Социально-экономические детерминанты доступа к профилактическим медицинским услугам. Проблемы и последствия проводимой политики: систематический обзор

Введение. Социально-экономические детерминанты оказывают большое влияние на степень доступности профилактических медицинских услуг. Цель исследования: на основании глобальных данных оценить препятствия, благоприятные факторы и последствия проводимой политики для обеспечения равных возможностей в системе здравоохранения.

Методы. В ходе исследования был проведен систематический обзор разных регионов и категорий населения с разным уровнем дохода. Были проанализированы данные исследований, посвященных социально-экономическим факторам, характеристикам системы здравоохранения и показателям равенства. В качестве статистических методов использовались регрессионный анализ, индексы концентрации и показатели неравенства для оценки благоприятных факторов и препятствий.

Результаты. Результаты свидетельствуют о том, что в условиях низкого и среднего уровней доходов наряду с географической недоступностью и культурными факторами основным препятствием для обеспечения равенства являются финансовые ограничения. В условиях высокого уровня доходов наблюдается значительное социально-экономическое неравенство, несмотря на внедрение системы всеобщего охвата услугами здравоохранения. Обеспечению доступности способствуют всеобщий охват населения услугами здравоохранения, проведение мероприятий на местном уровне и целенаправленные реформы. Преобладают тенденции гендерного неравенства и учета интересов населения с высоким уровнем доходов, однако политика, отвечающая принципу равенства, показывает свою эффективность в устранении пробелов в системе здравоохранения. Индексы концентрации показывают значительное неравенство при ДИ от 0,062 до 0,29.

Заключение. Исследование показало наличие многогранного влияния социально-экономических детерминант на доступность медицинского обслуживания. Существует необходимость в разработке политики, учитывающей конкретные условия и отвечающей принципу равенства. Также необходимо преодолеть финансовые и географические препятствия, повысить уровень медицинской грамотности и внедрить подходы, основанные на участии сообщества, для достижения всеобщей доступности здравоохранения.

1. Ni X, Li Z, Li X, Zhang X, Bai G, Liu Y, Zheng R, Zhang Y, Xu X, Liu Y, Jia C, Wang H, Ma X, Zheng H, Su Y, Ge M, Zeng Q, Wang S, Zhao J, Zeng Y, Feng G, Xi Y, Deng Z, Guo Y, Yang Z, Zhang J. Socioeconomic inequalities in cancer incidence and access to health services among children and adolescents in China: a cross-sectional study. Lancet. 2022;400(10357):1020–1032. https://doi.org/10.1016/S0140-6736(22)01541-0

2. Ahonen EQ, Winkler MR, Hajat A. Work, Health, and the Ongoing Pursuit of Health Equity. Int J Environ Res Public Health. 2022;19(21):14047. https://doi.org/10.3390/ijerph192114047

3. Mafla AC, Moran LS, Bernabe E. Maternal Oral Health and Early Childhood Caries amongst Low-Income Families. Community Dent Health. 2020;37(3):223–228. https://doi.org/10.1922/CDH_00040Mafla06

4. Brown LE, França UL, McManus ML. Socioeconomic Disadvantage and Distance to Pediatric Critical Care. Pediatr Crit Care Med. 2021;22(12):1033–1041. https://doi.org/10.1097/PCC.0000000000002807

5. Zhou Y, Guo Y, Liu Y. Health, income and poverty: evidence from China's rural household survey. Int J Equity Health. 2020;19(1):36. https://doi.org/10.1186/s12939-020-1121-0

6. D'Avila OP, Chisini LA, Costa FDS, Cademartori MG, Cleff LB, Castilhos ED. Use of Health Services and Family Health Strategy Households Population Coverage in Brazil. Cien Saude Colet. 2021;26(9):3955– 3964. https://doi.org/10.1590/1413-81232021269.11782021

7. Hong SN, Kim JK, Kim DW. The Impact of Socioeconomic Status on Hospital Accessibility in Otorhinolaryngological Disease in Korea. Asia Pac J Public Health. 2021;33(2–3):287–292. https://doi.org/10.1177/1010539520977320

8. Montañez-Hernández JC, Alcalde-Rabanal J, Reyes-Morales H. Socioeconomic factors and inequality in the distribution of physicians and nurses in Mexico. Rev Saude Publica. 2020;54:58. https://doi.org/10.11606/s1518-8787.2020054002011

