Geographic Variation Research Articles

Geographic disparities in Alzheimer's disease and related dementia mortality in the US: Comparing impacts of place of birth and place of residence

ObjectiveThis study investigates geographic variations in ADRD mortality in the US. By considering both state of residence and state of birth, we aim to discern the relative importance of these geospatial factors. MethodsWe conducted a secondary data analysis of the National Longitudinal Mortality Study (NLMS), that has 3.5 million records from 1973 to 2011 and over 0.5 million deaths. We focused on individuals born in or before 1930, tracked in NLMS cohorts from 1979 to 2000. Employing multi-level logistic regression, with individuals nested within states of residence and/or states of birth, we assessed the role of geographical factors in ADRD mortality variation. ResultsWe found that both state of birth and state of residence account for a modest portion of ADRD mortality variation. Specifically, state of residence explains 1.19% of the total variation in ADRD mortality, whereas state of birth explains only 0.6%. When combined, both state of residence and state of birth account for only 1.05% of the variation, suggesting state of residence could matter more in ADRD mortality outcomes. ConclusionFindings of this study suggest that state of residence explains more variation in ADRD mortality than state of birth. These results indicate that factors in later life may present more impactful intervention points for curbing ADRD mortality. While early-life environmental exposures remain relevant, their role as primary determinants of ADRD in later life appears to be less pronounced in this study.

Identifying sarcoidosis trends using web search and real-world data in Sweden: a retrospective longitudinal study

Web search data are associated with disease incidence, population interest, and seasonal variations. This study aimed to investigate seasonal and geographical variations of web search data for sarcoidosis and to explore its association with external factors and sarcoidosis incidence in Sweden. Therefore, sarcoidosis-related data from Google Ads Keyword Planer (2017–2020) were generated for Sweden according to its 21 counties. The relationship between search volume and season, region, population demographics, environmental factors, and the sarcoidosis incidence listed in the National Patient Register was assessed. Analyses revealed seasonal variations for Sweden with an overall peak in the spring and autumn. Geographical differences were observed, with a higher search volume for north-western counties and the lowest search volume for Stockholm County. At the country level, the search volume was positively associated with the sarcoidosis incidence. Higher male proportion and older mean age were associated with a higher search volume, while a higher proportion of foreign-born residents, humidity, and mean temperature were associated with a lower search volume. Our analyses detected correlations between web search data, sarcoidosis incidence, and external factors. Analyses of sarcoidosis web search data therefore appear to be a valuable approach to disease surveillance to address medical needs and public interest.

Trends in pancreatic cancer mortality in the United States 1999-2020: a CDC database population-based study.

Pancreatic cancer is a significant public health concern and a leading cause of cancer-related deaths worldwide. This study aimed to investigate pancreatic cancer mortality trends and disparities in the United States (US) from 1999 to 2020. Data were obtained from the Centers for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research database. Mortality rates were age-adjusted and standardized to the year 2000 US population. Joinpoint regression was used to analyze temporal trends in age-adjusted mortality rates (AAMRs) by sociodemographic and geographic variables. Between 1999 and 2020, pancreatic cancer led to a total of 810,628 deaths in the US, an average mortality of nearly 39,000 deaths per year. The AAMR slightly increased from 10.6 in 1999 to 11.1 in 2020, with an associated annual percent change (APC) of 0.2. Mortality rates were highest among individuals aged 65 and older. Black individuals experienced the highest overall pancreatic cancer-related AAMR at 13.8. Despite this, Black individuals experienced a decreasing mortality trend over time (APC -0.2) while White individuals experienced an increasing trend in mortality (APC 0.4). Additionally, individuals residing in rural areas experienced steeper rates of mortality increase than those living in urban areas (APC 0.6 for rural vs -0.2 for urban). White individuals in urban and rural populations experienced an increase in mortality, while Black individuals in urban environments experienced a decrease in mortality, and Black individuals in rural environments experienced stable mortality trends. Mortality from pancreatic cancer continues to increase in the US, with racial and regional disparities identified in minorities and rural-dwelling individuals. These disparate findings highlight the importance of ongoing efforts to understand and address pancreatic cancer treatment and outcomes disparities in the US, and future studies should further investigate the underlying etiologies of these disparities and potential for novel therapies to reduce the mortality.

