Avoidable Health Inequalities Research Articles

Persistence of severe global inequalities in the burden of Hypertension Heart Disease from 1990 to 2019: findings from the global burden of disease study 2019

AimsAssessing the global burden and health inequalities of Hypertension Heart Disease (HHD) during the period from 1990 to 2019.MethodsSecondary analysis of the Global Burden of Disease (GBD) study in 2019, focusing on the burden of diseases, injuries, and risk factors worldwide. Disability-Adjusted Life Years (DALYs) data related to HHD are extracted from the 2019 GBD. Inequality Slope Index (SII) and Concentration Index are calculated to assess health inequalities across regions and countries.ResultsThe total DALYs for HHD reached 21.51 million, demonstrating a substantial increase of 54.25% compared to the figures recorded in 1990, while the age-standardized DALY rates per 100,000 population for HHD in 2019 showed a notable decline to 268.19 (95% UI 204.57, 298.07), reflecting a significant decrease of 26.4% compared to the rates observed in 1990. The DALYs rate of hypertensive heart disease increases with age. Countries with moderate SDI accounted for 38.72% of the global burden of HHD in terms of DALYs. The highest age-standardized DALY rates (per 100,000) are predominantly concentrated in underdeveloped areas. In 1990 and 2019, the SII (per 100,000 population) for DALYs were − 121.6398 (95% CI -187.3729 to -55.90684) and − 1.592634 (95% CI -53.11027 to 49.925) respectively. The significant decline suggests a reduction in the inequality of age-standardized burden of HHD between high-income and low-income countries during this period.ConclusionThe unequal prevalence of HHD across different populations can hinder the achievement of the “health for all” objective. Persistent disparities in HHD have been observed globally over the past thirty years. It is crucial to prioritize efforts towards reducing avoidable health inequalities associated with hypertension-related heart disease, particularly in low-income and middle-income countries.

Exploring avoidable, preventable, treatable mortality trends and effect factors by income level

Abstract Background Avoidable mortality (AM) mean death caused by insufficient health policy and health care intervention, and is a rising public health issue. Income polarization in healthcare utilization is a significant concern. The aim of this study was to derive the trend and effect factors of AM, treatable mortality (TM), preventable mortality (PM) according to income levels in South Korea over the period 2008-2017. Methods This serial cross-sectional analysis was conducted using national health information data from 2008 to 2017. AM was classified based on criteria presented by the Office for National Statistics in 2011. Age-standardized AM was analyzed annually according to income levels. The odds ratio of AM was examined using multivariable logistic regression after adjusting health behaviors and clinical variables collected in 2016-2017. Results There were persistent income inequalities in AM, and the degree of inequality was larger in PM than in TM throughout the period. Medical benefit recipients had an AM of about 8.5 times higher than the highest income quartiles, and men were three times higher than women. In 2016-2017, compared to the highest income quartile, the risk of TM and PM of medical benefit recipients was about 10 times higher and 1.5 times higher in the first quintile. The risk of AM remained significantly higher in low-income levels even after adjusting for health behaviors and clinical variables. Conclusions While AM in South Korea has decreased over time, it remains high in low-income levels. There was a statistically significant difference in AM based on income level. Therefore, inclusion in health policy and services development and in health promotion programs is urgently required to address avoidable deaths and health inequalities for low-income levels. Key messages • AM in South Korea have declined over time, but, compared to the highest income quartile, the risk of TM and PM of medical benefit recipients was about 10 times higher. • Among health insurance eligible people, the first quintile, the more the proportion of TM and PM, and the highest income quartile, the lower the proportion of non-avoidable deaths.

Inequitable distribution of mortality between persons with and without disabilities

