[Relevance of the health insurance databases to study spatial disparities in asthma prevalence: A study in southeastern France]

BACKGROUND

Data on asthma prevalence at a small-area level would be useful to set up and monitor French local public health policies. This study, based on drug reimbursement databases in southeastern France, aimed to (1) compare asthma-like disorders prevalence estimated by using three different indicators; (2) study sociodemographic characteristics associated with these indicators; (3) verify whether these indicators are equivalent to study geographical disparities of the asthma-like disorders prevalence at a small-area level.

METHODS

The study was conducted among the beneficiaries of the National Health Insurance Fund aged 18-44 years residing in southeastern France in 2010 (n=1,371,816). Using data on asthma drugs reimbursements (therapeutic class R03), we built three indicators to assess asthma-like disorders prevalence: at least 1, 2 or 3 purchase(s) in 2010. We analyzed sociodemographic characteristics associated with these indicators, and their geographical disparities at a small-area level using multilevel logistic regression models.

RESULTS

The crude asthma-like disorders prevalence varied between 2.6 % and 8.4 % depending on the indicator. It increased with age, was higher for women than for men, and among low-income people for all three indicators. We measured significant geographical disparities. Areas with high prevalence rates were the same regardless of the indicator.

CONCLUSION

The indicators built in this study can be useful to identify high prevalence areas. They could contribute to launch discussion on environmental health issues at the local level.

Discrimination, racial identity, and cytokine levels among African-American adolescents

PURPOSE

Low-grade inflammation, measured by circulating levels of cytokines, is a pathogenic mechanism for several chronic diseases of aging. Identifying factors related to inflammation among African-American youths may yield insights into mechanisms underlying racial disparities in health. The purpose of the study was to determine whether (1) reported racial discrimination from ages 17-19 years forecasts heightened cytokine levels at the age of 22 years and (2) this association is lower for youths with positive racial identities.

METHODS

A longitudinal research design was used with a community sample of 160 African-Americans who were aged 17 years at the beginning of the study. Discrimination and racial identity were measured with questionnaires, and blood was drawn to measure basal cytokine levels. Ordinary least squares regression analyses were used to examine the hypotheses.

RESULTS

After controlling for socioeconomic risk, life stress, depressive symptoms, and body mass index, racial discrimination (β = .307; p < .01), racial identity (β = -.179; p < .05), and their interaction (β = -.180; p < .05) forecast cytokine levels. Youths exposed to high levels of racial discrimination evinced elevated cytokine levels 3 years later. This association was not significant for young adults with positive racial identities.

CONCLUSIONS

High levels of interpersonal racial discrimination and the development of a positive racial identity operate jointly to determine low-grade inflammation levels that have been found to forecast chronic diseases of aging, such as coronary disease and stroke.

Social inequalities in BMI trajectories: 8-year follow-up of the Pró-Saúde study in Rio de Janeiro, Brazil

OBJECTIVE

In a cohort of government employees in Rio de Janeiro, Brazil, we investigated prospectively, sex-specific associations between education and BMI trajectories and their potential effect modification by race.

DESIGN

Of the 4030 participants in Phase 1 (1999), 3253 (81 %) participated in Phase 2 (2003) and 3058 (76 %) participated in Phase 3 (2006). Education was categorized as elementary, high school or college graduate. Study participants self-identified as White, Black or Pardo. BMI was calculated from measured weight and height. BMI trajectories were modelled using a generalized additive regression model with mixed effects (GAMM).

SETTING

The Pro-Saúde Study, a longitudinal investigation of social determinants of health.

SUBJECTS

Women (n 1441) and men (n 1127) who participated in the three phases of data collection and had complete information for all study variables.

RESULTS

Women and men with less than high school, or only a high school education, gained approximately 1 kg/m(2) more than college graduates (women: 1·06 kg/m(2) (P<0·001) and 1·06 kg/m(2) (P<0·001), respectively; men: 1·04 kg/m(2) (P=0·013) and 1·01 kg/m(2) (P=0·277), respectively). For women only, race was independently associated with weight gain. Women identifying as Pardo or Black gained 1·03 kg/m(2) (P=0·01) and 1·02 kg/m(2) (P=0·10), respectively, more than Whites. No effect modification by race was observed for either men or women.

CONCLUSIONS

While both lower education and darker race were associated with greater weight gain, gender similarities and differences were observed in these associations. The relationship between weight gain and different indicators of social status are therefore complex and require careful consideration when addressing the obesity epidemic.

