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Welch V, Dewidar O, Tanjong Ghogomu E, Abdisalam S, Al Ameer A, Barbeau VI, Brand K, Kebedom K, Benkhalti M, Kristjansson E, Madani MT, Antequera Martín AM, Mathew CM, McGowan J, McLeod W, Park HA, Petkovic J, Riddle A, Tugwell P, Petticrew M, Trawin J, Wells GA. How effects on health equity are assessed in systematic reviews of interventions. Cochrane Database Syst Rev 2022; 1:MR000028. [PMID: 35040487 PMCID: PMC8764740 DOI: 10.1002/14651858.mr000028.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Enhancing health equity is endorsed in the Sustainable Development Goals. The failure of systematic reviews to consider potential differences in effects across equity factors is cited by decision-makers as a limitation to their ability to inform policy and program decisions. OBJECTIVES: To explore what methods systematic reviewers use to consider health equity in systematic reviews of effectiveness. SEARCH METHODS We searched the following databases up to 26 February 2021: MEDLINE, PsycINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Hein Index to Foreign Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on 10 June 10 2021. We contacted authors and searched the reference lists of included studies to identify additional potentially relevant studies. SELECTION CRITERIA We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. We define health inequalities as unfair and avoidable differences across socially stratifying factors that limit opportunities for health. We operationalised this by assessing studies which evaluated differences in health across any component of the PROGRESS-Plus acronym, which stands for Place of residence, Race/ethnicity/culture/language, Occupation, Gender or sex, Religion, Education, Socioeconomic status, Social capital. "Plus" stands for other factors associated with discrimination, exclusion, marginalisation or vulnerability such as personal characteristics (e.g. age, disability), relationships that limit opportunities for health (e.g. children in a household with parents who smoke) or environmental situations which provide limited control of opportunities for health (e.g. school food environment). DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a pre-tested form. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews. MAIN RESULTS: In total, 48,814 studies were identified and the titles and abstracts were screened in duplicate. In this updated review, we identified an additional 124 methodological studies published in the 10 years since the first version of this review, which included 34 studies. Thus, 158 methodological studies met our criteria for inclusion. The methods used by these studies focused on evidence relevant to populations experiencing health inequity (108 out of 158 studies), assess subgroup analysis across PROGRESS-Plus (26 out of 158 studies), assess analysis of a gradient in effect across PROGRESS-Plus (2 out of 158 studies) or use a combination of subgroup analysis and focused approaches (20 out of 158 studies). The most common PROGRESS-Plus factors assessed were age (43 studies), socioeconomic status in 35 studies, low- and middle-income countries in 24 studies, gender or sex in 22 studies, race or ethnicity in 17 studies, and four studies assessed multiple factors across which health inequity may exist. Only 16 studies provided a definition of health inequity. Five methodological approaches to consider health equity in systematic reviews of effectiveness were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (140 of 158 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (50 studies); 3) analytic approaches which assessed differential effects across one or more PROGRESS-Plus factors (16 studies); 4) applicability assessment (25 studies) and 5) stakeholder engagement (28 studies), which is a new finding in this update and examines the appraisal of whether relevant stakeholders with lived experience of health inequity were included in the design of systematic reviews or design and delivery of interventions. Reporting for both approaches (analytic and applicability) lacked transparency and was insufficiently detailed to enable the assessment of credibility. AUTHORS' CONCLUSIONS There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to consider health equity in systematic reviews of effectiveness.
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Affiliation(s)
- Vivian Welch
- Methods Centre, Bruyère Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Omar Dewidar
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | | | | | | | | | - Kevin Brand
- Telfer School of Management, University of Ottawa, Ottawa, Canada
| | | | | | | | | | | | | | - Jessie McGowan
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | | | | | - Alison Riddle
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Marmora, Canada
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Mark Petticrew
- Department of Social & Environmental Health Research, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Toselli S, Gualdi-Russo E, Mazzuca P, Campa F. Ethnic differences in body composition, sociodemographic characteristics and lifestyle in people with type 2 diabetes mellitus living in Italy. Endocrine 2019; 65:558-568. [PMID: 31368082 DOI: 10.1007/s12020-019-02031-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/19/2019] [Indexed: 01/02/2023]
Abstract
This study aimed to compare immigrants and Italian natives with type 2 diabetes mellitus (DM2) in terms of anthropometric parameters and lifestyle-related characteristics and to investigate the relationship between ethnicity and glycemic control in men and women with DM2 living in Italy. The sample included 100 immigrants (55 Albanians and 45 Africans) and 100 Italians, followed by the Public Health Clinics of Rimini. The association of ethnicity with sex, socioeconomic status, anthropometric and hematological characteristics, and lifestyle were examined. In addition, differences among groups in glycemic control were evaluated. Among males, African participants presented significantly lower values than other groups in adiposity parameters and triglycerides. The highest percentage of obesity and of normal weight was found in Italians and in Africans, respectively. Among females, there were scanty differences, but Italians presented higher WHR values than the other groups. No statistical differences appeared in hematological parameters among groups. There were no significant differences in glycemic control among groups and sexes. Also considering the differences between subjects with optimal (L) or nonoptimal (H) glycemic control, the differences in lifestyle, anthropometric, and hematological variables remained scarce. Among all groups, significantly higher values of glucose were detected in H than in L. A similar condition appeared for triglycerides in males. Immigrant and native Italian diabetics did not present any difference in their clinical characteristics, but Italians generally presented worst lifestyle habits. The percentage of subjects with poor metabolic control of diabetes was not low, but similar in immigrants and natives.
