Spatiotemporal Epidemiology of Female Thyroid Cancer: A Retrospective Population-Based Registry Study in the Hamadan Province, Iran (2010-2019).

Exploring the pattern of diseases in space and time enhances our understanding of truly needy areas. The present study aimed to explore spatiotemporal mapping of colorectal cancer (CRC) and gastric cancer (GC) incidence using Bayesian models and space-time scan statistics in Hamadan Province from 2010 to 2019. Study Design: An ecological time-series study. In this study, the data on CRC and GC cases were obtained from Hamadan cancer registry. The crude standardized incidence ratio (SIR) was calculated for each county per year. Hierarchical Bayesian space-time models were fitted to estimate adjusted SIRs. Space time cluster analysis was performed using space-time scan statistic. A total of 1864 CRC cases and 2340 GC cases were included in the analyses. The central counties, including Hamadan (smoothed SIR range: 1.24-1.28) and Tuyserkan (1.01-1.24), exhibited higher than expected number of CRC cases. Northern counties such as Razan (1.19-1.51) and Kabudarahang (1.21-1.42), along with Nahavand in the south (0.98, 1.53), also showed higher than expected number of GC cases. The most likely spatiotemporal cluster of CRC was identified in Hamadan and Tuyserkan occurring between 2015 and 2019 (relative risk [RR]=1.82, P<0.001). The most likely spatiotemporal cluster of GC was identified in Nahavand from 2010 to 2011 (RR=1.87, P<0.001). Spatiotemporal inequality in the incidence of CRC and GC was identified in Hamadan province over the past decade. The findings may help to reduce cancer disparities and allocate effective resources in the appropriate region and time in the future.

To evaluate the incidence and mortality trend of thyroid cancer, and compare its global incidence trends among different countries by age group and sex. Data on age-standardized incidence and mortality rate of thyroid cancer among 50 countries were collected from the Cancer Incidence in Five Continents Volume XI; the Surveillance, Epidemiology, and End Results Program (SEER), the National Cancer Institute; the Nordic Cancer Registries (NORDCAN), and the WHO mortality database. The Average Annual Percent Change (AAPC) of the incidence and mortality trends was calculated by joinpoint regression analysis. The age-standardized incidence of thyroid cancer was 3.1 and 10.1 cases per 100,000 persons in men and women, respectively. The incidence of thyroid cancer increased in most countries among individuals irrespective of age groups, and increased in populations aged <40 years in several countries, including Korea (male: AAPC 25.3, 95% C.I. 22.3-28.4, p < 0.001; female: AAPC 18.5, 95% C.I. 16.2-20.9, p < 0.001), Poland (male: AAPC 19.1, 95% C.I. 1.4-39.7, p = 0.036; female: AAPC 13.7, 95% C.I. 7.6-20.2), and China (male: AAPC 18.6, 95% C.I. 12.1-25.5, p < 0.001; female: AAPC 13.3, 95%C.I. 11.5-15.1, p < 0.001). An increasing incidence of thyroid cancer was observed in younger subjects in a majority of countries, highlighting the need for more preventive strategies in this population and possible avoidance of over-diagnosis.

This study was conducted to investigate the trend of some tuberculosis (TB) indices and identify existing gaps in addressing this important public health issue in Hamadan province over a long time period. Study Design: A registry-based cross-sectional study. In this study, we examined the trend of 10 TB indicators separately in males and females, including the incidence rates of smear-positive pulmonary TB (SPPT), extra-pulmonary TB (EPT), and smear-negative pulmonary TB (SNPT), co-infection with AIDS, relapse rate, smear conversion rate two months after treatment initiation, TB mortality rate, diagnosis rate of pulmonary TB with a smear grade of 3+, treatment success rate, and TB diagnosis rate by the private sector in Hamadan province during 2011-2022. The trend analysis of TB was conducted using Joinpoint regression model, and the annual percentage change (APC) and the average annual percentage change (AAPC) were calculated. A total of 481 females and 554 males were eligible for analysis. The incidence of SPPT in females showed a decreasing trend (AAPC: -7.72; 95% CI: -15.63, -1.10; P=0.008). The rates of EPT and treatment success showed a significant downward trend in both genders. In contrast, the recurrence rate among females exhibited a notable upward trend during the specified time period (AAPC: 18.45; 95% CI: 3.23, 46.47; P=0.0002). The findings of this study suggest that the epidemiological profile of TB has exhibited a relatively favorable trend in some of the examined indicators since 2011, with declines observed in both SPPT and EPT.

