among young age categories, infection is simulated to lead to more deaths in the less educated or foreign-born populations. Among the older ones, the inverse holds with infections having a greater potential to provoke deaths through the transmission of the virus within households headed by a highly educated or a native-born person. Demographic patterns such as the cohabitation of multiple generations and the survival of both partners of a couple help to explain these results. Even though inter-generational co-residence and large households are more common among the lower educated and foreign born in general, the higher educated are more likely to still live with their partner at higher ages.

Changes in Mortality Inequalities in Urban and Rural Populations during 1990–2018: Lithuanian Experience

Background and Objectives: Reduction in health inequalities is a highly important task in public health policies worldwide. In Lithuania, inequalities in mortality by place of residence are among the greatest, compared to other European Union (EU) countries. However, studies on inequalities in mortality by place of residence over a long-term period have not been investigated in Lithuania. The aim of this study was to present changes in mortality inequalities in urban and rural populations during 1990–2018. Materials and Methods: Mortality rates from all causes, cardiovascular diseases, cancer, external causes, and gastrointestinal diseases in urban and rural population by sex were calculated per 100,000 populations and were standardized by age. Inequalities in mortality were assessed using rate differences and rate ratio. For the assessment of inequality trends during 1990–2018, the joinpoint regression analysis was applied. Results: Mortality between urban and rural populations varied. In rural areas, mortality lower than that in urban areas was observed only in 1990 among women, in case of mortality from cancer and gastrointestinal diseases (compared with in 2018) (p < 0.05). In 2018, mortality from all causes, cardiovascular diseases, and external causes in urban and rural areas was lower than in 1990 in both sexes. However, mortality from gastrointestinal diseases was higher (p < 0.05). In 2018, mortality from cancer among both sexes was lower only in urban areas (p < 0.05). Mortality inequalities between rural and urban areas decreased statistically significantly only among men from external causes and from all causes (respectively, on average, by 0.52% per year and, on average, by 0.21% per year). Meanwhile, mortality from cardiovascular and gastrointestinal diseases increased in both sexes, and mortality from cancer and all causes of death increased among women. The increase in the inequalities of mortality from gastrointestinal diseases was the most rapid: among men—on average, by 0.69% per year, and among women—on average, by 1.43% per year, p < 0.0001. Conclusions: During 1990–2018, the inequalities in mortality by place of residence in Lithuania statistically significantly decreased only among men, in terms of mortality from external causes and from all causes. Therefore, reduction in inequalities in mortality must be the main the health policy challenge in Lithuania.

The mediating role of epigenetic clocks underlying educational inequalities in mortality: a multi-cohort study

Educational inequalities in mortality have been observed for decades, however the underlying biological mechanisms are not well known. We assessed the mediating role of altered aging of immune cells functioning captured by DNA methylation changes in blood (known as epigenetic clocks) in educational associated all-cause mortality. Data were from eight prospective population-based cohort studies, representing 13,021 participants. We found educational inequalities in mortality were larger for men than for women, estimated by hazard differences and ratios. Epigenetic clocks explained approximately 50% of educational inequalities in mortality for men, while the proportion was small for women. Most of this mediation was explained by differential effects of unhealthy lifestyles and morbidities of the WHO risk factors for premature mortality. These results support DNA methylation-based epigenetic aging as a signature of educational inequalities in life expectancy emphasizing the need for policies to address the unequal social distribution of these WHO risk factors.

Community factors and excess mortality in first wave of the COVID-19 pandemic in England

Risk factors for increased risk of death from COVID-19 have been identified, but less is known on characteristics that make communities resilient or vulnerable to the mortality impacts of the pandemic. We applied a two-stage Bayesian spatial model to quantify inequalities in excess mortality in people aged 40 years and older at the community level during the first wave of the pandemic in England, March-May 2020 compared with 2015–2019. Here we show that communities with an increased risk of excess mortality had a high density of care homes, and/or high proportion of residents on income support, living in overcrowded homes and/or with a non-white ethnicity. We found no association between population density or air pollution and excess mortality. Effective and timely public health and healthcare measures that target the communities at greatest risk are urgently needed to avoid further widening of inequalities in mortality patterns as the pandemic progresses.