Female and male differences in AIDS diagnosis rates among people who inject drugs in large U.S. metro areas from 1993 to 2007

PURPOSE

We estimated female and male incident AIDS diagnosis rates (IARs) among people who inject drugs (PWID) in U.S. metropolitan statistical areas (MSAs) over time to assess whether declines in IARs varied by sex after combination antiretroviral therapy (cART) dissemination.

METHODS

We compared IARs and 95% confidence intervals for female and male PWID in 95 of the most populous MSAs. To stabilize estimates, we aggregated data across three-year periods, selecting a period immediately preceding cART (1993-1995) and the most recent after the introduction of cART for which data were available (2005-2007). We assessed disparities by comparing IAR 95% confidence intervals for overlap, female-to-male risk ratios, and disparity change scores.

RESULTS

IARs declined an average of 58% for female PWID and 67% for male PWID between the pre-cART and cART periods. Among female PWID, IARs were significantly lower in the later period relative to the pre-cART period in 48% of MSAs. Among male PWID, IARs were significantly lower over time in 86% of MSAs.

CONCLUSIONS

IARs among female PWID in large U.S. MSAs have declined more slowly than among male PWID. This suggests a need for increased targeting of prevention and treatment programs and for research on MSA level conditions that may drive differences in declining AIDS rates among female and male PWID.

Racial and ethnic disparities in functioning at discharge and follow-up among patients with motor complete spinal cord injury

OBJECTIVE

To examine racial and ethnic differences in self-care and mobility outcomes for persons with a motor complete, traumatic spinal cord injury (SCI) at discharge and 1-year follow-up.

DESIGN

Retrospective cohort study.

SETTING

Sixteen rehabilitation centers contributing to the Spinal Cord Injury Model Systems (SCIMS) database.

PARTICIPANTS

Adults with traumatic, motor complete SCI (N=1766; American Spinal Injury Association Impairment Scale grade A or B) enrolled in the SCIMS between 2000 and 2011. Selected cases had complete self-reported data on race and ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic) and motor FIM scores assessed at inpatient rehabilitation admission, discharge, and 1-year follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Functional outcomes were measured by FIM self-care and mobility scores on a 1 to 7 FIM scale, at discharge and 1-year follow-up.

RESULTS

Multiple regression models stratified by neurologic category and adjusted for sociodemographic and injury characteristics assessed racial and ethnic group differences in FIM self-care and mobility change scores at discharge and 1-year follow-up. At discharge, non-Hispanic black participants with tetraplegia and paraplegia had significantly poorer gains in FIM self-care and mobility scores relative to non-Hispanic white and Hispanic participants. At 1-year follow-up, similar FIM self-care and mobility change scores were found across racial and ethnic groups within each neurologic category.

CONCLUSIONS

Non-Hispanic white and Hispanic participants had comparatively more improvement in self-care and mobility during inpatient rehabilitation compared with non-Hispanic black participants. At 1-year follow-up, no differences in self-care and mobility outcomes were observed across racial and ethnic groups. Additional research is needed to identify potential modifiable factors that may contribute to racially and ethnically different patterns of functional outcomes observed during inpatient rehabilitation.

Social determinants of disparities in weight among US children and adolescents

PURPOSE

To explore whether contextual variables attenuate disparities in weight among 18,639 US children and adolescents aged 2 to 18 years participating in the National Health and Nutrition Examination Survey, 2001 to 2010.

METHODS

Disparities were assessed using the Symmetrized Rényi Index, a new measure that summarizes disparities in the severity of a disease, as well as the prevalence, across multiple population groups. Propensity score subclassification was used to ensure covariate balance between racial and ethnic subgroups and account for individual-level and contextual covariates.

RESULTS

Before propensity score subclassification, significant disparities were evident in the prevalence of overweight and/or obesity and the degree of excess weight among overweight/obese children and adolescents. After propensity score subclassification, racial/ethnic disparities in the prevalence and severity of excess weight were completely attenuated within matched groups, indicating that racial and ethnic differences were explained by social determinants such as neighborhood socioeconomic and demographic factors.

CONCLUSIONS

The limited overlap in covariate distributions between various racial/ethnic subgroups warrants further attention in disparities research. The attenuation of disparities within matched groups suggests that social determinants such as neighborhood socioeconomic factors may engender disparities in weight among US children and adolescents.

Lifecourse socioeconomic position and 16 year body mass index trajectories: differences by race and sex

OBJECTIVE

The aim of this study is to evaluate the association between lifecourse socioeconomic position (SEP) and changes in body mass index (BMI), and assess disparities in these associations across racial/ethnic groups.