Background:Tuberculosis (TB) despite being preventive and treatable still imposes a huge burden of morbidity and mortality in developing and developed countries. We aimed to investigate the spatial and geographical distribution of TB in Hamadan province during 1992–2013.Materials and Methods:This cross-sectional study was performed in Hamadan province, West of Iran using the surveillance database. We examined the trend for incidence rates of all TB forms including Smear Positive Pulmonary TB (SPPT), Smear Negative Pulmonary TB (SNPT) and Extra pulmonary TB (EPT) per 100,000 populations. Poisson regression model was used to estimate the standardized rates for incidence rate of all types of TB per each county.Results:In this study 3,602 TB patients including 1,359 SPPT, 987 SNPT, and 1,256 EPT were included during 1992–2013. Trend of all types of TB decreased from 1992 to 2013. The Average Annual Percent change (AAPC) for all types of TB was significantly (P<0.05) decreased, AAPC= −6.4 (95% CIs: −10.7, −1.9). Among SPPT, SNPT, and EPT incidence rates, the maximum change was related to SNPT (−11.6; 95% CIs: −24.2, 3), while it was −1.4 (−8.7, 6.4) for SPPT and −5.8 (−11.4, 0.1) for EPT.Conclusion:Our results showed that the incidence of TB in Hamadan province during a 22-year period has decreased 6.4% on average, somehow higher than the national average. Furthermore, our study showed that the risk of extra-pulmonary occurrence in western parts of the province is higher than others parts.

BackgroundState-level racial/ethnic and age differences and the temporal trend of thyroid cancer (TC) incidence in the USA remain unknown. Our research purposes include: Characterizing state-level temporal variation in TC incidence; examining the disparities of TC incidence by state-level race/ethnicity and age; performing an ecological correlation between TC incidence and obesity/physical activity.MethodsTC incidence data during 2000–2017 were extracted from the United States cancer statistics. Using joinpoint regression to evaluate TC incidence trends. Annual percent change (APC), average APC (AAPC) and incidence rates were calculated. The obesity prevalence and physical activity level at the state-level were extracted from Behavioral Risk Factor Surveillance System, and the association between state-level AAPC of TC and obesity/physical activity was tested by Pearson correlation coefficient.ResultsWe found that the TC incidence had shown an overall downward trend in recent years, but 10 states continued increasing. There were significant differences in state-level race/ethnicity (non-Hispanic Whites as a reference) and age group (45–59 age group as a reference) incidence: Incidence Rate Ratio (IRR) was 0.4–1.2 for non-Hispanic Blacks, 0.7–1.6 for non-Hispanic Asian and Pacific Islanders, 0.4–1.2 for non-Hispanic American Indians/Alaskan Natives, and 0.5–1.3 for Hispanics. High IRR in young people were distributed in northern USA, while in older people were distributed in south. The state-level obesity/physical activity level and AAPC had a weak correlation (r = 0.34, P = 0.016) and inverse weak correlation (r = -0.29, P = 0.037), respectively. The AAPC of states with a consistent increasing trend had an extremely strong correlation with obesity prevalence (r = 0.80, p = 0.006), and an inverse strong correlation with physical activity level (r = -0.65, P = 0.04).ConclusionsThyroid cancer incidence in 10 states continued increasing. State-level variation in race/ethnicity and age group incidence were found. Lifestyle and environmental factors may interfere with the incidence trend of TC in the USA.

