Social capital has become a popular subject in the literature on determinants of health. The concept of social capital has been used in the sociological, political science, and economic development literatures, as well as in the health inequalities literature. Analysis of its use in the health inequalities literature suggests that each theoretical tradition has conceptualized social capital differently. Health researchers have employed a wide range of social capital measures, borrowing from several theoretical traditions. Given the wide variation in these measures and an apparent lack of consistent theoretical or empirical justification for their use, conclusions about the likely role of "social capital" on population health may be overstated or even misleading. Elements of a research agenda are proposed to further elucidate the potential role of factors currently subsumed under the rubric of "social capital."
RESUMO Este artigo revisa e sintetiza evidências sobre o impacto da Estratégia Saúde da Família (ESF) a partir do marco conceitual de sistemas de saúde da Organização Mundial da Saúde, o qual agrega os conceitos de acesso, proteção financeira, qualidade dos serviços, eficiência no sistema, impacto na saúde e equidade. Os resultados sugerem que a ESF contribuiu para a melhoria em todos esses indicadores, com alguns efeitos no acesso e equidade com resultados quase chegando aos níveis observados nos países da Organização para Cooperação e Desenvolvimento Econômico. Embora ainda haja bastante espaço para melhorias, a evidência é clara de que a ESF é uma abordagem poderosa e eficaz para a organização da atenção primária à saúde no Brasil.
Trust – particularly during emergencies – is essential for effective health care delivery and health policy implementation. We use data from the 2018 Wellcome Global Monitor survey (comprising nationally-representative samples from 144 countries; n=149,014 respondents) to examine levels and correlates of trust in governments and health workers, and attitudes toward vaccines. Only one-quarter of respondents globally trust their government a lot (more common among people with less schooling, living in rural areas, financially comfortable, and at older ages); and less than half of respondents globally trust doctors and nurses a lot. People's trust in these institutions is correlated with trust in health or medical advice from them, and with more positive attitudes toward vaccines. Vaccine enthusiasm varies substantially across regions with safety concerns as the most common concern. Policymakers should understand that the public may have varying levels of trust in different institutions and actors. Although much attention is paid to crafting public health messages, it may be equally important -- especially during a pandemic -- to identify appropriate, trusted messengers to deliver those messages more effectively to different target populations.
BackgroundBrazil has made progress towards a more equitable distribution of health care, but gains may be threatened by economic instability resulting from the 2008 global financial crisis. This study measured predictors of health care utilization and changes in horizontal inequity between 2008 and 2013.MethodData were from two nationally representative surveys that measured a variety of sociodemographic, health behaviors and health care indicators. We used Poisson regression models to estimate adjusted prevalence ratios and the Horizontal Equity Index (HEI) standardized by health needs to measure inequity in the utilization of doctor and dentist visits, hospitalizations and reporting of a usual source of care (USC) for those 18 and older. To estimate the HEI, we ranked the population from the poorest to the richest using a wealth index. We also decomposed the HEI into its different components and assessed changes from 2008 to 2013.ResultsThe population proportion with doctor and dentist visits in the past year and a USC increased between 2008 and 2013, while hospitalizations declined. In 2013, pro-rich inequity in doctor visits increased significantly while the distribution of hospitalizations shifted from pro-rich in 2008 to neutral in 2013. Dentist visits were highly pro-rich and USC was slightly pro-rich; the distribution of dentist visits and USC did not change over time. Health need was a strong predictor of health care utilization regardless of the type of coverage (public or private). Education, wealth, and private health plans were associated with the pro-rich orientation of doctor and dentist visits. Private health plans contributed to the pro-rich orientation of all outcomes, while the Family Health Strategy contributed to the pro-poor orientation of all outcomes.ConclusionThe results of this study support the claim that Brazil's population continued to see absolute gains in access to care despite recent economic crises. However, gains in equity have slowed and may even decline if investments are not maintained as the country enters deeper financial and political crises.