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Affiliation(s)
- Stefania Toselli
- Departments of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Emanuela Gualdi-Russo
- Department of Biomedical Sciences and Surgical Specialties, University of Ferrara, Ferrara, Italy
| | - Paolo Mazzuca
- Unit of Internal Medicine, Diabetes and Metabolic Disease Center, Romagna Health District, Rimini, Italy
| | - Francesco Campa
- Departments of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.
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Jull J, Whitehead M, Petticrew M, Kristjansson E, Gough D, Petkovic J, Volmink J, Weijer C, Taljaard M, Edwards S, Mbuagbaw L, Cookson R, McGowan J, Lyddiatt A, Boyer Y, Cuervo LG, Armstrong R, White H, Yoganathan M, Pantoja T, Shea B, Pottie K, Norheim O, Baird S, Robberstad B, Sommerfelt H, Asada Y, Wells G, Tugwell P, Welch V. When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework. BMJ Open 2017; 7:e015815. [PMID: 28951402 PMCID: PMC5623521 DOI: 10.1136/bmjopen-2016-015815] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 07/07/2017] [Accepted: 07/31/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials. METHODS An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials. RESULTS A randomised trial can usefully be classified as 'health equity relevant' if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as 'health equity relevant' may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies. CONCLUSION The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.
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Affiliation(s)
- J Jull
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - M Whitehead
- Department of Public Health and Policy, University of Liverpool, Liverpool, UK
| | - M Petticrew
- Department of Social and Environmental Health Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - E Kristjansson
- Centre for Research on Educational and Community Services, School of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - D Gough
- Department of Social Science, Evidence for Policy and Practice Information and Co-ordinating Centre, Social Science Research Unit, University College London, London, UK
| | - J Petkovic
- Bruyère Continuing Care, Bruyère Research Institute, Elisabeth Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - J Volmink
- The South African Cochrane Center, South African Medical Research Council, Cape Town, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - C Weijer
- Rotman Institute of Philosophy, University of Western Ontario, Ontario, Canada
| | - M Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - S Edwards
- Research Ethics and Governance, University College London, London, UK
| | - L Mbuagbaw
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - R Cookson
- Centre for Health Economics, University of York, York, UK
| | - J McGowan
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - A Lyddiatt
- Cochrane Musculoskeletal Group, Ontario, Canada
| | - Y Boyer
- Brandon University, Brandon, Manitoba, Canada
| | - L G Cuervo
- Office of Knowledge Management, Bioethics and Research, Pan American Health Organization/World Health Organization, Washington, District of Columbia, USA
| | - R Armstrong
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - H White
- Campbell Collaboration, New Delhi, India
| | - M Yoganathan
- Bruyère Continuing Care, Bruyère Research Institute, Elisabeth Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - T Pantoja
- Department of Family Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - B Shea
- Bruyère Continuing Care, Bruyère Research Institute, Elisabeth Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - O Norheim
- Centre for Intervention Science in Matnernal and Child Health (CISMAC), University of Bergen, Bergen, Norway
- Department of Global Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - S Baird
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - B Robberstad
- Centre for Intervention Science in Matnernal and Child Health (CISMAC), University of Bergen, Bergen, Norway
- Centre for International Health, University of Bergen, Bergen, Norway
| | - H Sommerfelt
- Centre for Intervention Science in Matnernal and Child Health (CISMAC), University of Bergen, Bergen, Norway
- Centre for International Health, University of Bergen, Bergen, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - Y Asada
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - G Wells
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - P Tugwell
- Bruyère Continuing Care, Bruyère Research Institute, Elisabeth Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - V Welch
- Bruyère Continuing Care, Bruyère Research Institute, Elisabeth Bruyere Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Testa R, Bonfigli AR, Genovese S, Ceriello A. Focus on migrants with type 2 diabetes mellitus in European Countries. Intern Emerg Med 2016; 11:319-26. [PMID: 26688327 DOI: 10.1007/s11739-015-1350-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/29/2015] [Indexed: 12/27/2022]
Abstract
The prevalence of type 2 diabetes mellitus, one of the major causes of morbility and mortality in Europe, is increasing in all European countries. Diabetes is not distributed equally among all population groups, as higher incidence, appearance of complications, and different mortality rates have been observed among migrants and the native population. These differences may be due to genetic profiles, lifestyle, and utilization of the health care system in different ways. Taking into account that the quantity of migrants is nowadays increasing, mainly in the southern part of Europe, the knowledge of diabetes in migrants through a better collection of data is necessary, considering that few limited epidemiological studies have evaluated the importance of this problem in EU countries. A special effort in developing a comprehensive management for native and immigrant populations in order to prevent and cure diabetes should be mandatory. This activity could be helpful to limit the incidence of future diabetes complications and to avoid the consequent burden of the health care system along with a control on its costs. It is clear that diabetes complication prevention is essential for long-term sustainability of the health care system.