The incidence of thyroid cancer (TC) is increasing annually worldwide, with a growing burden. This study aims to analyze temporal trends in the burden of TC by age and sex in China and globally from 1990 to 2021, including incidence, prevalence, mortality, and disability-adjusted life years (DALYs) rates, and to predict future trends. We obtained data on TC in China and globally from 1990 to 2021 from the Global Burden of Disease (GBD) database. Using the Joinpoint regression model, we calculated and analyzed the trends in age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR). Specifically, we estimated the annual percent change (APC), the average annual percent change (AAPC), and the corresponding 95% confidence intervals (95% CI) for each metric. Additionally, we conducted a decomposition analysis to investigate the impact of aging, population growth, and epidemiological factors on the incidence and mortality rates of TC. Furthermore, the autoregressive integrated moving average (ARIMA) model was employed to predict the burden of TC from 2022 to 2036. From 1990 to 2021, the ASIR for TC in China increased from 1.249 (95% uncertainty interval [UI]: 1.009–1.473) per 100,000 to 2.473 (95% UI: 1.993–3.088) per 100,000. Conversely, the ASMR decreased from 0.473 (95% UI: 0.403–0.550) per 100,000 to 0.387 (95% UI: 0.307–0.472) per 100,000. Both males and females demonstrated an upward trajectory in ASIR. However, while the ASMR for females decreased, that for males showed an overall increase despite a decline in the last decade. The age of peak onset for TC ranged from 30 to 79 years, whereas the age of peak mortality was between 50 and 89 years. The analysis using the AAPC indicates that the growth in the ASIR (AAPC = 2.242, 95% CI: 2.112–2.371) and ASPR (AAPC = 2.975, 95% CI: 2.833–3.117) in China exceeds the global rate. Furthermore, the reduction in ASMR (AAPC = -0.651, 95% CI: -0.824 - -0.479) and ASDR (AAPC = -0.590, 95% CI: -0.787 - -0.392) in China is also more pronounced than globally. Decomposition analysis indicates that the increasing TC burden in China is primarily driven by population aging, whereas globally, population growth plays a more significant role. Projections based on predictive models suggest that from 2021 to 2036, the ASIR for both China and the global population is expected to continue rising, while the ASMR is anticipated to decline further. The incidence rates of TC in China and globally have shown a continuous upward trend, which is expected to persist over the next 15 years. Additionally, although the number of male TC cases is relatively lower compared to females, the overall ASMR and ASDR for males have shown an upward trend, despite a slight decline in recent years. This highlights the need to enhance prevention, diagnosis, and treatment measures, and to develop differentiated screening and treatment strategies based on age and sex.

Thyroid cancer constitutes a major and increasing proportion of head and neck cancers in children and adolescents. The purpose of this study was to determine the incidence and survival of thyroid cancer in Danish patients aged 0-24 years from 1980 to 2014. Patients aged 0-24 years registered with primary thyroid cancer in the Danish Cancer Registry or the Danish Pathology Data Bank during 1980-2014 were included. Crude incidence rates and age-adjusted incidence rates (AAIR) per 100,000, average annual percent change (AAPC), and overall survival (OS) were evaluated in relation to sex, histopathological tumor type, age at diagnosis, and year of diagnosis. A total of 297 thyroid cancer patients (72% female, 72% papillary carcinoma) were identified. The AAIR per 100,000 increased significantly from 0.36 in 1980 to 0.97 in 2014, with an AAPC of 2.9%. There was no significant increase in incidence among children and adolescents (0-17 years). However, among young adults (18-24 years), a significant increase in incidence was observed (AAPC 3.7%). The incidence of thyroid cancer increased with age from 0.05 among infants aged 0 years to 1.73 among young adults aged 24 years. Female patients and papillary carcinoma showed significant increase in incidence (AAPC 3.3% and 3.2%), whereas male patients and other histopathological tumor types showed no change. The 15-year OS was 99%. The lowest 15-year OS was observed among patients with medullary carcinomas at 96%. There was no significant difference in OS between groups based on histopathological tumor type, and there was no significant change in OS over time. In this nationwide study, no change in OS was observed, but a significant increase was seen in the incidence of thyroid cancer among young adults (aged 18-24 years), mainly attributed to an increase among females and patients with papillary carcinoma. No increase in incidence was seen among children and adolescents. These findings demonstrate the excellent prognosis for children and adolescents diagnosed with thyroid cancer.