Abstract Background People with disabilities (PWD) experience avoidable health inequalities throughout their lives, which can lead to disparities in end-of-the-line health outcomes, such as death. We compared the trends in mortality between PWD and those without disabilities (PWOD) over the past decade and assessed the mortality gap for PWD based on health determinants. Methods We linked the National Health Insurance Database, which includes the entire Korean population, with National Disability Registration Database and Cause of Death Database. Crude mortality rate (CMR) and age- and sex-standardized mortality rate (SMR) for PWD and PWOD were calculated using data from over 50 million individuals per year from 2008 to 2017. Sociodemographic and health variables including age, sex, income, place of residence, and Charlson comorbidity index (CCI) were considered. Results All-cause CMR increased for both PWD and PWOD from 2008 to 2017, but the upsurge was greater among PWD (+11.2% vs. +7.3%). PWD continuously had higher CMRs (2668.3 vs. 412.9 per 100,000 in 2017) and SMRs (768.0 vs. 252.9 per 100,000 in 2017) than PWOD. However, the ratio of the mortality rate for PWD to PWOD intensified among less vulnerable groups in the population, including those who were younger, had higher incomes, or had no comorbidities. Compared to PWOD, the odds of death for PWD increased by 1.40-fold (95% CI = 1.38-1.41). The association between disability and death was stronger in the young age group (OR = 8.34, 95% CI = 7.20-9.65 for <20 years) than in the older age group (OR = 1.10, 95% CI = 1.08-1.11 for ≥80 years). Greater disparities were also observed in groups with higher income or no comorbidities. Conclusions These findings suggest that macro-level social barriers, such as institutional discrimination against PWD in health care and inaccessible public health interventions, may contribute to the mortality disparities for PWD in a broader and more profound manner. Key messages • Disability was associated with an increased risk of mortality, and a larger mortality gap compared to the general population was observed, particularly among less vulnerable groups in the population. • Fundamental policies are required to mitigate inequalities in mortality among persons with disabilities.

Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity.

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a)provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments-communicable diseases, non-communicable conditions, and injuries-and (b)through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Migration health research in the Nordic countries: Priorities and implications for public health.

The past 50 years have witnessed an increase in immigration to the Nordic countries from and beyond neighbouring countries in Europe. Diversity implies variations and differences in health status and health outcomes both within and across populations. Migrant health research has not been prioritized and health policies and practice, especially long-term national plans, often exclude migrants. In this article, we briefly trace the history, the groups, reasons for migration and the road to migrant health research in Norway, Sweden, Finland and Denmark. We discuss the case for data and research including needs, basis for data collection and the methodological challenges. We provide a brief snapshot of migrant health research, identify current gaps and discuss the implications for research. We recommend a regional Nordic strategy to promote intercountry exchange, sharing and learning. Finally, we reflect on the larger picture, implications for policy and practice that could enable societal conditions to reduce avoidable health inequalities.

Health Inequalities: Law & the Pain of Others

Health inequalities are a social injustice experienced globally. State action to address this has generally been insufficient, with inequities persisting, or - as in the case of the UK - worsening. This article contends that social epigenetics has a role in generating more robust state responses and makes two related arguments. First, it is argued that an epigenetic explanation of avoidable health inequalities has the potential to provoke change because it works within the gene paradigm. Second, epigenetics provides an opportunity to challenge a different paradigm, that of the liberal legal subject. This fictive figure has long impoverished understandings of harm and responsibility; including in the context of health inequalities. Martha Fineman’s model of the vulnerable subject is engaged as an alternative to this figure. The original and expansive articulation of the epigenetic landscape - an idea now significantly narrowed – is articulated as a space for an interdisciplinary exploration of the role of epigenetics in securing a state more responsive to inequalities.

Sustainable health equity: achieving a net-zero UK

Sustainable health equity: achieving a net-zero UK

Open Comparisons in Public Health Not Only a Report But Also a Practical Tool Package

Abstract Sweden is a high-income country with about 10 million people 2018. The public health policy has a clear focus on equitable health throughout the population, and a goal to reduce avoidable health inequalities within a generation. The 21 regions and 290 municipalities in Sweden are political self-government and important as most of the welfare services that impact citizens’ lifelong health fall under their remit, for example; healthcare, childcare, education, social service, elderly care and support to people with disabilities, some emergency services, environmental issues urban planning. Therefore, the municipalities and regions need reliable data that can be compared. Such data is available in the report Open Comparisons in Public Health (OCPH). The OPCH 2019 demonstrate large inequities in determinants of health and in health outcomes between municipalities in Sweden. Further work is needed to reduce these unjust and avoidable differences. The OPCH 2019 is not only a report, but rather a concept with additional practical tools to be used by local and regional public health officers, leaders and politicians. Following tools, developed in collaboration with stakeholders, are available in the concept OPCH. OPCH 2019: various managementresearch review, result comparisons, suggested improvement areas Factsheet: for leaders and politicians at policy level Municipality reports: tailored for public health officers to save time Socioeconomic compass: a tool to analyze differences in socioeconomics across municipalities Kolada: the Swedish database for municipal benchmarking Toolbox: tools to facilitate systematic interpretation and analysis The National Public Health Agency: various statistics are available for additional analyses Key messages The OPCH and the tools contributes to initiate local/regional development, improvement, monitoring and analysis concerning the quality and efficiency of the services delivered by these organisations. Governmental policies are important structural links16, but according to the OCPH 2019 the reduction of health disparities also requires measures in each local community.