IntroductionThis study assesses trends in horizontal equity in the utilization of healthcare services from 1998 to 2008--a period of major economic and social change in Brazil.MethodsData are from nationally representative surveys repeated in 1998, 2003, and 2008. We apply established methods for assessing horizontal inequity in healthcare access (the principle that people with the same healthcare needs should have similar access to healthcare services). Horizontal inequity is calculated as the difference between observed healthcare utilization and utilization predicted by healthcare needs. Outcomes examined include the probability of a medical, dental, or hospital visit during the past 12 months; any health service use in the past two weeks; and having a usual source of healthcare. We use monthly family income to measure differences in socioeconomic position. Healthcare needs include age, sex, self-rated health, and chronic conditions. Non-need factors include income, education, geography, health insurance, and Family Health Strategy coverage.ResultsThe probability of having at least one doctor visit in the past 12 months became substantially more equitable over time, ending with a slightly pro-rich orientation in 2008. Any hospitalization in the past 12 months was found to be pro-poor in all periods but became slightly less so in 2008. Dental visits showed the largest absolute decrease in horizontal inequity, although they were still the most inequitably (pro-rich) distributed outcome in 2008. Service use in the past two weeks showed decreased inequity in 2003 but exhibited no significant change between 2003 and 2008. Having a usual source of care became less pro-rich over time and was nearly income-neutral by 2008. Factors associated with greater inequities include income, having a private health plan, and geographic location. Factors associated with greater equity included health needs, schooling, and enrolment in the Family Health Strategy.ConclusionsHealthcare utilization in Brazil appears to have become increasingly equitable over the past 10 years. Although this does not imply that equity in health outcomes has improved correspondingly, it does suggest that government policies aimed at increasing access, especially to primary care, have helped to make healthcare utilization in Brazil fairer over time.
A universal question in network science entails learning about the topology of interaction from collective dynamics. Here, we address this question by examining diffusion of laws across US states. We propose two complementary techniques to unravel determinants of this diffusion process: information-theoretic union transfer entropy and event synchronization. In order to systematically investigate their performance on law activity data, we establish a new stochastic model to generate synthetic law activity data based on plausible networks of interactions. Through extensive parametric studies, we demonstrate the ability of these methods to reconstruct networks, varying in size, link density, and degree heterogeneity. Our results suggest that union transfer entropy should be preferred for slowly varying processes, which may be associated with policies attending to specific local problems that occur only rarely or with policies facing high levels of opposition. In contrast, event synchronization is effective for faster enactment rates, which may be related to policies involving Federal mandates or incentives. This study puts forward a data-driven toolbox to explain the determinants of legal activity applicable to political science, across dynamical systems, information theory, and complex networks.
Death due to motor vehicle collisions (MVCs) remains a leading cause of death in the US and alcohol plays a prominent role in a large proportion of these fatalities nationwide. Rates for these incidents vary widely among states and over time. Here, we explore the extent to which driving volume, alcohol consumption, legislation, political ideology, and geographical factors influence MVC deaths across states and time. We specify structural equation models for extracting associations between the factors and outcomes for MVC deaths and compute correlation functions of states relative geographic and political positions to elucidate the relative contribution of these factors. We find evidence that state-level variation in MVC deaths is associated with time-varying driving volume, alcohol consumption, and legislation. These relationships are modulated by state spatial proximity, whereby neighboring states are found to share similar MVC death rates over the thirty-year observation period. These results support the hypothesis that neighboring states exhibit similar risk and protective characteristics, despite differences in political ideology. ; Peer Reviewed
Death due to motor vehicle collisions (MVCs) remains a leading cause of death in the US and alcohol plays a prominent role in a large proportion of these fatalities nationwide. Rates for these incidents vary widely among states and over time. Here, we explore the extent to which driving volume, alcohol consumption, legislation, political ideology, and geographical factors influence MVC deaths across states and time. We specify structural equation models for extracting associations between the factors and outcomes for MVC deaths and compute correlation functions of states' relative geographic and political positions to elucidate the relative contribution of these factors. We find evidence that state-level variation in MVC deaths is associated with time-varying driving volume, alcohol consumption, and legislation. These relationships are modulated by state spatial proximity, whereby neighboring states are found to share similar MVC death rates over the thirty-year observation period. These results support the hypothesis that neighboring states exhibit similar risk and protective characteristics, despite differences in political ideology.