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Affiliation(s)
- Roberto Testa
- Experimental Models in Clinical Pathology, INRCA-IRCCS National Institute, Ancona, Italy
| | | | - Stefano Genovese
- Department of Cardiovascular and Metabolic Diseases, IRCCS Gruppo Multimedica, Sesto San Giovanni, Italy
| | - Antonio Ceriello
- Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), C/Rosselló, 149-153, 08036, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain.
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Lane NE, Maxwell CJ, Gruneir A, Bronskill SE, Wodchis WP. Absence of a Socioeconomic Gradient in Older Adults' Survival with Multiple Chronic Conditions. EBioMedicine 2015; 2:2094-100. [PMID: 26844290 PMCID: PMC4703730 DOI: 10.1016/j.ebiom.2015.11.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/06/2015] [Accepted: 11/10/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Individuals of low socioeconomic status experience a disproportionate burden of chronic conditions; however it is unclear whether chronic condition burden affects survival differently across socioeconomic strata. METHODS This retrospective cohort study used health administrative data from all residents of Ontario, Canada aged 65 to 105 with at least one of 16 chronic conditions on April 1, 2009 (n = 1,518,939). Chronic condition burden and unadjusted mortality were compared across neighborhood income quintiles. Multivariable Cox proportional hazards models were used to examine the effect of number of chronic conditions on two-year survival across income quintiles. FINDINGS Prevalence of five or more chronic conditions was significantly higher among older adults in the poorest neighborhoods (18.2%) than the wealthiest (14.3%) (Standardized difference > 0·1). There was also a socioeconomic gradient in unadjusted mortality over two years: 10.1% of people in the poorest neighborhoods died compared with 7.6% of people in the wealthiest neighborhoods. In adjusted analyses, having more chronic conditions was associated with a statistically significant increase in hazard of death over two years, however the magnitude of this effect was comparable across income quintiles. Individuals in the poorest neighborhoods with four chronic conditions had 2.07 times higher hazard of death (95% CI: 1.97-2.19) than those with one chronic condition, but this was comparable to the hazard associated with four chronic conditions in the wealthiest neighborhoods (HR: 2.29, 95% CI: 2.16-2.43). INTERPRETATION Among older adults with universal access to health care, the deleterious effect of increasing chronic condition burden on two-year hazard of death was consistent across neighborhood income quintiles once baseline differences in condition burden were accounted for. This may be partly attributable to equal access to, and utilization of, health care. Alternate explanations for these findings, including study limitations, are also discussed.