Thyroid cancer (TC) represents the most common endocrine malignancy worldwide, with incidence increasing rapidly across diverse geographic regions. However, population-based evidence from North Africa remains limited, and comprehensive longitudinal analyses examining sex-specific incidence patterns, histological subtypes, and trends in tumor extension are lacking in Tunisia. This study aimed to (i) quantify TC incidence trends by sex and age group, (ii) characterize histological subtype-specific temporal patterns and tumor extension at diagnosis in northern Tunisia between 2000 and 2018, and (iii) to address projections in incidence by sex until 2040. A retrospective, population-based registry study was conducted using data from the Northern Tunisia Cancer Registry (NTCR), covering 11 governorates with a population of 5,233,700 in 2018. All primary invasive TC cases diagnosed between 2000 and 2018 were included (n = 3639). Age-standardized incidence rates (ASIRs) were calculated using the WHO standard population. Temporal trends were assessed using Joinpoint regression to estimate average annual percentage change (AAPC) with 95% confidence intervals. Projections of TC incidence to 2040 were generated using Bayesian autoregressive age-period-cohort models. TC incidence increased significantly between 2000 and 2018, with overall ASIR rising from 2.8 to 5.0 per 100,000 person-years (AAPC = 3.8%, p < 0.001). In males, ASIR increased from 0.9 to 2.4 (AAPC = 3.0%, p < 0.001), while in females it rose from 3.7 to 7.8 (AAPC = 4.3%, 95% CI: 3.0-5.7; p < 0.001). The increase was predominantly driven by papillary thyroid carcinoma (PTC) (AAPC = 6.4% in males; 5.8% in females; both p < 0.001), whereas follicular thyroid carcinoma (FTC) remained stable. Notably, the proportion of metastatic cases decreased significantly in females (AAPC = -7.2%, p = 0.033), and the proportion of regionally advanced disease decreased in males (AAPC = -5.0%, p = 0.034). This population-based study demonstrates a sustained rise in TC incidence in northern Tunisia, disproportionately affecting women and largely driven by papillary histology. The concurrent increase in TC incidence alongside a reduction in regional and metastatic extension at diagnosis occurred. These findings have important implications for cancer prevention and control, highlighting the need for risk-adapted screening strategies and rationalized diagnostic practices.

Fasciolosis caused by Fasciola hepatica is a widespread parasitic disease in cattle farms. The aim of this study was to detect clusters of fasciolosis in dairy cow herds in Munster Province, Ireland and to identify significant climatic and environmental predictors of the exposure risk. In total, 1,292 dairy herds across Munster was sampled in September 2012 providing a single bulk tank milk (BTM) sample. The analysis of samples by an in-house antibody-detection enzyme-linked immunosorbent assay (ELISA), showed that 65% of the dairy herds (n = 842) had been exposed to F. hepatica. Using the Getis-Ord Gi* statistic, 16 high-risk and 24 low-risk (P &lt;0.01) clusters of fasciolosis were identified. The spatial distribution of high-risk clusters was more dispersed and mainly located in the northern and western regions of Munster compared to the low-risk clusters that were mostly concentrated in the southern and eastern regions. The most significant classes of variables that could reflect the difference between high-risk and low-risk clusters were the total number of wet-days and rain-days, rainfall, the normalized difference vegetation index (NDVI), temperature and soil type. There was a bigger proportion of well-drained soils among the low-risk clusters, whereas poorly drained soils were more common among the high-risk clusters. These results stress the role of precipitation, grazing, temperature and drainage on the life cycle of F. hepatica in the temperate Irish climate. The findings of this study highlight the importance of cluster analysis for identifying significant differences in climatic and environmental variables between high-risk and low-risk clusters of fasciolosis in Irish dairy herds.

Objective: To analyze the trend of incidence and mortality of thyroid cancer and estimate its age-period-cohort effect in Shandong Province from 2012 to 2022. Methods: The Joinpoint regression was used to analyze the trend of incidence and mortality of thyroid cancer and calculate the average annual percentage change (AAPC) based on the data on thyroid cancer from 2012 to 2022. The age-period-cohort model was used to analyze the age-effect, time-effect and cohort-effect of thyroid cancer risk in the population aged over 20 years. Results: From 2012 to 2022, the incidence of thyroid cancer in Shandong province showed a significant upward trend, with an AAPC of 21.68% (95%CI: 19.14%-24.27%, P<0.001). The incidence of females was higher than that of males, and the incidence of urban areas was higher than that of rural areas. The trend of thyroid cancer mortality was relatively stable with an AAPC of -3.04% (95%CI:-8.81%-3.09%, P=0.323). The age effect of incidence increased with age before 60 years old and decreased with age after 60 years old. The incidence peaked in the age group of 55-59. The period effect increased with time. The cohort effect showed that the cohort born before 1957 had a downward trend over time, while the cohort born after 1957 had an upward trend. Conclusion: The incidence of thyroid cancer in Shandong shows a rising trend from 2012 to 2022. Age is an important factor affecting the risk of thyroid cancer. The mortality of thyroid cancer remains stable.