Public health monitoring in Sweden focusing on inequality – a developmental work

Abstract Issue/problem The overarching goal of the Swedish public health policy is to create the right societal conditions for good and equitable health throughout the population, and to reduce avoidable health inequalities within a generation. Relevant health topics and dimensions of inequalities in health should be monitored to enable effective interventions on the local, regional and national level. To achieve this a strong national health monitoring system (HMS) is central. Description of the problem The objective was to develop a high quality HMS to monitor a broad perspective of public health and its determinants, complemented by a more focused monitoring system of inequalities in health, with relevance on the local, regional and national level. A theoretical framework was developed and empirical mapping of relevant indicators conducted. An expert group was consulted and a country assessment of how to monitor health inequalities was carried out within the Joint action Health Equity Europe project. The developmental work started in 2018 and is not yet completed. Results A web-based monitoring system has been implemented to cover the broad perspective of public health and its determinants. All indicators are reported at the national level and, when possible, degradable at the local and regional level. In addition, a report with a focus on inequalities in health on a national level is published annually, and a longitudinal indicator-based comparative study, with results from Sweden’s 21 regions and 290 municipalities was published in 2019. Lessons General public health and inequalities in health may need to be monitored in different ways. To enable effective interventions, consideration must be given to at what level - local, regional or national - policy decisions are made. Key messages High quality health monitoring enables effective interventions. To reduce inequalities in health focused monitoring is required.

Health disparities based on neighbourhood and social conditions: Open Comparisons—an indicator-based comparative study in Sweden

ObjectiveThe overarching goal of the Swedish public health policy is to create the right societal conditions for good and equitable health throughout the population and to reduce avoidable health inequalities within a generation. The objective of this article is to highlight the main findings of the Open Comparisons in Public Health (OCPH) 2019 study. Study designThe OCPH is a longitudinal indicator-based comparative study, encompassing 39 public health indicators with results from Sweden's 21 regions and 290 municipalities. MethodsDescriptive statistics and 95% confidence intervals were used to compare results between municipalities, regions and time points. Correlation analysis was used to study the strength of the relationship between the results of municipalities and their socio-economic conditions. ResultsAcross the population, levels of health are good and have, in some areas, improved over recent decades. However, some significant health disparities remain according to neighbourhood, sex, age and educational background. Health disparities related to the level of education are often larger than those between women and men, and there are larger differences within a region than between regions. Health disparities have, in some cases, increased, such as for life expectancy. ConclusionIf health equity is to be achieved, leaders at all levels must collaborate and advocate for political action and local efficient public health interventions to eliminate health disparities as a result of neighbourhood and social conditions.

Understanding and tackling oral health inequalities in vulnerable adult populations: from the margins to the mainstream.

Vulnerable and socially excluded groups in society persistently experience significantly worse oral health and poorer access to dental services than the mainstream population. Action to tackle these unfair, unjust and avoidable inequalities in oral health needs to be informed by an understanding of the broad range of interacting factors that ultimately influence oral health across society and specifically the most vulnerable and marginalised. Failure to understand the underlying factors that create and perpetuate the oral health equity gap risks the development and implementation of ineffective interventions that do not achieve meaningful improvements in oral health for the most vulnerable. This paper presents a theoretical framework that combines a broad public health perspective on oral health inequalities, combined with more specific factors determining the oral health of vulnerable and marginalised groups. Actions to improve access to dental services and policies to combat oral health inequalities among vulnerable adult populations are then presented.