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Affiliation(s)
- Natasha E Lane
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, N2L 3G1, Canada
| | - Andrea Gruneir
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Women's College Hospital, 790 Bay Street, Toronto, Ontario M5G 1N8, Canada; Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta T6G 2T4, Canada
| | - Susan E Bronskill
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, 4th Floor, Toronto, Ontario M5T 3M6, Canada; Institute for Clinical Evaluative Sciences, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Toronto Rehabilitation Institute, 550 University Avenue, Toronto, Ontario M5G 2A2, Canada
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Modesti PA, Bianchi S, Borghi C, Cameli M, Capasso G, Ceriello A, Ciccone MM, Germanò G, Maiello M, Muiesan ML, Novo S, Padeletti L, Palmiero P, Pillon S, Rotella CM, Saba PS, Scicchitano P, Trimarco B, Volpe M, Pedrinelli R, Di Biase M. Cardiovascular health in migrants: current status and issues for prevention. A collaborative multidisciplinary task force report. J Cardiovasc Med (Hagerstown) 2015; 15:683-92. [PMID: 25090156 DOI: 10.2459/jcm.0000000000000069] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To review information on cardiovascular health and migration, to stress the attention of researchers that much needs to be done in the collection of sound data in Italy and to allow policy makers identifying this issue as an important public health concern. BACKGROUND In Italy, the rate of immigrants in the total number of residents increased from 2.5% in 1990 to 7.4% in 2010, and currently exceeds 10% in regions such as Lombardia, Emilia Romagna and Toscana. METHODS A consensus statement was developed by approaching relevant Italian national scientific societies involved in cardiovascular prevention. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. To obtain a widespread consensus, drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft was finally approved by scientific societies. RESULTS In several western European countries, the prevalence of hypertension, diabetes, chronic kidney disease, obesity and metabolic syndrome was found to be higher among immigrants than in the native population. Although migrants are often initially healthier than non-migrant populations in their host countries, genetic factors, and changing environments with lifestyle changes, social exclusion and insufficient medical control may expose them to health challenges. Cultural reasons may also hamper both the dissemination of prevention strategies and migrant communication with healthcare providers. However, great diversity exists across and within different groups of migrants, making generalizations very difficult and many countries do not collect registry or survey data for migrant's health. CONCLUSIONS In the present economic context, the European Union is placing great attention to improve data collection for migrant health and to support the implementation of specific prevention policies aimed at limiting the future burden of cardiovascular and renal disease, and the consequent load for health systems. Wider initiatives on the topic are awaited in Italy.
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Affiliation(s)
- Pietro A Modesti
- aDepartment of Medicina Sperimentale e Clinica, University of Florence, Florence bDepartment of Medicina Interna, Nefrologia e Dialisi, Ospedali Riuniti di Livorno, Livorno cDepartment of Scienze Mediche e Chirurgiche, S.Orsola-Malpighi University Hospital, Bologna dDepartment of Malattie Cardiovascolari, University of Siena, Siena eDepartment of Nephrology, Second University of Naples, Naples, Italy fInstitute d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain gDepartment of Emergenza e dei trapianti d'Organo DETO, Sezione di Malattie dell'Apparato Cardiovascolare, University of Bari, Bari hDepartment of Scienze Cardiovascolari, Respiratorie, Geriatriche e Nefrologiche, University 'La Sapienza', Rome iAS Department of Cardiology, Brindisi District jDepartment of Clinical and Experimental Sciences, University of Brescia, Brescia kDivision of Cardiology, Dipartimanto di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, University of Palermo, Palermo lDepartment of Medicina Sperimentale e Clinica, University of Florence, Florence mDivision of Cardiology, ASL BR, Brindisi nUOD Telemedicina, Dipartimento Cardiovascolare, A.O.San Camillo-Forlanini, Roma oDivision of Cardiology, Department of Fisiopatologia Clinica - Sezione di Endocrinologia, University of Florence, Florence pDivision of Cardiology, AOU Sassari, Sassari qDepartment of Emergenza e dei trapianti d'Organo DETO, Sezione di Malattie dell'Apparato Cardiovascolare, University of Bari, Bari rDepartment of Advanced Biomedical Sciences, Federico II University, Naples sDivision of Cardiology, Department of Medicina Clinica e Molecolare, Facoltà di Medicina e Psicologia Università di Roma 'Sapienza' - Azienda Ospedaliera Sant'Andrea, and IRCCS Neuromed, Rome tDepartment Cardio Toracico e Vascolare, University of Pisa, Pisa uDepartment of Scienze Mediche e Chirurgiche, University of Foggia, Foggia, Italy
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Kapral MK, Fang J, Chan C, Alter DA, Bronskill SE, Hill MD, Manuel DG, Tu JV, Anderson GM. Neighborhood income and stroke care and outcomes. Neurology 2012; 79:1200-7. [PMID: 22895592 DOI: 10.1212/wnl.0b013e31826aac9b] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate factors that may contribute to the increased stroke case fatality rates observed in individuals from low-income areas. METHODS We conducted a cohort study on a population-based sample of all patients with stroke or TIA seen at 153 acute care hospitals in the province of Ontario, Canada, between April 1, 2002, and March 31, 2003, and April 1, 2004, and March 31, 2005. Socioeconomic status measured as income quintiles was imputed from median neighborhood income. In the study sample of 7,816 patients we determined 1-year mortality by grouped income quintile and used multivariable analyses to assess whether differences in survival were explained by cardiovascular risk factors, stroke severity, stroke management, or other prognostic factors. RESULTS There was no significant gradient across income groups for stroke severity or stroke management. However, 1-year mortality rates were higher in those from the lowest income group compared to those from the highest income group, even after adjustment for age, sex, stroke type and severity, comorbid conditions, hospital and physician characteristics, and processes of care (adjusted hazard ratio for low- vs high-income groups, 1.18; 95 confidence interval 1.03 to 1.29). CONCLUSIONS In Ontario, 1-year survival rates after an index stroke are higher for those from the richest compared to the least wealthy areas, and this is only partly explained by age, sex, comorbid conditions, and other baseline risk factors.