Background and Objectives: More than 12 types of cancer are caused by contact with environmental factors and occupational carcinogens. Therefore, this study aimed to evaluate the trend of mortality and disability-adjusted life years (DALYs) rates attributed to occupational carcinogens in Hamedan province, Iran, from 1990 to 2021. Methods: In this ecological study, the Global Burden of Diseases database was used to collect the required data. The trend of changes in the mortality and disability-adjusted life years rates was examined using joinpoint regression analysis and the Join Point Regression software. Results: The years of life lost (YLLs) due to premature death and disability attributed to occupational carcinogens in Hamadan Province increased from 10.31 per 1,000 population in 1990 to 23.33 per 1,000 population in 2021. The average annual percent change (AAPC) in DALYs was 3.79% for women and 2.57% for men. The all-cause mortality rate attributed to occupational carcinogens rose from 0.31 per 100,000 population in 1990 to 0.74 per 100,000 in 2021 (AAPC = 2.78%; 95% CI: 2.68% to 2.90%). Conclusion: The trend of mortality and disability-adjusted life years due to occupational carcinogens in Hamadan province had an increasing trend overally. Periodic screenings for workers in high-risk occupations are essential to mitigate the burden of occupational cancers.

Background and Objectives: Occupational injuries are considered as one of the most important health, social and economic risk factors in industrial and developing societies. Therefore, the aim of the present study was to investigate the trend of mortality and Disability Adjusted Life Years rates due to occupational injuries in Hamedan province during 1990 to 2021. Methods: In this cross-sectional descriptive study, the trend of changes in the mortality and Disability Adjusted Life Years rates due to occupational injuries in Hamedan province in a period of 32 years was investigated using join point regression and Join Point Regression software version 5.1.0. Results: The Disability Adjusted Life Years (due to premature death and disability) from occupational injuries in Hamedan province decreased from 496.75 years per thousand population in 1990 to 229.98 years per thousand population in 2021 (the average annual percent changes (AAPC) was -2.40%). This decreasing trend in DALY caused by occupational injuries was also evident in men and women (the AAPC in men and women was -2.40% and -1.10%, respectively).On the other hand, the mortality rate due to injuries in both sexes had decreased from 7.55 cases per 100,000 population in 1990 to 3.46 cases per 100,000 population in 2021 (AAPC was -2.50%). Conclusion: Generally, the trend of mortality and Disability Adjusted Life Years rates due to occupational injuries in Hamedan province had a decreasing trend, which was consistent with other studies conducted in Iran and the world.

Thyroid cancer incidence rates have been increasing globally over past decades. However, no study examining those trends in the canton of Zurich, Switzerland exists. In this study, we describe the incidence and mortality trends of thyroid cancer in the canton of Zurich during a 37-year period (1980-2016) including factors such as sex, histological subtypes and age at diagnosis. We analysed population-based cancer registry data from 1980-2016 for the canton of Zurich, Switzerland. We estimated the age-standardised incidence and mortality rates using the European standard population. Joinpoint regression was used to detect average annual percentage changes (AAPCs) and their corresponding 95% confidence intervals (CIs). We included 2972 primary cases of thyroid cancer (72.3% in women). The papillary cases accounted for the majority of incident cases (65.8%). In 2016, women had a higher age-standardised incidence rate than men for both papillary (10.4 and 3.3, respectively, per 100,000) and non-papillary (1.6 and 0.7, respectively, per 100,000) thyroid cancer. In both men and women, the incidence rates of thyroid cancer increased significantly over the study period with AAPCs of 1.4% (95% CI 0.6-2.2%) and 2.6% (95% CI 2-3.1%), respectively. These increasing incidence trends are mainly driven by papillary thyroid cancer with AAPCs of 3.4% in men (95% CI 2.3% to 4.4%) and 4.3% in women (95% CI 3.7% to 5%). Mortality rates significantly decreased in both sexes (men AAPC -3.6%, 95% CI -4.7% to -2.4%; women AAPC -3.7%, 95% CI -4.8% to -2.6%). Our results show significantly increasing age-standardised incidence rates of thyroid cancer over time in both sexes, mainly due to papillary thyroid cancer, the most frequent histological subtype, and the only subtype for which a significant increase was observed. It is possible that many indolent thyroid cancers, and more specifically papillary microcarcinomas, are increasingly diagnosed, which may not lead to symptoms if undetected. Therefore, targeted diagnostic strategies are necessary to avoid overdiagnosis of thyroid cancer. Nevertheless, we cannot completely exclude a partly true increase.