Temporal trends in Parkinson's disease among older adults in the United States from 1999 to 2020: Retrospective analysis from CDC WONDER database

This retrospective study assessed the mortality trends related to Parkinson's Disease (PD) between 1999 and 2020. We assessed individuals aged 65 years and older and a total of 831,793 deaths were identified. Of these total number of deaths, place of death was accessible for 830,176 cases. Majority of the deaths occurred in nursing homes of long-term care facilities (367,633), followed by at home (212,886), medical facilities (165,450), other locations (44,506), and hospice (39,701). Analysis of age-adjusted mortality rates (AAMR) revealed an overall rise from 1999 to 2020, 88.9 to 119.6 per 100,000 population. AAMR showed an initial decline between 1999 and 2013, followed by a slight increase between 2013 and 2018 and then a significant rise from 2018 to 2020. Gender-based analysis showed a constantly higher AAMR for older men compared to older women. Variations in AAMR based on race and ethnicity revealed that Non-Hispanic White population had the highest AAMRs. Geographic disparities among states showed that Nebraska, Vermont, Minnesota, Utah, and Idaho had a significantly higher AAMR than Hawaii, Florida, Nevada. New York, and District of Columbia. Midwest region had a consistently higher AAMR followed by West, South, and Northeast. Additionally, nonmetropolitan areas had a higher AAMR than metropolitan areas. These findings offer valuable insights into mortality patterns related to PD among the elderly, highlighting the significance of incorporating demographic and geographic variables into public health planning and interventions.

Current Role of PET CT in Staging and Management of Penile Cancers.

Penile cancer (PeCa) is a rare urological malignancy characterized by significant geographical variations in both incidence and mortality rates. Due to its rarity and the consequent lack of randomized trials, current management is based on retrospective studies and small prospective trials. In addition, both the diagnostic pathways and treatment strategies exhibit substantial heterogeneity, differing significantly between less-developed and well-developed countries. The prognosis of PeCas is determined by the presence and extent of regional lymph node (LN) involvement. Therefore, the early detection and treatment of LN metastasis is paramount to ensure better outcomes. In recent decades, overall survival of PeCas has increased, mainly due to advancements in imaging techniques and risk stratification. We aim to provide an overview of the current role of PET CT imaging in the management of patients with PeCa.

Niche evolution during allopatric and sympatric diversification of Aeonium (Crassulaceae) on the Canary Islands

Abstract Although species radiations on island archipelagos are broadly studied, the geographic and ecological modes of speciation that underlie diversification are often not fully understood. Both allopatry and sympatry play a role during radiations, particularly on islands with profound habitat diversity. Here, we use the most diverse Canary Island plant radiation, Aeonium (Crassulaceae), to phylogenetically test two hypotheses: (1) allopatric speciation, which predicts that closely related taxa are ecologically similar but do not co-occur, and (2) sympatric speciation, whereby closely related taxa co-occur geographically but are ecologically distinct. We fitted niche and spatial distribution models based on extensive field surveys to quantify geographic and ecological divergence among taxa integrated in a phylogenetic context. Contrary to our expectation, phylogenetically closely related species tend to occupy similar ecological niches, revealing that ecological niche divergence among species accumulates slowly, even in sympatry. This suggests that evolutionary young taxa may be partially reproductively isolated due to subtle phenotypic differences, such as reproductive morphology and phenology, rather than by ecological niche and may putatively exacerbate divergence among populations. Thus, allopatry and sympatry are complementary speciation mechanisms on oceanic islands, jointly spurring this enigmatic radiation.

Phytochemical Marker-based Analysis, Antioxidant Potential, and Shelf-Life Study of Geographically Different Samples of Tinospora cordifolia (Stem)

Background: Tinospora cordifolia (TC), commonly referred to as Guduchi, holds a prominent position in the Indian traditional system of medicine and has been cited in Ayurvedic literature for its efficacy in the treatment of a range of ailments, including jaundice, urinary issues, diabetes, prolonged diarrhea, skin conditions, stomachaches, and dysentery. Methods: The present study analyzed the content of phytochemical markers present in the stems of TC collected from five distinct geographical locations (TC-01 to TC-05) and assessed the corresponding variations in their in-vitro antioxidant potential. Results: Lupeol content in various samples of TC varied from 217.9 to 510.9 μg/mg, while palmatine ranged from 0.002% to 0.025%. Total phenolic content (TPC) ranged from 0.77 to 6.35 mg GAE/g wt., and total flavonoid content (TFC) from 12.15 to 20.03 mg QCE/g wt., with IC50 values between 21.02 and 81.81 mg/mL. Elemental analysis of TC-01 to TC-05 showed significant essential elements and permissible levels of heavy metals. A shelf-life study of TC samples indicated stability beyond three years. Conclusion: The considerable diversity in phytochemical content and antioxidant values underscores the substantial influence of geographical variation on the therapeutic potential of TC.