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Affiliation(s)
- Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, Canada.
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Manuel DG, Rosella LC, Hennessy D, Sanmartin C, Wilson K. Predictive risk algorithms in a population setting: an overview. J Epidemiol Community Health 2012; 66:859-65. [PMID: 22859516 DOI: 10.1136/jech-2012-200971] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health. OBJECTIVE To describe the role of predictive risk algorithms in a population setting. METHODS First, predictive risk algorithms and how clinicians use them are described. Second, the population uses of risk algorithms are described, highlighting the strengths of risk algorithms for health planning. Lastly, the way in which predictive risk algorithms are developed is discussed briefly and a guide for algorithm assessment in population health presented. CONCLUSION For the past 20 years, absolute and baseline risk has been a cornerstone of population health planning. The most accurate and discriminating method to generate such estimates is the use of multivariable risk algorithms. Routinely collected data can be used to develop algorithms with characteristics that are well suited to health planning and such data are increasingly available. The widespread use of risk algorithms in clinical medicine is testimony to how they have helped transform clinical decision-making. Risk algorithms have a similar but underdeveloped potential to support decision-making for population health.
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Lumme S, Sund R, Leyland AH, Keskimäki I. Socioeconomic equity in amenable mortality in Finland 1992-2008. Soc Sci Med 2012; 75:905-13. [PMID: 22647563 DOI: 10.1016/j.socscimed.2012.04.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 02/16/2012] [Accepted: 04/13/2012] [Indexed: 11/29/2022]
Abstract
This study presents an approach to assess socioeconomic equity in the effectiveness of health services. As an indicator of health system performance we use amenable mortality which captures premature deaths that should not occur in the presence of effective and timely health care. Data on amenable deaths by income groups in Finland in 1992-2008 came from the National Causes of Death Register which was linked to sociodemographic data in population registers. We evaluate the extent of and trends in socioeconomic differences with two widely used inequity indices, the concentration index and the slope index of inequality, and also for different categories of amenable mortality. By categorizing conditions according to the level of intervention associated with the conditions it is possible to evaluate the effect of types of health interventions. Causes of death attributable to specialized and primary care interventions comprise the main groups. By this approach of decomposing equity in amenable mortality in Finland we detected major and increasing socioeconomic inequities and also greater inequity among deaths amenable to specialized health care interventions. Moreover, we saw that inequity increased at a faster pace among deaths amenable to specialized health care interventions yet primary health care interventions made a greater contribution to overall inequity. Although the overall rate of amenable mortality decreased notably during the follow-up, the time trends of socioeconomic differences in amenable health care indicate a substantial increase in inequities in health care in Finland.
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Affiliation(s)
- Sonja Lumme
- The National Institute for Health and Welfare (THL), Health and Social Services, Service System Department, Helsinki, Finland.
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Maindal HT, Skriver MV, Kirkevold M, Lauritzen T, Sandbaek A. Comorbidity and lack of education countered participation in a diabetes prevention self-management program. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1752-9824.2011.01103.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mustard CA, Bielecky A, Etches J, Wilkins R, Tjepkema M, Amick BC, Smith PM, Aronson KJ. Avoidable mortality for causes amenable to medical care, by occupation in Canada, 1991-2001. Canadian Journal of Public Health 2011. [PMID: 21370790 DOI: 10.1007/bf03403973] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the incidence of avoidable mortality for causes amenable to medical care among occupation groups in Canada. METHOD A cohort study over an 11-year period among a representative 15% sample of the non-institutionalized population of Canada aged 30-69 at cohort inception. Age-standardized mortality rates for causes amenable to medical care and all other causes of death were calculated for occupationally-active men and women in five categories of skill level and 80 specific occupational groups as well as for persons not occupationally active. RESULTS Age-standardized mortality rates per 100,000 person-years at risk for causes amenable to medical care and for all other causes were 132.3 and 218.6, respectively, for occupationally-active women, and 216.6 and 449.3 for occupationally-active men. For causes amenable to medical care and for all other causes, for both sexes, there was a gradient in mortality relative to the five-level ranking by occupational skill level, but the gradient was less strong for women than for men. Across the 80 occupation minor groups, for both men and women, there was a linear relationship between the rates for causes amenable to medical care and the rates for all other causes. CONCLUSIONS For occupationally-active adults, this study found similar gradients in mortality for causes amenable to medical care and for all other causes of mortality over the period 1991-2001. Avoidable mortality is a valuable indicator of population health, providing information on outcomes pertinent to the organization and delivery of health care services.