Socioeconomic inequalities in cardiovascular risks among mid-aged and older Chinese: A nationally representative longitudinal study

Background China is the fastest ageing nation and will become the world's most ageing society by 2030. Cardiovascular disease (CVD) remains the leading cause of mortality in China and ageing further complicate the picture of CVD profile in China. This study aims to examine socioeconomic disparities in cardiovascular risks among mid-aged and older Chinese. Methods Data were from 2011 baseline survey of China Health and Retirement Survey (CHALRS), which is a nationally representative longitudinal study of persons in China 45-years-older and their spouses. A sample of 12749 ≥ 45 years (male: n = 5968, mean age = 58.85; female: n = 6791, mean age = 58.35) were included in this paper. This paper concerns four CVD risk factors: systolic blood pressure, diastolic blood pressure, BMI and waist circumference. Hypertension was defined as a systolic blood pressure (SBP) ≥ 140 mmHg, and/or diastolic blood pressure (DBP) ≥ 90 mmHg. Overweight (and obesity) was defined as a BMI ≥ 24. Abdominal obesity was defined as a waist circumference ≥ 90 cm for men and ≥ 80 for women. Main socioeconomic predictors include socio-residential status based on hukou (household registration) and residence of living (urban hukou living in urban areas—urban residents, rural hukou living in urban areas—migrants, and rural hukou living in rural areas—rural residents); labour market status (agricultural work, non-agricultural work, retirement and other), quintiles of household wealth/assets (long-term household socioeconomic status) and household per capita consumption (short-term household socioeconomic status). Logistic regression was performed for women and men separately. Adjusted odds ratios with 95% confidence intervals following logistic regression to account for confounding variables were presented. Results The results show substantial socioeconomic disparities in CVD risks among middle-aged and older people in China. For men, migrants (OR: 0.79, 95% CI: 0.64, 0.98) and rural residents (OR: 0.60, 95% CI: 0.49, 0.72) are less likely to be overweight (and obesity) compared to urban residents. The OR for rural men developing abdominal obesity is 0.59 (95% CI: 0.47, 0.73). Labour market status is closely associated with the odds of developing overweight (and obese) and abdominal obesity for men and women. Compared to people who work in agricultural sector, those who work in non-agricultural sectors (OR: 1.64, 95% CI: 1.39, 1.92 for men; OR: 1.51, 95% CI: 1.25, 1.83 for women) and those who already retired (OR: 1.75, 95% CI: 1.46, 2.09 for men; OR: 1.81, 95% CI: 1.55, 2.10 for women) are more likely to be overweight. For abdominal obesity, the ORs are 1.63 (95% CI: 1.36, 1.97) for men with non-agricultural work and 1.66 (95% CI: 1.35, 2.05) for retired men. The corresponding ORs for women are 1.15 (95% CI: 0.91, 1.45) and 1.68 (95% CI: 1.39, 2.03), respectively. Being married/partnered appears to significantly increase the odds of being overweight (and obese) and decrease the odds of hypertension for both men and women. Short-term household economic status shows a modest and graded association with the odds of all CVD risk including overweight (and obesity), abdominal obesity and hypertension at higher quintiles compared to bottom quintile. Conclusions There are substantial socioeconomic inequalities in CVD risks among Chinese middle-aged and older people, which can be further enhanced by China's rapid urbanisation and ageing. Since China's urbanisation is strongly driven by state. There is, therefore, a possibility that socioeconomic inequalities among older people might be ‘broken’ provided appropriate policy interventions are put in place. The findings will aid an understanding of identifying modifiable risk factors that can prevent avoidable health inequalities, and developing evidence-based policies to tackle health inequalities among older people in China.

