What is new?
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PROGRESS refers to place of residence, race/ethnicity/culture/language, occupation, gender/sex, religion, education, socioeconomic status, and social capital.
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This article provides examples of unfair differences in disease burden and an intervention that can effectively address these health inequities for each of the PROGRESS factors.
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The acronym PROGRESS can be used as an aide-memoire, a framework to guide data extraction, and a tool to guide equity analyses for researchers to ensure explicit consideration of equity in the design of new intervention studies and in systematic reviews.
Many factors contribute to whether a population is described as “disadvantaged.” Globally, populations are, on average, living longer and healthier lives than at any other time in history. The average life expectancy at birth in 1955 was 48 years. By 1995, it was 65 years, and by 2025, it is predicted to reach 73 years. There are now more than 5 billion people with life expectancy of more than 60 years [1]. However, these improvements do not reach all groups of the world's population equally. Just as there are inequalities in access to natural resources that affect well-being, there are also inequalities in health status, which are not coincidental. Rather, they are driven by socially stratifying forces that are systemic in societies.
The World Health Organization has defined health inequalities as “differences in health status or in the distribution of health determinants between different population groups” [2] (e.g., racial, ethnic, sexual orientation, or socioeconomic groups). Some health inequalities are attributable to biological variations or free choice and others are attributable to the external environment and conditions that are mainly outside of an individual's control. In the first case, it may be impossible, or in the second case, ethically unacceptable, to change the underlying factor that is driving the inequity, and thus, it can be deemed unavoidable. However, in the third case, the uneven distribution of health may be avoidable, as well as unjust and unfair [4]. These differences have been described as disparities [3] or as “health inequities” [4]. It is the context in which one is born, lives, and works that causes underlying inequities in health. These inequities may result in differences across a population in terms of incidence of disease, health outcomes, and access to health care. Inequities in health are therefore linked to income, occupation, place of residence, and gender among other factors. Unlike the individual behavioral-based determinants of health (downstream factors), these upstream factors are ones over which individuals have little or no direct control but which can only be altered through social and economic policies and political processes [5]. To understand and act on health inequities, both upstream and downstream factors must be considered [6]. Depending on the context, particular factors may be more or less important for a certain population.
Although much of the literature has focused on inequities between countries, unfair differences in health are prevalent within countries as well. For example, in China, rates of childhood stunting are three times higher in rural areas than in urban areas [7], and maternal mortality is higher in poorer provinces than in richer provinces [8]. In India, immunization rates vary by caste and certain castes have low rates [9]. These differential health outcomes are not coincidental but rather are grouped according to socially stratifying forces such as place of residence and level of income [10]. There are also many significant differences in health outcomes among countries, regions, or continents [5] such as differences in child mortality in high-income countries (HICs) compared with low- or middle-income countries (LMICs). In 2010, neonatal mortality in Africa was 34 per 1,000 live births compared with just 9 per 1,000 live births in the Americas [11].