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Welch V, Tugwell P, Petticrew M, de Montigny J, Ueffing E, Kristjansson B, McGowan J, Benkhalti Jandu M, Wells GA, Brand K, Smylie J. How effects on health equity are assessed in systematic reviews of interventions. Cochrane Database Syst Rev 2010; 2010:MR000028. [PMID: 21154402 PMCID: PMC7391240 DOI: 10.1002/14651858.mr000028.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Enhancing health equity has now achieved international political importance with endorsement from the World Health Assembly in 2009. The failure of systematic reviews to consider effects on health equity is cited by decision-makers as a limitation to their ability to inform policy and program decisions. OBJECTIVES To systematically review methods to assess effects on health equity in systematic reviews of effectiveness. SEARCH STRATEGY We searched the following databases up to July 2 2010: MEDLINE, PsychINFO, the Cochrane Methodology Register, CINAHL, Education Resources Information Center, Education Abstracts, Criminal Justice Abstracts, Index to Legal Periodicals, PAIS International, Social Services Abstracts, Sociological Abstracts, Digital Dissertations and the Health Technology Assessment Database. We searched SCOPUS to identify articles that cited any of the included studies on October 7 2010. SELECTION CRITERIA We included empirical studies of cohorts of systematic reviews that assessed methods for measuring effects on health inequalities. DATA COLLECTION AND ANALYSIS Data were extracted using a pre-tested form by two independent reviewers. Risk of bias was appraised for included studies according to the potential for bias in selection and detection of systematic reviews. MAIN RESULTS Thirty-four methodological studies were included. The methods used by these included studies were: 1) Targeted approaches (n=22); 2) gap approaches (n=12) and gradient approach (n=1). Gender or sex was assessed in eight out of 34 studies, socioeconomic status in ten studies, race/ethnicity in seven studies, age in seven studies, low and middle income countries in 14 studies, and two studies assessed multiple factors across health inequity may exist.Only three studies provided a definition of health equity. Four methodological approaches to assessing effects on health equity were identified: 1) descriptive assessment of reporting and analysis in systematic reviews (all 34 studies used a type of descriptive method); 2) descriptive assessment of reporting and analysis in original trials (12/34 studies); 3) analytic approaches (10/34 studies); and 4) applicability assessment (11/34 studies). Both analytic and applicability approaches were not reported transparently nor in sufficient detail to judge their credibility. AUTHORS' CONCLUSIONS There is a need for improvement in conceptual clarity about the definition of health equity, describing sufficient detail about analytic approaches (including subgroup analyses) and transparent reporting of judgments required for applicability assessments in order to assess and report effects on health equity in systematic reviews.
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Affiliation(s)
- Vivian Welch
- University of OttawaCentre for Global Health, Institute of Population Health1 Stewart Street, Room 206OttawaOntarioCanadaK1N 6N5
| | - Peter Tugwell
- Ottawa HospitalCentre for Global Health, Institute of Population Health, Department of Medicine1 Stewart StreetOttawaOntarioCanadaK1N 6N5
| | - Mark Petticrew
- London School of Hygiene and Tropical MedicineDepartment of Social & Environmental Health Research, Faculty of Public Health & Policy15‐17 Tavistock PlaceLondonUKWC1H 9SH
| | | | - Erin Ueffing
- University of OttawaCentre for Global Health, Institute of Population Health1 Stewart Street, Room 206OttawaOntarioCanadaK1N 6N5
| | - Betsy Kristjansson
- University of OttawaSchool of Psychology, Faculty of Social SciencesRoom 407C, Montpetit Hall125 UniversityOttawaOntarioCanadaK1N 6N5
| | - Jessie McGowan
- University of OttawaInstitute of Population Health/Ottawa Health Research Institute1 Stewart St. room 206OttawaOntarioCanadaK1N 6N5
| | - Maria Benkhalti Jandu
- University of OttawaCenter for Global Health, Institute of Population Health1 Stewart StreetOttawaONCanadaK1N 6N5
| | - George A Wells
- University of Ottawa Heart InstituteCardiovascular Research Reference CentreRoom H1‐140 Ruskin StreetOttawaOntarioCanadaK1Y 4W7
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Manuel DG, Rosella LC. Commentary: assessing population (baseline) risk is a cornerstone of population health planning--looking forward to address new challenges. Int J Epidemiol 2010; 39:380-2. [PMID: 20100821 PMCID: PMC2846444 DOI: 10.1093/ije/dyp373] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Douglas G Manuel
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, The Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada, Statistics Canada, Ottawa, Ontario, Canada, The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- *Corresponding author. Ottawa Hospital Research Institute, Room 1-008 Administrative Services Building, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada. E-mail:
| | - Laura C Rosella