9. Asare AO, Maurer D, Wong AMF, Ungar WJ, Saunders N. Socioeconomic Status and Vision Care Services in Ontario, Canada: A Population-Based Cohort Study. J Pediatr. 2022;241:212–220.e2. https://doi.org/10.1016/j.jpeds.2021.10.020

10. Dantas MNP, Souza DLB, Souza AMG, Aiquoc KM, Souza TA, Barbosa IR. Factors associated with poor access to health services in Brazil. Rev Bras Epidemiol. 2020;24:e210004. Portuguese, English. https://doi.org/10.1590/1980-549720210004

11. Cheng JM, Batten GP, Cornwell T, Yao N. A qualitative study of healthcare experiences and challenges faced by ageing homebound adults. Health Expect. 2020;23(4):934–942. https://doi.org/10.1111/hex.13072

12. Meshesha BR, Sibhatu MK, Beshir HM, Zewude WC, Taye DB, Getachew EM, Merga KH, Kumssa TH, Alemayue EA, Ashuro AA, Shagre MB, Gebreegziabher SB. Access to surgical care in Ethiopia: a cross-sectional retrospective data review. BMC Health Serv Res. 2022;22(1):973. https://doi.org/10.1186/s12913-022-08357-9

13. Olfson M, Mauro C, Wall MM, Choi CJ, Barry CL, Mojtabai R. Healthcare coverage and service access for low-income adults with substance use disorders. J Subst Abuse Treat. 2022;137:108710. https://doi.org/10.1016/j.jsat.2021.108710

14. Aronu NI, Atama CS, Chukwu NE, Ijeoma I. Socioeconomic Dynamics in Women's Access and Utilization of Health Technologies in Rural Nigeria. Community Health Equity Res Policy. 2022;42(2):225–232. https://doi.org/10.1177/0272684X20972643

15. Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, McKenzie JE. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160. https://doi.org/10.1136/bmj.n160

16. Igelström E, Campbell M, Craig P, Katikireddi SV. Cochrane's risk of bias tool for non-randomized studies (ROBINS-I) is frequently misapplied: A methodological systematic review. J Clin Epidemiol. 2021 Dec;140:22–32. https://doi.org/10.1016/j.jclinepi.2021.08.022

17. Downes MJ, Brennan ML, Williams HC, Dean RS. Development of a critical appraisal tool to assess the quality of cross-sectional studies (AXIS). BMJ Open. 2016;6(12):e011458. https://doi.org/10.1136/bmjopen-2016-011458

18. Andersson K, Ozanne A, Edelvik Tranberg A, E Chaplin J, Bolin K, Malmgren K, Zelano J. Socioeconomic outcome and access to care in adults with epilepsy in Sweden: A nationwide cohort study. Seizure. 2020;74:71–76. https://doi.org/10.1016/j.seizure.2019.12.001

19. Improving Health in Slums Collaborative. Inequity of healthcare access and use and catastrophic health spending in slum communities: a retrospective, cross-sectional survey in four countries. BMJ Glob Health. 2021;6(11):e007265. https://doi.org/10.1136/bmjgh-2021-007265

20. Boccolini CS, de Souza Junior PR. Inequities in Healthcare utilization: results of the Brazilian National Health Survey, 2013. Int J Equity Health. 2016;15(1):150. https://doi.org/10.1186/s12939-016-0444-3

21. Chen X, Giles J, Yao Y, Yip W, Meng Q, Berkman L, Chen H, Chen X, Feng J, Feng Z, Glinskaya E, Gong J, Hu P, Kan H, Lei X, Liu X, Steptoe A, Wang G, Wang H, Wang H, Wang X, Wang Y, Yang L, Zhang L, Zhang Q, Wu J, Wu Z, Strauss J, Smith J, Zhao Y. The path to healthy ageing in China: a Peking University-Lancet Commission. Lancet. 2022;400(10367):1967–2006. https://doi.org/10.1016/S0140-6736(22)01546-X

22. Dorjdagva J, Batbaatar E, Dorjsuren B, Kauhanen J. Income-related inequalities in health care utilization in Mongolia, 2007/2008-2012. Int J Equity Health. 2015;14:57. https://doi.org/10.1186/s12939-015-0185-8