Constructing Global Identity Through Creative Linguistic and Artistic Branding of African Countries’ Monikers

This qualitative study investigated into the complex dynamics of African nation monikers and their profound implications for national identity and international branding. The purpose of the research was to examine the interplay between linguistic inventiveness and artistic representation in 54 African nations, exploring how these components contributed to shaping global perceptions. Adopting a content analysis approach, the study systematically investigated linguistic nuances and artistic depictions associated with each nation's moniker. The population comprised the 54 diverse African nations, ensuring a purposive and representative sampling approach that considered linguistic, cultural, and geographical variations. Data was sourced from official documents, historical records, and public discourse surrounding each nation's moniker, with a focus on linguistic analysis from official statements, literature, and media representations. Artistic representations were examined through visual sources such as national emblems, flags, and associated symbols. The findings revealed a complex tapestry of linguistic features firmly anchored in cultural and historical contexts. Artistic depictions, including visual metaphors and symbols, contributed significantly to each nation's unique character. Notable examples included Nigeria's "The Giant of Africa" and South Africa's "The Rainbow Nation." Recommendations emphasized the strategic use of linguistic and artistic components to enhance international image, recognizing their critical role in shaping global perceptions of African nations. The study also acknowledged its limitations and proposed directions for future research, offering valuable insights into the nuanced dynamics of language and creative expression in constructing national identity on the global stage.

Mapping the main harmful algal species in the East China Sea (Yangtze River estuary) and their possible response to the main ecological status and global climate change via a global vision

The Yangtze River Estuary (YRE) is one of the areas in China most severely affected by harmful algal blooms (HABs). This study explored the distributive patterns of HABs in the YRE and how they are influenced by the El Niño-Southern Oscillation (ENSO) and other environmental factors. Quantitative real-time PCR (qPCR) was employed to detect and quantify the four predominant HAB species in the YRE, Karenia mikimotoi, Margalefidinium polykrikoides, Prorocentrum donghaiense, and Heterosigma akashiwo. Additionally, the study analyzed how turbidity, pH, salinity, and temperature influence these algae. Distribution of the four HAB species in the YRE area shows clear geographical variations: K. mikimotoi is predominantly found in the northwest and central sea areas, M. polykrikoides (East Asian Ribotype, EAR) is mainly distributed in the southeastern part, P. donghaiense is abundant in the northern regions, and H. akashiwo is especially prevalent at stations S26 and S27 in the northeastern part of the study area. HABs dominated by H. akashiwo and P. donghaiense were observed in the northeastern sea area of the YRE on July 22, 2020. Our study reveals that K. mikimotoi, M. polykrikoides (EAR), and P. donghaiense are mainly affected by turbidity, pH, and salinity, while temperature predominantly influences the blooms of H. akashiwo. Moreover, runoff in the YRE has a certain correlation with ENSO events, which may also impact the nutrient content of the region. The findings of this study illustrate the distributive patterns of the four HAB species under various ecological conditions in the YRE and emphasize the importance of establishing practical cases for future warning systems. To better understand how climate change affects HABs, exploring the link between ENSO and HABs is essential.

Spatial distribution of cliff plant species in the Balearic Islands under current and projected climatic scenarios

Cliff ecology has been studied for decades, providing information about its high biodiversity values and their vulnerability to climate change. Also, insular ecosystems present biodiversity hotspots with high endemicity, but they are also severely affected by anthropogenic effects. Together, insular cliff communities combine both biodiversity uniqueness and high vulnerability to global change, but few studies have evaluated these particular ecosystems. Our aim was to provide information on the spatial distribution of insular cliff-specific vegetation assessing which environmental and climatic variables contribute to the definition of cliff habitat conditions. Ecological niche modelling for cliff populations in Balearic Islands has been calculated with presences of 20 plant species and climatic and geographical variables using a Random Forest model. The most important climatic variables for the model generation were mean temperature of the driest quarter and precipitation of the coldest quarter. The map obtained showed that mountain ranges from all islands provide highly suitable conditions for rupicolous species. Both the pessimistic and optimistic models showed that the habitat suitability of cliff vegetation in the mountain ranges would decrease, while they are close to zero in lowlands for the period 2021–2040. This study emphasizes the vulnerability of cliff habitats to climate change due to their limited dispersal capacity and distribution and the strict requirements for habitat suitability. From this work, future studies can focus on single-species analysis to evaluate if any cliff specialist species can be at risk of extinction due to climate change.