- The Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada, The Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada, Statistics Canada, Ottawa, Ontario, Canada, The Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and Training (Writing Committee to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease): developed in collaboration with the American Academy of Neurology; American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Preventive Medicine; American College of Sports Medicine; American Diabetes Association; American Society of Hypertension; Association of Black Cardiologists; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute; National Lipid Association; and Preventive Cardiovascular Nurses Association. J Am Coll Cardiol 2009; 54:1336-63. [PMID: 19778678 DOI: 10.1016/j.jacc.2009.05.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Bairey Merz CN, Alberts MJ, Balady GJ, Ballantyne CM, Berra K, Black HR, Blumenthal RS, Davidson MH, Fazio SB, Ferdinand KC, Fine LJ, Fonseca V, Franklin BA, McBride PE, Mensah GA, Merli GJ, O'Gara PT, Thompson PD, Underberg JA. ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease. Circulation 2009; 120:e100-26. [DOI: 10.1161/circulationaha.109.192640] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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16
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Roberson DW. Inequities in screening for sexually transmitted infections in African American adolescents: can health policy help? J Transcult Nurs 2007; 18:286-91. [PMID: 17615655 DOI: 10.1177/1043659607301300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although rates of sexually transmitted infections (STIs) in African Americans are higher than other populations, there are disparities in the screening and treatment of STIs for African American adolescents. Many African Americans distrust the health care system, resulting in a reluctance to seek health care. Adolescents may lack access to and the resources to pay for health care. This article reviews historical events believed to influence African American distrust of the health care system, discusses socioeconomic factors influencing adolescent access to services, and offers descriptions of services available to assist adolescents in receiving preventative services. Last, potential health policy solutions for nurses are noted.
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Dans AM, Dans L, Oxman AD, Robinson V, Acuin J, Tugwell P, Dennis R, Kang D. Assessing equity in clinical practice guidelines. J Clin Epidemiol 2007; 60:540-6. [PMID: 17493507 DOI: 10.1016/j.jclinepi.2006.10.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Revised: 09/29/2006] [Accepted: 10/06/2006] [Indexed: 11/30/2022]
Abstract
Recognition of the need for systematically developed clinical practice guidelines (CPGs) has increased dramatically over the past 20 years. CPGs have focused primarily on the effectiveness of interventions, explicitly or implicitly addressing the following question: Will adherence to a recommendation do more good than harm? At times they have also focused on the cost-effectiveness of interventions: Are the net benefits worth the costs? They rarely have focused on equity: Are the recommendations fair? The Knowledge Plus Project of the International Clinical Epidemiology Network attempts to improve the process of CPG development by formulating strategies to consider not just technical issues (effectiveness, and efficiency) but sociopolitical dimensions as well (equity and local appropriateness). This article discusses a proposed lens for users to evaluate how well CPGs address issues of equity.
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Affiliation(s)
- Antonio Miguel Dans
- Department of Medicine, Philippine General Hospital, Section of Adult Medicine, Taft Avenue, Manila, The Philippines.
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18
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James PD, Wilkins R, Detsky AS, Tugwell P, Manuel DG. Avoidable mortality by neighbourhood income in Canada: 25 years after the establishment of universal health insurance. J Epidemiol Community Health 2007; 61:287-96. [PMID: 17372287 PMCID: PMC2652935 DOI: 10.1136/jech.2006.047092] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2006] [Indexed: 11/03/2022]
Abstract
AIM To examine neighbourhood income differences in deaths amenable to medical care and public health over a 25-year period after the establishment of universal insurance for doctors and hospital services in Canada. METHODS Data for census metropolitan areas were obtained from the Canadian Mortality Database and population censuses for the years 1971, 1986, 1991 and 1996. Deaths amenable to medical care, amenable to public health, from ischaemic heart disease and from other causes were considered. Data on deaths were grouped into neighbourhood income quintiles on the basis of the census tract percentage of population below Canada's low-income cut-offs. RESULTS From 1971 to 1996, differences between the richest and poorest quintiles in age-standardised expected years of life lost amenable to medical care decreased 60% (p<0.001) in men and 78% (p<0.001) in women, those amenable to public health increased 0.7% (p = 0.94) in men and 20% (p = 0.55) in women, those lost from ischaemic heart disease decreased 58% in men and 38% in women, and from other causes decreased 15% in men and 9% in women. Changes in the age-standardised expected years of life lost difference for deaths amenable to medical care were significantly larger than those for deaths amenable to public health or other causes for both men and women (p<0.001). CONCLUSIONS Reductions in rates of deaths amenable to medical care made the largest contribution to narrowing socioeconomic mortality disparities. Continuing disparities in mortality from causes amenable to public health suggest that public health initiatives have a potentially important, but yet un-realized, role in further reducing mortality disparities in Canada.
