Marked Inequalities Research Articles

Trends in per Capita Food and Protein Availability at the National Level of the Southeast Asian Countries: An Analysis of the FAO's Food Balance Sheet Data from 1961 to 2018.

We aimed to analyze the temporal trends in the per capita food (kcal/day/person) and protein (g/day/person) availability at the national level in the Southeast Asian (SEA) countries from 1961 to 2018. To avoid intercountry variations and errors, we used a dataset derived from the FAO’s old and new food balance sheets. We used the joinpoint model and the jump model to analyze the temporal trends. The annual percentage change (APC) was computed for each segment of the trends. Per capita food and protein availability in the SEA countries increased significantly by 0.8% per year (54.0%) and 1.1% per year (85.1%), respectively, from 1961 to 2018. During the 1960s, 1970s, and 1980s the per capita food availability in mainland SEA did not change significantly and was less than 2200 kcal/person/day. Since the early 1990s, food availability increased appreciably in the mainland SEA countries, except for Cambodia, which has experienced the increasing trend from the late 1990s. Distinct from the mainland, maritime SEA countries showed an up–down–up growth trend in their per-capita food availability from 1961 to 2018. Food-availability growth slowed down for Brunei (since the mid-1980s) and Malaysia (since mid-the 1990s) whereas it increased for Indonesia (1.5% per year), Timor-Leste (0.9% per year), and the Philippines (0.8% per year). Per capita protein availability trends in the mainland SEA countries were similar to the countries’ per capita food availability trends. Since the late 1980s, Thailand and since the late 1990s, other mainland SEA countries experienced a significant growth in their per capita protein availability. Since the late 1990s, per capita protein availability in Vietnam increased markedly and reached the highest available amount in the SEA region, following Brunei and Myanmar. Per capita protein availability increased almost continuously among the maritime SEA countries, except for Timor-Leste. Marked inequality did exist between maritime and mainland SEA countries in per capita food-availability growth till the mid-1990s. Considerable increases in per capita food availability have occurred in most of the SEA countries, but growth is inadequate for Timor-Leste and Cambodia.

Social inequalities among Brazilian older adults: a secondary cross-sectional analysis of a national survey

OBJECTIVE: This study aimed to evaluate sociodemographic and economic differences among Brazilian older adults according to region. METHODS: This cross-sectional, descriptive-analytical study was conducted with individuals ≥ 60 years of age based on a secondary analysis of public data from a nationally representative survey called the Family Budget Survey. The data were separated according to the 5 regions of the country and were associated with sociodemographic and economic characteristics. Analyses were performed of categorical and numerical variables and their associations using multinomial logistic regression. RESULTS: Among all participants in the Family Budget Survey, 26 199 (15%) were older adults. It was found that the southeast and south had better living conditions and higher proportions of older adults. Regarding race, the southern region had the highest proportion of self-declared Whites, the southeastern region had the highest mean education level, and the northern and northeastern regions had the lowest levels of education and household income. CONCLUSIONS: The results suggest that the aging process is heterogeneous due to marked regional inequalities, which are related to social issues. Regional differences can be determinant in socioeconomic and demographic inequalities among the older population.

Reproductive genetic carrier screening for cystic fibrosis, fragile X syndrome and spinal muscular atrophy: patterns of community and healthcare provider participation in a Victorian screening program.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and The Royal Australian College of General Practice recommend that information on carrier screening for at least the most common inherited genetic conditions in our population, that is, thalassaemia, cystic fibrosis (CF), spinal muscular atrophy (SMA), and fragile X syndrome (FXS), should be offered to all women planning pregnancy or in early pregnancy regardless of family history or ethnicity. The aim of this study was to investigate patterns of participation by healthcare providers (HCP) and the community in screening. Participation in a Victorian program screening for CF, SMA and FXS between September 2013 and October 2018 was analysed. Requesting HCP and patient data were extracted from screening request forms. Data were analysed with respect to profession of requesting HCP, and characteristics of women screened (age, pregnancy status, socioeconomic status, geographic location, and family history of CF, SMA or FXS). In total, 21 172 women and 1288 HCPs participated in the program over this period. There was a steep socioeconomic gradient in screening uptake, with nearly half the women screened (10 349) being in the highest socioeconomic quintile. The screening rate was much higher in metropolitan areas than in regional areas. Obstetricians made most of the requests for screening, whereas 20% of requests were by GPs. Most participating GPs only made a single screening request (78%) and very few GPs made >100 screening requests compared with obstetricians (0.2% vs 17%). GPs were more likely to screen women before pregnancy compared with obstetricians (47% vs 11%). Approximately 1.5% of Victorian women of child-bearing age and 3% of pregnant Victorian women were screened by this program over the period of this study. This study highlights the translation gap between recommendations and practice, with marked inequity of access to reproductive genetic carrier screening in relation to socioeconomic status and geography. Increased participation by GPs could improve community access to reproductive genetic carrier screening, particularly access to preconception screening. Addressing the causes of inequity of access will allow more women and couples the opportunity to make informed choices about participation in screening.