23. Ha R, Jung-Choi K, Kim CY. Employment Status and Self-Reported Unmet Healthcare Needs among South Korean Employees. Int J Environ Res Public Health. 2018;16(1):9. https://doi.org/10.3390/ijerph16010009

24. Hoebel J, Rommel A, Schröder SL, Fuchs J, Nowossadeck E, Lampert T. Socioeconomic Inequalities in Health and Perceived Unmet Needs for Healthcare among the Elderly in Germany. Int J Environ Res Public Health. 2017;14(10):1127. https://doi.org/10.3390/ijerph14101127

25. Hoven H, Backhaus I, Gerő K, Kawachi I. Characteristics of employment history and self-perceived barriers to healthcare access. Eur J Public Health. 2023;33(6):1080–1087. https://doi.org/10.1093/eurpub/ckad178

26. Jindal RM, Tiwari S. Challenges to Achieving Surgical Equity in Slums. Int J Public Health. 2025 Jan 13;69:1608098. https://doi.org/10.3389/ijph.2024.1608098

27. Liu PY, Bell O, Wu O, Holguin M, Lozano C, Jasper E, Saleeby E, Smith L, Szilagyi P, Schickedanz A. Interest in Clinic-Based Financial Services among Low-Income Prenatal Patients and its Association with Health-Related Social Risk Factors. J Prim Care Community Health. 2021;12:21501327211024425. https://doi.org/10.1177/21501327211024425

28. Mather T, Banks E, Joshy G, Bauman A, Phongsavan P, Korda RJ. Variation in health inequalities according to measures of socioeconomic status and age. Aust N Z J Public Health. 2014;38(5):436–440. https://doi.org/10.1111/1753-6405.12239

29. Mziwira M, Ahaji A, Naciri K, Belahsen R. Socio-economic characteristics, health status and access to health care in an elderly Moroccan community: study of the gender factor. Rocz Panstw Zakl Hig. 2022;73(3):341–349. https://doi.org/10.32394/rpzh.2022.0224

30. Njagi P, Arsenijevic J, Groot W. Cost-related unmet need for healthcare services in Kenya. BMC Health Serv Res. 2020;20(1):322. https://doi.org/10.1186/s12913-020-05189-3

31. Petroze RT, Joharifard S, Groen RS, Niyonkuru F, Ntaganda E, Kushner AL, Guterbock TM, Kyamanywa P, Calland JF. Injury, disability and access to care in Rwanda: results of a nationwide cross-sectional population study. World J Surg. 2015;39(1):62–69. https://doi.org/10.1007/s00268-014-2544-9

32. Rahman M, Rana MS, Rahman MM, Khan MN. Healthcare services access challenges and determinants among persons with disabilities in Bangladesh. Sci Rep. 2024;14(1):19187. https://doi.org/10.1038/s41598-024-70418-2

33. Saito E, Gilmour S, Yoneoka D, Gautam GS, Rahman MM, Shrestha PK, Shibuya K. Inequality and inequity in healthcare utilization in urban Nepal: a cross-sectional observational study. Health Policy Plan. 2016;31(7):817–824. https://doi.org/10.1093/heapol/czv137

34. Sangare M, Coulibaly YI, Coulibaly SY, Dolo H, Diabate AF, Atsou KM, Souleymane AA, Rissa YA, Moussa DW, Abdallah FW, Dembele M, Traore M, Diarra T, Brieger WR, Traore SF, Doumbia S, Diop S. Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali. BMC Public Health. 2021;21(1):421. https://doi.org/10.1186/s12889-021-10481-w

35. Tran BX, Nguyen LH, Nong VM, Nguyen CT. Health status and health service utilization in remote and mountainous areas in Vietnam. Health Qual Life Outcomes. 2016;14:85. https://doi.org/10.1186/s12955-016-0485-8

36. Vahedi S, Torabipour A, Takian A, Mohammadpur S, Olyaeemanesh A, Kiani MM, Mohamadi E. Socioeconomic determinants of unmet need for outpatient healthcare services in Iran: a national cross-sectional study. BMC Public Health. 2021;21(1):457. https://doi.org/10.1186/s12889-021-10477-6

37. Vora K, Saiyed S, Shah AR, Mavalankar D, Jindal RM. Surgical Unmet Need in a Low-Income Area of a Metropolitan City in India: A Cross-Sectional Study. World J Surg. 2020;44(8):2511–2517. https://doi.org/10.1007/s00268-020-05502-5