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Affiliation(s)
- Paul D James
- Institute for Clinical Evaluative Sciences, G-119, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada
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Avendano M, Boshuizen HC, Schellevis FG, Mackenbach JP, Van Lenthe FJ, Van den Bos GAM. Disparities in stroke preventive care in general practice did not explain socioeconomic disparities in stroke. J Clin Epidemiol 2006; 59:1285-94. [PMID: 17098571 DOI: 10.1016/j.jclinepi.2006.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2005] [Revised: 03/16/2006] [Accepted: 03/20/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess socioeconomic disparities in stroke incidence and in the quality of preventive care for stroke in the Netherlands. STUDY DESIGN AND SETTINGS A total of 190,664 patients who registered in 96 general practices were followed up for 12 months. Data were collected on diagnoses, referrals, prescriptions, and diagnostic procedures. Hazard ratios (HR) were calculated to assess the association between educational level and stroke incidence. Multilevel logistic regression was used to assess socioeconomic disparities in the quality of preventive care for stroke precursors. RESULTS Lower educational level was associated with higher incidence of stroke in men (HR=1.36, 95% CI=1.06-1.74) but not in women. Among both men and women, there were socioeconomic disparities in the prevalence of hypertension, hypercholesterolemia, diabetes, angina pectoris, heart failure, and peripheral artery disease. Lower educated hypercholesterolemia patients under medication were less likely to be prescribed statins (odds ratio=0.62, 95% CI=0.42-0.91). However, for other precursors of stroke, there were no major disparities in the quality of preventive care. CONCLUSION There are socioeconomic disparities in stroke incidence among men but not among women. Socioeconomic differences in factors such as hypertension and diabetes are likely to contribute to stroke disparities. However, general practitioners (GPs) provide care of a similar quality to patients from different socioeconomic groups.
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Affiliation(s)
- M Avendano
- Department of Public Health, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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Gushulak BD, MacPherson DW. The basic principles of migration health: population mobility and gaps in disease prevalence. Emerg Themes Epidemiol 2006; 3:3. [PMID: 16674820 PMCID: PMC1513225 DOI: 10.1186/1742-7622-3-3] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 05/04/2006] [Indexed: 11/11/2022] Open
Abstract
Currently, migrants and other mobile individuals, such as migrant workers and asylum seekers, are an expanding global population of growing social, demographic and political importance. Disparities often exist between a migrant population's place of origin and its destination, particularly with relation to health determinants. The effects of those disparities can be observed at both individual and population levels. Migration across health and disease disparities influences the epidemiology of certain diseases globally and in nations receiving migrants. While specific disease-based outcomes may vary between migrant group and location, general epidemiological principles may be applied to any situation where numbers of individuals move between differences in disease prevalence. Traditionally, migration health activities have been designed for national application and lack an integrated international perspective. Present and future health challenges related to migration may be more effectively addressed through collaborative global undertakings. This paper reviews the epidemiological relationships resulting from health disparities bridged by migration and describes the growing role of migration and population mobility in global disease epidemiology. The implications for national and international health policy and program planning are presented.
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Affiliation(s)
- Brian D Gushulak
- Migration Health Consultants, Inc., Vienna, Austria/Cheltenham, Ontario, Canada
| | - Douglas W MacPherson
- Migration Health Consultants, Inc., Vienna, Austria/Cheltenham, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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Tugwell P, Robinson V, Kristjansson E. The role of clinical epidemiology in health equity: Let's take action! J Clin Epidemiol 2005; 58:751-2. [PMID: 16018908 DOI: 10.1016/j.jclinepi.2005.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- P Tugwell
- Institute of Population Health, University of Ottawa, 1 Stewart St, 2nd floor, Ottawa, Ontario K1N 6N5.
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