Young Emancipated Women in Guatemala

Abstract. Social support is an important factor influencing the development of resilience across cultures and contexts. In this study, we explored the experiences of social support to the development of resilience among young Guatemalan women who were emancipated from system-based care. The study included 12 participants with an average age of 21 years who resided in the San Lucas Guatemala region. Thematic coding revealed the necessity of relational social support. Subthemes included social support identified and experienced through unconditional love, religiosity, and interpersonal relationships expressed within the realm of Guatemalan cultural values. Opportunities for social support varied considerably and were dependent upon the individual's ecological systems as well as the organizational and individual resources related to staffing and economic funds of the orphanages and group homes. Socioeconomic burdens are consistently present in Guatemala due to the marked inequality of wealth distribution. The disparities were greater among those facing significant life changes such as early separation from families of origin and those with access to fewer resources. This study demonstrates that social support serves as a strong protective factor in resiliency development, mitigating many of the risks present for Guatemalan women in their daily lives, workplaces, families, and communities.

Egalitarianism to gender inequality: Cross-cultural exploration of gender relations, in economic systems

Gender inequality has generated a lot of debates among scholars across disciplines. Much of these studies have not explored a robust scholarship on the historical development of gender inequality by comparing different human societies and their subsistence strategies. This review study is designed to fill this gap, thereby contributing to corpus of literature on gender inequality in economic relations. As a historical research, the study uses secondary materials. These materials are mainly ethnographies of the societies under comparison. The study compares the roles of each of the gender categories in subsistence activities, in economic systems, to trace the sources of gender inequality in economic relations. Data available suggest egalitarian gender and economic relations. However, as societies evolved, there became a gradual decline in egalitarianism, leading to marked inequality. The inequality is relative to the complexity of social structure peculiar to the societies under review.

Measuring Health Equity in Emergency Care Using Routinely Collected Data: A Systematic Review.

Introduction: Achieving equity in health care remains a challenge for health care systems worldwide and marked inequities in access and quality of care persist. Identifying health care equity indicators is an important first step in integrating the concept of equity into assessments of health care system performance, particularly in emergency care.Methods: We conducted a systematic review of administrative data-derived health care equity indicators and their association with socioeconomic determinants of health (SEDH) in emergency care settings. Following PRISMA-Equity reporting guidelines, Ovid MEDLINE, EMBASE, PubMed, and Web of Science were searched for relevant studies. The outcomes of interest were indicators of health care equity and the associated SEDH they examine.Results: Among 29 studies identified, 14 equity indicators were identified and grouped into four categories that reflect the patient emergency care pathway. Total emergency department (ED) visits and ambulatory care-sensitive condition-related ED visits were the two most frequently used equity indicators. The studies analyzed equity based on seven SEDH: social deprivation, income, education level, social class, insurance coverage, health literacy, and financial and nonfinancial barriers. Despite some conflicting results, all identified SEDH are associated with inequalities in access to and use of emergency care.Conclusion: The use of administrative data-derived indicators in combination with identified SEDH could improve the measurement of health care equity in emergency care settings across health care systems worldwide. Using a combination of indicators is likely to lead to a more comprehensive, well-rounded measurement of health care equity than using any one indicator in isolation. Although studies analyzed focused on emergency care settings, it seems possible to extrapolate these indicators to measure equity in other areas of the health care system. Further studies elucidating root causes of health inequities in and outside the health care system are needed.