Mindfulness Meditation in College Students to Advance Health Equity

Purpose High levels of mindfulness correspond with some positive health behaviors such as exercise participation, fruit and vegetable intake, and effective stress management. This study provided mindfulness meditation during an academic semester to a group of predominantly minority college students derived from a population in which 77.9% of the students are considered economically disadvantaged, to assess the effects of mindful meditation on various health behaviors and mindfulness to combat avoidable health inequalities. Methods The meditation occurred for eight weeks, twice per week for 30 minutes; the control group did no meditation. Data collection tools included Five Facet Mindfulness Questionnaire (FFMQ), Mindful Eating Scale (MES), 7-Day Physical Activity Questionnaire and a self- reported daily fruit and vegetable intake. Two open-ended questions were posed post-test. Results 43 undergraduate students completed the pre and post-test data with 81.4% self-identifying as non-white. Analysis revealed a significant within and between subjects increase in mindfulness with FFMQ (p < 0.002) and (p < 0.000) respectively; a significant between-subjects cross over effect with MES, (p < 0.023); a significant between and within group effect with fruit and vegetable intake (p < 0.040); and a nonsignificant trend in physical activity, the intervention group’s physical activity increased and control groups’ decreased (p < 0.057). Qualitative data revealed that participants were sleeping better, eating better, exercising more, reacting less, knowing themselves better, and enjoying an elevated mood. Conclusions Mindfulness meditation is an effective intervention in a group of primarily non-white college students and may be an effective strategy in the fight against avoidable health inequities.

Engendering the Attainment of the SDG-3 in Africa: Overcoming the Socio Cultural Factors Contributing to Maternal Mortality.

At the conclusion of the Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs) provide an opportunity to ensure healthy lives, promote the social well-being of women and end preventable maternal death. However, inequities in health and avoidable health inequalities occasioned by adverse social, cultural and economic influences and policies are major determinants as to whether a woman can access evidence-based clinical and preventative interventions for reducing maternal mortality. This review discusses sociocultural influences that contribute to the high rate of maternal mortality in Nigeria, a country categorised as having made -no progress‖ towards achieving MDG 5. We highlight the need for key interventions to mitigate the impact of negative sociocultural practices and social inequality that decrease women's access to evidence-based reproductive health services that lead to high rate of maternal mortality. Strategies to overcome identified negative sociocultural influences and ultimately galvanize efforts towards achieving one of the tenets of SDG-3 are recommended.

Advancing health equity to improve health: The time is now

Health inequities, or avoidable inequalities in health between groups of people, are increasingly recognized and tackled to improve public health. Canada's interest in health inequities goes back over 40 years, with the landmark 1974 Lalonde report, and continues with the 2011 Rio Political Declaration on Social Determinants of Health, which affirmed a global political commitment to implementing a social determinants of health approach to reducing health inequities. Research in this area includes documenting and tracking health inequalities, exploring their multidimensional causes, and developing and evaluating ways to address them. Inequalities can be observed in who is vulnerable to infectious and chronic diseases, the impact of health promotion and disease prevention efforts, how disease progresses, and the outcomes of treatment. Many programs, policies and projects with potential impacts on health equity and determinants of health have been implemented across Canada. Recent theoretical and methodological advances in the areas of implementation science and population health intervention research have strengthened our capacity to develop effective interventions. With the launch of a new health equity series this month, the journals Canada Communicable Disease Report (CCDR) and Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice (HPCDP Journal) will continue to reflect and foster analysis of social determinants of health and focus on intervention studies that advance health equity.

The provision of NHS health checks in a community setting: an ethnographic account.

BackgroundThe UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.MethodsThis paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.ResultsAnalysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.ConclusionsOutreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1209-1) contains supplementary material, which is available to authorized users.

An Official American Thoracic Society/European Respiratory Society Policy Statement: Disparities in Respiratory Health

Health disparities, defined as a significant difference in health between populations, are more common for diseases of the respiratory system than for those of other organ systems, because of the environmental influence on breathing and the variation of the environment among different segments of the population. The lowest social groups are up to 14 times more likely to have respiratory diseases than are the highest. Tobacco smoke, air pollution, environmental exposures, and occupational hazards affect the lungs more than other organs, and occur disproportionately in ethnic minorities and those with lower socioeconomic status. Lack of access to quality health care contributes to disparities. The executive committees of the American Thoracic Society (ATS) and European Respiratory Society (ERS) established a writing committee to develop a policy on health disparities. The document was reviewed, edited, and approved by the full executive committees and boards of directors of the societies. This document expresses a policy to address health disparities by promoting scientific inquiry and training, disseminating medical information and best practices, and monitoring and advocating for public respiratory health. ERS and ATS have strong international commitments, and work with leaders from governments, academia, and organizations to address and reduce avoidable health inequalities. Their training initiatives improve the function of health care systems and health equality. Both the ATS and ERS support all aspects of this document, confer regularly, and act together when possible, but the activities to bring about change may vary because of the differences in the continents where the two organizations carry out most of their activities. The ATS and ERS pledge to frame their actions to reduce respiratory health disparities. The vision of the ATS and ERS is that all persons attain better and sustained respiratory health. They call on all their members and other societies to join in this commitment.