38. Wendt A, Marmitt LP, Nunes BP, Dumith SC, Crochemore-Silva I. Socioeconomic inequalities in the access to health services: a population-based study in Southern Brazil. Cien Saude Colet. 2022;27(2):793– 802. https://doi.org/10.1590/1413-81232022272.03052021

39. Zhuoga C, Cuomu Z, Li S, Dou L, Li C, Dawa Z. Income-related equity in inpatient care utilization and unmet needs between 2013 and 2018 in Tibet, China. Int J Equity Health. 2023;22(1):85. https://doi.org/10.1186/s12939-023-01889-4

40. Steiner TJ, Stovner LJ. Global epidemiology of migraine and its implications for public health and health policy. Nat Rev Neurol. 2023;19(2):109–117. https://doi.org/10.1038/s41582-022-00763-1

41. Lim Z, Sebastin SJ, Chung KC. Health Policy Implications of Digital Replantation. Clin Plast Surg. 2024;51(4):553–558. https://doi.org/10.1016/j.cps.2024.02.017

42. Manji K, Perera S, Hanefeld J, Vearey J, Olivier J, Gilson L, Walls H. An analysis of migration and implications for health in government policy of South Africa. Int J Equity Health. 2023;22(1):82. https://doi.org/10.1186/s12939-023-01862-1

43. Townsend JR, Kirby TO, Marshall TM, Church DD, Jajtner AR, Esposito R. Foundational Nutrition: Implications for Human Health. Nutrients. 2023;15(13):2837. https://doi.org/10.3390/nu15132837

44. Wong BLH, Maaß L, Vodden A, van Kessel R, Sorbello S, Buttigieg S, Odone A; European Public Health Association (EUPHA) Digital Health Section. The dawn of digital public health in Europe: Implications for public health policy and practice. Lancet Reg Health Eur. 2022;14:100316. https://doi.org/10.1016/j.lanepe.2022.100316

45. Li C, Zhu B, Zhang J, Guan P, Zhang G, Yu H, Yang X, Liu L. Epidemiology, health policy and public health implications of visual impairment and age-related eye diseases in mainland China. Front Public Health. 2022;10:966006. https://doi.org/10.3389/fpubh.2022.966006

46. Franco-Rocha OY, Carillo-Gonzalez GM, Garcia A, Henneghan A. Cancer Survivorship Care in Colombia: Review and Implications for Health Policy. Hisp Health Care Int. 2022;20(1):66–74. https://doi.org/10.1177/15404153211001578

47. Reyna VF. A scientific theory of gist communication and misinformation resistance, with implications for health, education, and policy. Proc Natl Acad Sci USA. 2021;118(15):e1912441117. https://doi.org/10.1073/pnas.1912441117

48. Broadbent P, Thomson R, Kopasker D, McCartney G, Meier P, Richiardi M, McKee M, Katikireddi SV. The public health implications of the cost-of-living crisis: outlining mechanisms and modelling consequences. Lancet Reg Health Eur. 2023;27:100585. https://doi.org/10.1016/j.lanepe.2023.100585

49. Liburd LC, Hall JE, Mpofu JJ, Williams SM, Bouye K, Penman-Aguilar A. Addressing Health Equity in Public Health Practice: Frame- works, Promising Strategies, and Measurement Considerations. Annu Rev Public Health. 2020;41:417–432. https://doi.org/10.1146/annurev-publhealth-040119-094119

50. Mytton OT, Donaldson L, Goddings AL, Mathews G, Ward JL, Greaves F, Viner RM. Changing patterns of health risk in adolescence: implications for health policy. Lancet Public Health. 2024;9(8):e629–e634. https://doi.org/10.1016/S2468-2667(24)00125-7

51. Vikan M, Haugen AS, Bjørnnes AK, Valeberg BT, Deilkås ECT, Danielsen SO. The association between patient safety culture and adverse events — a scoping review. BMC Health Serv Res. 2023;23(1):300. https://doi.org/10.1186/s12913-023-09332-8

52. Preker AS, Cotlear D, Kwon S, Atun R, Avila C. Universal health care in middle-income countries: Lessons from four countries. J Glob Health. 2021;11:16004. https://doi.org/10.7189/jogh.11.16004