METHODS

With longitudinal data from 4 waves of the Americans' Changing Lives Study (1986-2002), we employed mixed-effects modeling to estimate BMI trajectories for 1174 Blacks and 2323 White adults. We also estimated associations between these trajectories and lifecourse SEP variables, including father's education, perceived childhood SEP, own education, income, wealth, and financial security.

RESULTS

Blacks had higher baseline BMIs, and steeper increases in BMI, compared to Whites. Childhood SEP, as measured by high father's education, was associated with lower baseline BMI among Whites. High education was associated with a lower baseline BMI within both race and sex categories. Income had contrasting effects among men and women. Higher income was associated with higher BMI only among males. Associations between indicators of SEP and BMI trajectories were only found for Whites.

CONCLUSIONS

Our study demonstrates that lifecourse SEP may influence adult BMI differently within different racial and sex groups.

[Health inequalities in self-perceived health among older adults in Spain]

OBJECTIVE

Recent publications have concluded that there are social health inequalities in people older than 65 years in Spain, especially among women and people with low socioeconomic status. Self-perceived health is an indicator that is related to the possibility of chronic disease, the use of health services, and mortality. The aim of this study was to assess inequalities in self-perceived health in relation to age, gender, socioeconomic factors, and functional dependence.

METHODS

A systematic review was conducted following the PRISMA criteria. An exhaustive search was performed in PubMed, WOK, Science Direct, EMBASE, IME, Cochrane, JSTOR, Ovid, Proquest, the BMJ Group and in Spanish doctoral theses up to April 2013. The quality of the studies was assessed by two independent editors through the Berra Tool.

RESULTS

A total of 20 documents were selected. These studies were in agreement in the deterioration of self-perceived health among older people (except the oldest), in those with functional dependence, lower socioeconomic status, and in women.

CONCLUSIONS

This review shows that, among older people, inequalities in self-perceived health due to socioeconomic status and gender have persisted in time. Future research is needed to cast light on the factors determining the persistence of these inequalities among older people, so that specific health policies can be designed for this sector of the population.

Assessing environmental support for better health: active living opportunity audits in rural communities in the southern United States

OBJECTIVE

Leisure-time physical activity in the United States is lower rural areas and the South and has been linked to socioeconomic and environmental aspects of where people live. The purpose of this study is to assess the built environment and policies for physical activity in rural communities.

METHODS

Eight rural communities in Alabama and Mississippi were assessed in 2011 using the Rural Active Living Assessment (RALA) street segment (SSA), town-wide (TWA), and town program and policies (PPA) assessment tools. Community Health Advisors Trained as Research Partners (CHARPS) and local staff conducted the assessments. The TWA and PPA were scored by domain and total scores. Data were analyzed using descriptive and nonparametric statistics.

RESULTS

117 segments were assessed in 22 towns in 8 counties. Built environmental barriers existed in all communities. Sidewalks were available in only 10-40% of the segments. TWA identified parks and playgrounds as the most available community feature. PPA scores indicated few policies for physical activity outside of school settings with mean scores higher in Mississippi compared to Alabama (61 vs. 49, respectively).

CONCLUSIONS

Multiple components of rural communities can be successfully assessed by CHARPs using RALA tools, providing information about resources and barriers for physical activity.

Have we left some behind? Trends in socio-economic inequalities in breastfeeding initiation: a population-based epidemiological surveillance study

OBJECTIVES

Breastfeeding is associated with improved health. Surveillance data show that breastfeeding initiation rates have increased; however, limited work has examined trends in socio-economic inequalities in initiation. The study's research question was whether socio-economic inequalities in breastfeeding initiation have changed over the past 20 years.

METHODS

This population-based study is a project within PATHS Equity for Children. Analyses used hospital discharge data for Manitoba mother-infant dyads with live births, 1988-2011 (n=316,027). Income quintiles were created, each with ~20% of dyads. Three-year, overall and by-quintile breastfeeding initiation rates were estimated for Manitoba and two hospitals. Age-adjusted rates were estimated for Manitoba. Rates were modelled using generalized linear models. Three measures, rate ratios (RRs), rate differences (RDs) and concentration indices, assessed inequality at each time point. We also compared concentration indices with Gini coefficients to assess breastfeeding inequality vis-à-vis income inequality. Trend analyses tested for changes over time.

RESULTS

Manitoba and Hospital A initiation rates increased; Hospital B rates did not change. Significant inequalities existed in nearly every period, across all three measures: RRs, RDs and concentration indices. RRs and concentration indices suggested little to no change in inequality from 1988 to 2011. RDs for Manitoba (comparing initiation in the highest to lowest income quintiles) did not change significantly over time. RDs decreased for Hospital A, suggesting decreasing socio-economic inequalities in breastfeeding; RDs increased for Hospital B. Income inequality increased significantly in Manitoba during the study period.