An official American Thoracic Society and European Respiratory Society policy statement: disparities in respiratory health

Health disparities, defined as a significant difference in health between populations, are more common for diseases of the respiratory system than for those of other organ systems, because of the environmental influence on breathing and the variation of the environment among different segments of the population. The lowest social groups are up to 14 times more likely to have respiratory diseases than are the highest. Tobacco smoke, air pollution, environmental exposures, and occupational hazards affect the lungs more than other organs and occur disproportionately in ethnic minorities and those with lower socioeconomic status. Lack of access to quality healthcare contributes to disparities. The executive committees of the American Thoracic Society (ATS) and European Respiratory Society (ERS) established a writing committee to develop a policy on health disparities. The document was reviewed, edited, and approved by their full executive committees and boards of directors of the societies. This document expresses a policy to address health disparities by promoting scientific inquiry and training, disseminating medical information and best practices, and monitoring and advocating for public respiratory health. The ERS and the ATS have strong international commitments and work with leaders from governments, academia, and other organisational bodies to address and reduce avoidable health inequalities. Their training initiatives improve the function of healthcare systems and health equality. Both the ATS and the ERS support all aspects of this document, confer regularly, and act together when possible, but the activities to bring about change may vary because of the differences in the continents where the two organisations carry out most of their activities. The ATS and ERS pledge to frame their actions to reduce respiratory health disparities. The vision of the ATS and ERS is that all persons attain better and sustained respiratory health. They call on all their members and other societies to join in this commitment.

Gender and racial inequalities in trends of oral cancer mortality in Sao Paulo, Brazil

OBJECTIVE:To analyse recent trends in oral cancer mortality, focusing specifically on differences concerning gender and race.METHODS:Official information on deaths and population in the city of Sao Paulo, 2003 to 2009, were used to estimate mortality rates from oral cancer (C00 to C10, International Classification of Diseases, 10th Revision), adjusted for age and stratified by gender (females and males) and race (blacks and whites). The Prais-Winsten auto-regression procedure was used to analyse the time series.RESULTS:During the study period, 8,505 individuals living in the city of Sao Paulo died of oral cancer. Rates increased for females (rate of yearly increase = 4.4%, 95%CI 1.4;7.5), and levelled off for men, which represents an inversion of previous trends among genders in the city. Increases were identified for blacks, with a high rate of yearly increase of 9.1% (95%CI 5.5;12.9), and levelled off for whites. Oral cancer mortality in blacks almost doubled during the study period, and surpassed mortality in whites for almost all categories.CONCLUSIONS:Mortality presented a higher increase among women than in men, and it doubled among backs. The surveillance of trends of oral cancer mortality across gender and racial groups may contribute to implementing socially appropriate health policies, which concurrently reduce the burden of disease and the attenuation of unfair, avoidable and unnecessary inequalities in health.

Determinants of changes in income-related health inequalities among working-age adults in Japan, 1986–2007: Time-trend study

This study aimed to quantify the contributions of the factors that have influenced changes in income-related health inequalities. We used data from a nationally representative sample of Japanese men and women aged 20–59 years who participated in eight repeated cross-sectional surveys between 1986 and 2007. A concentration index (CI) was used to measure income-related inequalities in self-rated health (SRH) and decomposed into contributing factors. We then examined temporal changes in CIs and their contributing factors. Results showed that income-related inequalities in SRH, unfavourable to low-income groups, persisted throughout the study period. Despite widening income inequalities, inequalities in SRH narrowed during the period of economic stagnation since the late 1990s because of the profound deterioration in SRH among middle- to high-income groups. Decomposition analysis showed that income itself and unemployment or economic inactivity were the most important contributors to inequalities in SRH for both sexes at almost all time points. However, from 1986 to 2007, the relative contribution of income to these inequalities decreased from 78% to 14% in men and from 85% to 38% in women. By contrast, the relative contribution of unemployment or economic inactivity increased from 18% to 77% in men and from 10% to 31% in women. Our results suggest that a reduction in avoidable health inequalities could be achieved by reducing the influence of unemployment or economic inactivity on health.