Prevalence of Parent-Reported Food Allergies Among Children in Saudi Arabia.

(1) Background: Food allergy (FA) is an immune-mediated hypersensitivity to foods, significantly contributing to childhood morbidity and mortality. This study aimed to assess the prevalence, characteristics, and influencing factors of parent-reported FAs among children in Saudi Arabia. (2) Methods: This cross-sectional study utilized a validated parental questionnaire distributed across all regions of Saudi Arabia. Data from 2130 participants were collected and analyzed using SPSS v. 26 and Prism software v. 10.3.0. (3) Results: Parent-reported FA prevalence was 15.2%. Egg was the most common allergen (6.2%), followed by tree nuts (4.1%), peanuts (4.0%), milk (3.8%), and sesame (3.2%). Significant geographical variations were observed, with the western region having the highest burden (p < 0.001). Older children had higher rates of shellfish and fish allergies. Parental allergies and co-existing asthma/drug allergies were positively associated with childhood FAs. (4) Conclusions: This study highlights a substantial burden of parent-reported FAs in Saudi Arabia, with regional variations in food allergen distribution. Parental allergies and co-existing allergic conditions may influence FA risk.

Geographic Gradients in Species Interactions: From Latitudinal Patterns to Ecological Mechanisms

The idea that species interactions are more ecologically and evolutionarily important toward lower latitudes underpins seminal theories in ecology and evolution. Recent global studies have found the predicted latitudinal gradients in interactions, particularly predation. However, latitudinal patterns alone do not reveal why interactions vary geographically and so do not provide strong predictions in space (e.g., for specific ecosystems) or time (e.g., forecasting responses to global change). Here, I review theory to identify a clearer, mechanistic, and testable framework for predicting geographic variation in the importance of species interactions. I review competing metrics of importance, proximate mechanisms that can increase interaction importance, and environmental gradients that could generate predictable geographic patterns (climate extremes and stability, warmth, productivity, and biodiversity). Strong empirical tests are accumulating thanks to the rise of global experiments and datasets; renewed focus on testing why interactions vary spatially will help move the field from identifying latitudinal patterns to understanding broader mechanisms.

Life expectancy and geographic variation in mortality: an observational comparison study of six high-income Anglophone countries

ObjectiveTo compare life expectancy levels and within-country geographic variation in life expectancy across six high-income Anglophone countries between 1990 and 2018.DesignDemographic analysis using aggregated mortality data.SettingSix high-income Anglophone countries (USA,...

Spatiotemporal Trends of Birth Defects in North Carolina, 2003-2015.

Birth defects are a leading cause of infant mortality in the United States, but little is known about causes of many types of birth defects. Spatiotemporal disease mapping to identify high-prevalence areas, is a potential strategy to narrow the search for potential environmental and other causes that aggregate over space and time. We described the spatial and temporal trends of the prevalence of birth defects in North Carolina during 2003-2015, using data on live births obtained from the North Carolina Birth Defects Monitoring Program. By employing a Bayesian space-time Poisson model, we estimated spatial and temporal trends of non-chromosomal and chromosomal birth defects. During 2003-2015, 52,524 (3.3%) of 1,598,807 live births had at least one recorded birth defect. The prevalence of non-chromosomal birth defects decreased from 3.8% in 2003 to 2.9% in 2015. Spatial modeling suggested a large geographic variation in non-chromosomal birth defects at census-tract level, with the highest prevalence in southeastern North Carolina. The strong spatial heterogeneity revealed in this work allowed to identify geographic areas with higher prevalence of non-chromosomal birth defects in North Carolina. This variation will help inform future research focused on epidemiologic studies of birth defects to identify etiologic factors.