Background: Knowledge of the extent of geographic disparities in the burden of myocardial infarction (MI) is useful for allocation of scarce public health resources to reduce health disparities and improve population health, regardless of whether MI is the primary or secondary cause for hospitalization. The objectives of this study were to identify: (a) geographic disparities in hospitalization risks for MI in Florida; and (b) the temporal changes in these disparities from 2005 to 2014. Methodology: We aggregated county-level data for principal and secondary inpatient MI-related hospital discharges in Florida between 2005 and 2014 by 2-year intervals and calculated age- and sex- adjusted MI hospitalization risks for each time interval. We identified spatial clusters of low- and high-risk MI hospitalization risks using circular spatial scan statistics and tracked MI risks in clusters that persisted throughout the 10-year study period. We also assessed health disparities between persistent high- and low-risk clusters at the end of the study (2013-2014) compared to the beginning of the study (2005-2006) periods. Results: MI hospitalization risks decreased by 15% in Florida overall during the 10-year study period. However, we found persistent disparities in MI risks by geographic location, with high-risk clusters occurring in north-, west-, south-central and southeast Florida, and low-risk clusters occurring in southeast and southwest Florida. A low-risk cluster that transitioned to high-risk status in the last four years of study was identified in northwest Florida. We also found substantial differences in the magnitude of decline in MI risks amongst clusters, with risks decreasing by 5%, 16% and 31% in high-risk clusters in west central, south central and north central Florida, respectively, and by 6.5% and 26% in low-risk clusters in southwest and southeast Florida, respectively. Furthermore, the risks only decreased during the first 6-8 years of study, after which they leveled off or ticked upwards. Consequently, health disparities between high- and low-risk clusters at the end of the study compared to the beginning of the study period decreased by 57% and 31.5% in north- and south-central Florida, respectively, but they remained relatively unchanged in west central Florida. Moreover, MI hospitalization risks in high-risk clusters lag behind those in low-risk clusters by at least a decade. Conclusion: Myocardial infarction hospitalization risks declined modestly during 10-year study period. However, persistent disparities continue to exist across space and time. Addressing these disparities will require targeting intervention efforts to counties with persistently high risks.

To analyze the incidence and mortality trend of stomach cancer in the Greater Cuiabá, in the state of Mato Grosso, Brazil, from 2000 to 2016. The incidence information was obtained from the Population-Based Cancer Registry, and the mortality information from the Mortality Information System. Crude and standardized rates were calculated using the direct method, with the world population as reference. The trends were estimated using the Joinpoint regression method, according to sex and age group, and evaluated through the Annual Percent Change (APC) and the Average Annual Percent Change (AAPC). The Joinpoint Regression Program software, version 4.9.0.0, was used. There was a decreasing incidence trend of stomach cancer in males (AAPC=-5.2; 95% confidence interval - 95%CI -7.7--2.6), in men aged 60 to 69 years (AAPC=-3.7; 95%CI -5.6--1.8) and in 70-79 years (AAPC=-3.7; 95%CI -5.6--1.8), as well as in women aged 50 to 59 years (AAPC=-5.2; 95%CI -7.8--2.6) and 80 years or older (AAPC=-5.2; 95%IC -7.8--2.6). The mortality initially increased in women aged 60-69 years (AAPC=28.4; 95%CI 9.7-50.4), decreased for 80 years or older (AAPC=-26.4; 95%CI -38.0--12.6) and stable for the other age groups and males. A decreasing incidence trend of stomach cancer was found among men and, when analyzed by age, among elderly males and adults and elderly females, as well as a stability in the mortality, with an initial variation in elderly women. The production of regional information supports the planning of local policies aimed at reducing the burden of disease and deaths, considering unequal risk conditions and access to health services.