For the second straight year, large cities in the U.S. are experiencing an alarming increased in homicides, mostly committed with firearms. Philadelphia reported 406 homicides in 2006, giving it the highest rate of homicides among the ten largest cities (27.8 per 100,000 people). This trend has renewed interest in policies to limit the availability of firearms. However, the effectiveness of such policies at reducing injury remains controversial, often creating political deadlock. To inform this debate, we look at evidence from Brazil, a country with even greater levels of violence than the U.S. This Issue Brief analyzes recent gun legislation and other violence reduction policies in Brazil and their effects on firearm violence.
This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.
Detecting and explaining the relationships among interacting components has long been a focal point of dynamical systems research. In this paper, we extend these types of data-driven analyses to the realm of public policy, whereby individual legislative entities interact to produce changes in their legal and political environments. We focus on the U.S. public health policy landscape, whose complexity determines our capacity as a society to effectively tackle pressing health issues. It has long been thought that some U.S. states innovate and enact new policies, while others mimic successful or competing states. However, the extent to which states learn from others, and the state characteristics that lead two states to influence one another, are not fully understood. Here, we propose a model-free, information-theoretical method to measure the existence and direction of influence of one state's policy or legal activity on others. Specifically, we tailor a popular notion of causality to handle the slow time-scale of policy adoption dynamics and unravel relationships among states from their recent law enactment histories. The method is validated using surrogate data generated from a new stochastic model of policy activity. Through the analysis of real data in alcohol, driving safety, and impaired driving policy, we provide evidence for the role of geography, political ideology, risk factors, and demographic and economic indicators on a state's tendency to learn from others when shaping its approach to public health regulation. Our method offers a new model-free approach to uncover interactions and establish cause-and-effect in slowly-evolving complex dynamical systems.
BackgroundThe UK government is pursuing policies to improve primary care access, as many patients visit accident and emergency (A and E) departments after being unable to get suitable general practice appointments. Direct admission to hospital via a general practitioner (GP) averts A and E use, and may reduce total hospital costs. It could also enhance the continuity of information between GPs and hospital doctors, possibly improving healthcare outcomes.ObjectiveTo determine whether primary care access is associated with the route of emergency admission-via a GP versus via an A and E department.MethodsRetrospective analysis of national administrative data from English hospitals for 2011-2012. Adults admitted in an emergency (unscheduled) for ≥1 night via a GP or an A and E department formed the study population. The measure of primary care access-the percentage of patients able to get a general practice appointment on their last attempt-was derived from a large, nationally representative patient survey. Multilevel logistic regression was used to estimate associations, adjusting for patient and admission characteristics.ResultsThe analysis included 2 322 112 emergency admissions (81.9% via an A and E department). With a 5 unit increase in the percentage of patients able to get a general practice appointment on their last attempt, the adjusted odds of GP admission (vs A and E admission) was estimated to increase by 15% (OR 1.15, 95% CI 1.12 to 1.17). The probability of GP admission if ≥95% of appointment attempts were successful in each general practice was estimated to be 19.6%. This probability reduced to 13.6% when <80% of appointment attempts were successful. This equates to 139 673 fewer GP admissions (456 232 vs 316 559) assuming no change in the total number of admissions. Associations were consistent in direction across geographical regions of England.ConclusionsAmong hospital inpatients admitted as an emergency, patients registered to more accessible general practices were more likely to have been admitted via a GP (vs an A and E department). This furthers evidence suggesting that access to general practice is related to use of emergency hospital services in England. The relative merits of the two admission routes remain unclear.