Interconnectivity can be as important as habitat type in explaining carbon stocks in the coastal lagoons of arid regions

Coastal blue carbon ecosystems, typically comprising interconnected habitat mosaics, are globally important pathways of carbon sequestration and play a significant role in climate change regulation and mitigation. Current coastal management strategies often rely on simplified regional carbon stock estimates, that overlook the geographical variability and intricate ecological dynamics within these ecosystems. This study adopts a seascape ecology approach to evaluate the role of multiple seascape characteristics on carbon storage in two arid region coastal lagoons. We show that seascape location is the most influential driver of carbon stocks. Additionally, carbon isotopic variability, a proxy for connectivity, can be as influential as habitat type, particularly in the UAQ lagoon. This challenges the conventional reliance on data from individual habitat types (e.g., seagrass, mangrove, or tidal marsh) and highlights the context-dependency of carbon stocks. Moreover, the specific characteristics driving carbon stocks vary between seascapes: in Khor Faridah, connectivity to seagrass and mangrove habitats is crucial, while in the UAQ lagoon, sheltered and elevated areas are more influential. Our findings suggest that the interconnectivity between different habitat types, such as mangroves and saltmarshes, significantly enhances carbon storage. This is especially pronounced in large, sheltered mangrove habitat types within upper intertidal zones. Notably, small patches of mangroves, up to 10 ha, are associated with an approximate 10 % increase in carbon stocks. These results underscore the need for a more holistic, context-specific approach to designing nature-based solutions for coastal management and ecosystem restoration. By considering the specific characteristics and connectivity of seascape mosaics, we can more effectively enhance carbon stock potential in coastal ecosystems. This study contributes to a deeper spatially explicit understanding of the complex factors influencing carbon stocks in blue carbon ecosystems, highlighting the importance of tailored management strategies that reflect the unique ecological patterns of each seascape.

Predictors of long-acting contraceptive utilization hot spots in Ethiopia: using geographical weighted regression analysis.

The use of long-acting contraceptives is a common health challenge in Ethiopia. Therefore, the current study aimed to assess the determinants of using long-acting contraceptive hot spots in Ethiopia using data from the Ethiopian Mini Demographic and Health Survey for 2019. This study used data from the Ethiopia Mini Demographic and Health Survey 2019 and included a total weighted sample of 8,885 women in the analysis. The geographical variation of long-acting contraceptive usage was initially observed using hot spot analysis. Arc GIS version 10.7 was used for geographically weighted regression. Ordinarily, least squares regression was performed to identify predictors that explain the geographical variation in the use of long-acting contraceptives. Geographic weighted regression was used to predict the hot spot area of long-acting contraceptive methods. The overall prevalence of long-acting contraceptive utilization use was 6.9% (95% confidence interval: 6.4-7.45). Most of the statistically significant hot spots for long-acting contraceptives were found in lactated areas of the Oromia part of Amhara and Dire Dawa. Primary education, followers of the Muslim religion, marital status, and women with >4 children were the determinants of spatial variation use of hot spot areas for long-acting contraceptive methods. A detailed map of long-acting contraceptive use hot spots and their determinants will enable decisions to target their sociodemographic-related predictors of women.

Comparative Analysis of Phytochemical Composition and Antioxidant Properties of Smilax china Rhizome from Different Regions

This study aimed to investigate variations in the phytochemical compound contents and antioxidant potential of the ethanol rhizome extracts of Smilax china L., belonging to the Liliaceae family, from different parts of Korea, namely Uiwang (Mt. Gamnamugol), Gyeonggi Province (SC1); Geochang, Gyeongnam Province (SC2); Yeongwol, Gangwon Province (SC3); and Chungju, Chungbuk Province (SC4). The phenolic and flavonoid contents, radical scavenging activity, and proximate composition of the ethanol extracts from the rhizome samples were determined. The total polyphenol content (TPC) of the extracts ranged between 13.6 and 67.5 mg tannic acid equivalent/g. TPC analysis showed that TPC was higher in SC2 than in SC3, SC4, or SC1. Among the rhizome samples, the SC3 rhizomes had the highest total flavonoid content (TFC) (5.2 mg quercetin equivalents/g). Additionally, SC2 showed the highest radical scavenging activity against DPPH and ABTS+ radicals. Chemical characterization using UPLC/UV revealed that the extracts contained compounds such as apiin, kaempferol-3-rutinoside, and chlorogenic acid. Specifically, in SC2, chlorogenic acid was the dominant compound, which supported the levels observed in the UPLC/UV and HPLC/ELSD investigations. Dioscin, another phytochemical, was detected in SC2, SC3, and SC4, indicating the diversity of compounds among the rhizome extracts. Variations in the phytochemical content and antioxidant activity were observed in the extracts from the different regions, underlining the role of geographical variation in the functional characteristics of S. china. The observed differences could have important implications for the medicinal use of S. china extracts in applications such as anti-inflammatory treatments, diabetes management, and potential anticancer therapies. This study underscores the critical need to consider geographical origin when sourcing and utilizing S. china for therapeutic purposes, as it may significantly impact its bioactive profile and efficacy.

