Bridging ethics and epidemiology: Modelling ethical standards of health equity

Brendan T Smith; Christine M Warren; Laura C Rosella; Maxwell J Smith

doi:10.1016/j.ssmph.2023.101481

Bridging ethics and epidemiology: Modelling ethical standards of health equity

SSM Popul Health. 2023 Aug 2:24:101481. doi: 10.1016/j.ssmph.2023.101481. eCollection 2023 Dec.

Authors

Brendan T Smith^{1

2}, Christine M Warren¹, Laura C Rosella^{2

3

4}, Maxwell J Smith⁵

Affiliations

¹ Public Heath Ontario, 480 University Avenue, Suite 300, Toronto, ON, M5G 1V2, Canada.
² Dalla Lana School of Public Health, University of Toronto, 155 College St Room 500, Toronto, ON, M5T 3M7, Canada.
³ Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, ON, L5B 1B8, Canada.
⁴ Department of Laboratory Medicine and Pathobiology, Temerty Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
⁵ School of Health Studies, Faculty of Health Sciences, Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada.

Abstract

Health inequities are differences in health that are 'unjust'. Yet, despite competing ethical views about what counts as an 'unjust difference in health', theoretical insights from ethics have not been systematically integrated into epidemiological research. Using diabetes as an example, we explore the impact of adopting different ethical standards of health equity on population health outcomes. Specifically, we explore how the implementation of population-level weight-loss interventions using different ethical standards of equity impacts the intervention's implementation and resultant population health outcomes. We conducted a risk prediction modelling study using the nationally representative 2015-16 Canadian Community Health Survey (n = 75,044, 54% women). We used the Diabetes Population Risk Tool (DPoRT) to calculate individual-level 10-year diabetes risk. Hypothetical weight-loss interventions were modelled in individuals with overweight or obesity based on each ethical standard: 1) health sufficiency (reduce DPoRT risk below a high-risk threshold (16.5%); 2) health equality (equalize DPoRT risk to the low risk group (5%)); 3) social-health sufficiency (reduce DPoRT risk <16.5 in individuals with lower education); 4) social-health equality (equalize DPoRT risk to the level of individuals with high education). For each scenario, we calculated intervention impacts, diabetes cases prevented or delayed, and relative and absolute educational inequities in diabetes. Overall, we estimated that achieving health sufficiency (i.e., all individuals below the diabetes risk threshold) was more feasible than achieving health equality (i.e., diabetes risk equalized for all individuals), requiring smaller initial investments and fewer interventions; however, fewer diabetes cases were prevented or delayed. Further, targeting only diabetes inequalities related to education reduced the target population size and number of interventions required, but consequently resulted in even fewer diabetes cases prevented or delayed. Using diabetes as an example, we found that an explicit, ethically-informed definition of health equity is essential to guide population-level interventions that aim to reduce health inequities.

Keywords: Ethics; Health equity; Population health interventions; Risk prediction; Social epidemiology; Social justice.