CONCLUSIONS

Overall breastfeeding initiation rates can improve while inequality persists or worsens.

Population-based disparities in survival among patients with core-binding factor acute myeloid leukemia: a SEER database analysis

We performed a retrospective population-based study using the SEER database to assess survival trends in CBF-AML between 2000 and 2010. Median OS increased from 16 months in 2000-2002 to 25 months in 2006-2008 (P=0.002). The 3-year OS rate for patients with inv(16) was 57.3%, but in t(8;21) was only 35.5%. Patients aged 75-84 had worse survival than patients aged 15-44 (HR 5.61, P=0.0002). Black race was associated with higher mortality (HR 1.50, P=0.03). Compared to clinical trial outcomes, CBF-AML survival is poorer in the general population, particularly among African Americans and the elderly, and in t(8;21) compared to inv(16) AML.

Socioeconomic inequalities in premature mortality in Colombia, 1998-2007: the double burden of non-communicable diseases and injuries

OBJECTIVES

Non-communicable diseases have become the leading cause of death in middle-income countries, but mortality from injuries and infections remains high. We examined the contribution of specific causes to disparities in adult premature mortality (ages 25-64) by educational level from 1998 to 2007 in Colombia.

METHODS

Data from mortality registries were linked to population censuses to obtain mortality rates by educational attainment. We used Poisson regression to model trends in mortality by educational attainment and estimated the contribution of specific causes to the Slope Index of Inequality.

RESULTS

Men and women with only primary education had higher premature mortality than men and women with post-secondary education (RRmen=2.60, 95% confidence interval [CI]: 2.56, 2.64; RRwomen=2.36, CI: 2.31, 2.42). Mortality declined in all educational groups, but declines were significantly larger for higher-educated men and women. Homicide explained 55.1% of male inequalities while non-communicable diseases explained 62.5% of female inequalities and 27.1% of male inequalities. Infections explained a small proportion of inequalities in mortality.

CONCLUSION

Injuries and non-communicable diseases contribute considerably to disparities in premature mortality in Colombia. Multi-sector policies to reduce both interpersonal violence and non-communicable disease risk factors are required to curb mortality disparities.

Social disparity in breast and ovarian cancer incidence in iran, 2003-2009: a time trend province-level study

Purpose

This pioneering study aimed to investigate social disparities in breast cancer (BC) and ovarian cancer (OC) incidence rates among women across Iran's provinces from 2003 to 2009.

Methods

Provincial level population distribution data pertaining to women were obtained from the Statistical Centre of Iran. Age-standardized incidence rates of BC and OC were gathered from the National Cancer Registry. Human Development Index was used as the provinces' social rank (SR), and rate ratio and Kunst and Mackenbach relative index of inequality were used to assess social disparities. Annual percentage change (APC) was calculated using joinpoint regression, and Spearman rank correlation was used to examine the association between APC and SR.

Results

It was found that over the study period, annual incidence rates rose by 11.6% and 9.7% for BC and OC, respectively. Social disparities were substantial and stable in favor of provinces with lower SR in Iran, and were more profound for BC than OC. Correlations between APC and SR were small and nonsignificant for both BC and OC.

Conclusion

The results showed that both BC and OC incidence increased in Iran during 2003 to 2009. There were positive associations between BC and OC incidence rates and the provinces' SR. This study's recommendations provide valuable information for health resource allocation pertaining to BC and OC control programs across provinces in Iran.

Health outcome disparities among subgroups of people with disabilities: a scoping review

BACKGROUND

A growing body of research has found that people with disabilities experience lower health status and an excess burden of disease relative to the general US population. However, the population of people with disabilities is quite diverse. Thus, it is important to understand health differences between subgroups of people with disabilities in order to most effectively target interventions to address disparities. An initial step in this process is reviewing and synthesizing available research addressing these subgroup differences.

OBJECTIVES

To conduct a scoping review of literature to describe recent research activity that has examined health outcome disparities within populations of people with disabilities.

METHODS

We searched for relevant articles in MEDLINE, PsycINFO, and CINAHL databases. Three staff independently reviewed abstracts according to inclusion criteria. Two authors then independently extracted data from each included article.

RESULTS

For many of the health outcomes of interest, there was no published literature in relation to key disparity factors (e.g. race, income) within the population of people with disabilities. The health outcomes most frequently examined were diabetes and heart disease. The most frequently examined disparity factors were the type of disabling condition and gender.