Prevalence of hepatitis A and E viruses in wastewater in Asian countries

Hepatitis A and E viruses (HAV and HEV, respectively) remain a significant global health concern despite advancements in healthcare and vaccination programs. Regular monitoring and vaccine efficacy of HAV are still lacking in different countries. This study aimed to investigate HAV and HEV prevalence in developed, developing, and least-developed Asian countries using wastewater as a surveillance tool. A total of 232 untreated wastewater samples were collected from six wastewater treatment plants, a sewage treatment plant, or an open drainage in six countries [Nepal (n = 51), Indonesia (n = 37), Thailand (n = 30), Vietnam (n = 27), the Philippines (n = 17), and Japan (n = 70)] between April and October 2022. Viruses in wastewater were concentrated by simple centrifugation or polyethylene glycol precipitation method, followed by viral RNA extraction and reverse transcription-quantitative polymerase chain reaction. HAV and HEV RNA were detected in the samples from Nepal (51 % for HAV and 2 % for HEV), Thailand (3 % for both viruses), and Japan (1 % for HAV and 24 % for HEV). Only HAV RNA was found in 11 % of the samples in Indonesia, whereas only HEV RNA was detected in Vietnam and the Philippines, with a positive ratio of 15 % and 12 %, respectively. These results highlighted the geographic variability in HAV and HEV prevalence, underscoring the need for localized public health strategies to address specific viral hepatitis challenges in each country.

Dwindling dollars: The inflation-adjusted decline of Medicare reimbursement in endocrine surgery (2003–2023)

Medicare determines reimbursement rates for medical services, often setting a benchmark that is followed by private insurers. Across various medical specialties, decreases in Medicare reimbursement have been observed. However, the extent of Medicare reimbursement for endocrine surgery remains unexplored. This study investigates the trajectory of reimbursement rates for endocrine surgical procedures. Data spanning 2003 to 2023 were gathered from the Physician Fee Schedule Look-Up Tool for 16 endocrine operations and procedures. Each operation's or procedure's relative value units and conversion factor, which accounts for geographic variation in relative value units, are determined annually by the Centers for Medicare and Medicaid Services. The total annual Medicare reimbursement for each operation or procedure was determined by multiplying procedure-specific relative value units with the conversion factor. Raw yearly percentage changes in reimbursement were computed and compared to changes in the general consumer price index. All data were then corrected for inflation. The compound annual growth rate for each procedure was calculated using inflation-adjusted data. From 2003 to 2023, the mean unadjusted percentage change for all queried procedures was+14.14% (standard deviation 0.28). During this same time, the consumer price index increased by 69.15% (P < .001). After adjusting for inflation, the mean total adjusted percentage change for all queried procedures over the entire study period was -31% (standard deviation 0.17). The adjusted average yearly compound annual growth rate was -1.93% (standard deviation 0.92). Only 1 procedure showed an increase in reimbursement (image-guided fine-needle aspiration,+32%). Inflation-adjusted Medicare reimbursement rates for endocrine surgical procedures have consistently declined. Stakeholders must address these trends to ensure access to quality surgical endocrine care in an evolving health care landscape.

[Translated article] Socioeconomic status, osteoporosis and fragility fractures

Low socioeconomic status (SES) is associated with a higher risk of fragility fractures, as well as higher mortality in the first-year post-fracture. The SES variables that have the greatest impact are educational level, income level, and cohabitation status. Significant disparities exist among racial and ethnic minorities in access to osteoporosis screening and treatment.In Spain, a higher risk of fractures has been described in people with a low-income level, residence in rural areas during childhood and low educational level. The civil war cohort effect is a significant risk factor for hip fracture. There is significant geographic variability in hip fracture care, although the possible impact of socioeconomic factors has not been analyzed. It would be desirable to act on socioeconomic inequalities to improve the prevention and treatment of osteoporotic fractures.