CONCLUSIONS

There are significant gaps in available research. Building a body of research that identifies disparities and potentially vulnerable subgroups may improve understanding of the causes of disparities and contribute to efforts to improve quality of life and health outcomes for individuals with disabilities.

The impact of peer support and mp3 messaging on adherence to inhaled corticosteroids in minority adolescents with asthma: a randomized, controlled trial

BACKGROUND

Poor adherence to inhaled corticosteroids (ICS) is a critical risk factor contributing to asthma morbidity among low-income minority adolescents.

OBJECTIVE

This trial tested whether peer support group meetings and peer asthma messages delivered via mp3 players improved adherence to ICS.

METHODS

Low-income African American and/or Hispanic adolescents, ages 11-16 years old, with persistent asthma, and poor (≤ 48%) adherence to prescription ICS during the 3-week run-in were randomized to intervention or attention control groups (ATG) for the 10-week treatment. During treatment, the intervention arm subjects participated in weekly coping peer group support sessions and received mp3 peer-recorded asthma messages that promoted adherence. The ATG participated in weekly meetings with a research assistant and received an equivalent number of mp3 physician-recorded asthma messages. Adherence was measured by using self-report and the Doser CT, an electronic dose counter. The primary outcome was the difference in adherence at 10 weeks between the 2 arms.

RESULTS

Thirty-four subjects were randomized to each arm. At 10 weeks, no statistical difference in objectively measured adherence could be detected between the 2 arms when adjusting for baseline adherence (P = .929). Adherence declined in both groups over the course of the active treatment period. In both study arms, self-reported adherence by participants was significantly higher than their objectively measured adherence at week 10 (P < .0001).

CONCLUSION

Improving medication adherence in longitudinal studies is challenging. Peer support and mp3-delivered peer asthma messages may not be of sufficient dose to improve outcomes.

Frailty and migration in middle-aged and older Europeans

We evaluated life course influences on health by investigating potential differences in levels of frailty between middle-aged and older European immigrants born in low- and middle-income countries (LMICs), immigrants born in high income countries (HICs), and their native-born European peers. Using data from the Survey of Health, Ageing, and Retirement in Europe (SHARE), we constructed a frailty index from 70 age-related health measures for 33,745 participants aged 50+ (mean=64.9 ± 10.2 years; 54% women) in 14 European countries. Participants were grouped as native-born or as immigrants born in LMICs or in HICs, and further by current residence in Northern/Western or Southern/Eastern Europe. Seven percent of participants (n=2369) were immigrants (mean=64.4 ± 10.2 years; 56% women; LMIC-born=3.4%, HIC-born=3.6%). In Northern/Western Europe, after adjustment for age, gender, and education, LMIC-born immigrants demonstrated higher frailty index scores (mean=0.18, 95% confidence interval=0.17-0.19) than both HIC-born immigrants (0.16, 0.16-0.17) and native-born participants (0.15, 0.14-0.15 both p<0.001). In Southern/Eastern Europe, frailty index scores did not differ between groups (p=0.2). Time since migration explained significant variance in frailty index scores only in HIC-born immigrants to Southern/Eastern Europe (4.3%, p=0.03). Despite differences in frailty, survival did not differ between groups (p=0.2). LMIC-born immigrants demonstrated higher levels of frailty in Northern/Western Europe, but not Southern/Eastern Europe. Country of birth and current country of residence were each associated with frailty. Life course influences are demonstrable, but complex.

Disparities in chronic conditions and health status by type of disability

BACKGROUND

Prior research has established health disparities between people with and without disabilities. However, disparities within the disability population, such as those related to type of disability, have been much less studied.

OBJECTIVE

To examine differences in chronic conditions and health status between subgroups of people with different types of disability.

METHODS

We analyzed Medical Expenditure Panel Survey annual data files from 2002 to 2008. Logistic regression analyses considered disparity from three perspectives: 1) basic differences, unadjusted for other factors; 2) controlling for key demographic and health covariates; and 3) controlling for a larger set of demographic variables and socioeconomic status as well as health and access to healthcare.

RESULTS

Individuals with vision, physical, cognitive, or multiple disability types fared worse than people with hearing impairment on most health outcomes. This was most consistently true for people with multiple disabilities. Even when all covariates were accounted for, people with multiple types of disability were significantly more likely (p < 0.05) than those with hearing impairment (reference group) to report every poor health outcome with the exception of BMI ≥ 25 and lung disease.

CONCLUSIONS

While many of the differences between disability types were reduced when controlling for other factors, some differences remained significant. This argues for a more individualized approach to understanding and preventing chronic conditions and poor health in specific disability groups.