Social inequalities in maternal depressive symptomatology after childbirth: Comparison across birth cohorts in Brazil

• Depressive symptomatology increased amongst southern women in the postpartum period;. • Depressive symptomatology amongst women residents in the north decreased over time;. • Black/brown women showed higher frequencies of depressive symptomatology;. • Poor mothers showed the highest frequencies of depressive symptomatology;. • Socioeconomic and skin colour inequalities remained stable over the studied period. Approximately 40% of women experience their first depressive episode during the postpartum period. In Brazil, several maternal health outcomes are affected by profound social inequalities. Investigating inequalities in maternal depressive symptomatology in two different regions of the country in the first 24 months after childbirth may help clarify these patterns and appropriate support services. Data from three birth cohorts from two Brazilian cities (Cruzeiro do Sul, North region, and Pelotas, South region) were analysed. The baseline of each cohort consisted of 4,231 (2004 Pelotas), 4,275 (2015 Pelotas), and 1,246 (MINA-Brazil) live births. Depressive symptomatology was repeatedly measured using the Edinburgh Postnatal Depression Scale (EPDS) at 3, 12, and 24 months postpartum. Socioeconomic status and skin colour inequalities in depressive symptomatology were analysed at each point. Between the 3rd and 24th months postpartum, maternal depressive symptomatology increased amongst women from the south, but decreased amongst women in the north. Black/brown women and those belonging to the lowest socioeconomic stratum showed the highest frequency of depressive symptomatology. Absolute and relative inequalities remained stable throughout the study period. Depressive symptomatology was most common amongst women with few years of schooling, multiparae, and amongst those who smoked during pregnancy. There was no information regarding any psychological/psychiatric treatment at the time the EPDS was evaluated, and economic status was assessed differently amongst the cohorts. Marked social inequalities were found in postpartum depressive symptoms. Actions aimed at early detection and reducing social inequalities in maternal postpartum depressive symptomatology are vital.

Inequality in access to dental services in a market-based dental care system: A population study from Norway 1975-2018.

To examine income-related inequalities in access to dental services from 1975 to 2018. In Norway, dental care services for adults are privately financed. This may lead to income-related inequalities in access. In the early 1970s, that is, at the beginning of the study period, there were marked inequalities in access to dental services according to personal income. However, from the beginning of the 1970s, there has been a large increase in gross national income per capita in Norway as a result of the growth of the oil and gas industry. This increase in income also meant that people with a low income in 1975had a rise in their level of income. According to the law of diminishing utility, an increase in income leads to higher consumption of dental services for people with a low level of income compared to people with a high level of income. The study hypothesis is that the inequalities in access to dental services that existed in 1975 became less over time. Statistics Norway collected samples of cross-sectional health survey data for the following years: 1975, 1985, 1995, 2002, 2008, 2012 and 2018. For each sample, individuals 21years and older were drawn randomly from the non-institutionalized adult population using a two-stage stratified cluster sample technique. Inequalities were measured using the concentration index. The dependent variable was the use of dental services during the last year, and the key independent variable was equivalized household income. The concentration index for inequalities in use of dental services according to income decreased from 0.10 (95% CI=0.09, 0.11) in 1975 to 0.04 (95% CI=0.03, 0.05) in 2018. The decrease was particularly large from 2002 to 2012. This was a period with a large growth in gross national income. People with a low income had a marked increase in their purchasing power from 1975 to 2018. This coincided with an increase in demand for dental care for this low-income group.

Social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents in Montreal, Canada

BackgroundThe success of current and prospective COVID-19 vaccine campaigns for children and adolescents will in part depend on the willingness of parents to accept vaccination. This study examined social determinants of parental COVID-19 vaccine acceptance and uptake for children and adolescents. MethodsWe used cross-sectional data from an ongoing COVID-19 cohort study in Montreal, Canada and included all parents of 2 to 18-year-olds who completed an online questionnaire between May 18 and June 26, 2021 (n = 809). We calculated child age-adjusted prevalence estimates of vaccine acceptance by parental education, race/ethnicity, birthplace, household income, and neighbourhood, and used multinomial logistic regression to estimate adjusted prevalence differences (aPD) and ratios (aPR). Social determinants of vaccine uptake were examined for the vaccine-eligible sample of 12 to 18 year-olds (n = 306). ResultsIntention to vaccinate children against COVID-19 was high, with only 12.4% of parents unlikely to have their child vaccinated. Parents with younger children were less likely to accept vaccination, as were those from lower-income households, racialized groups, and those born outside Canada. Children from households with annual incomes <$100,000 had 18.4 percent lower prevalence of being vaccinated/very likely vaccinated compared to household incomes ≥$150,000 (95% CI: 10.1 to 26.7). Racialized parents reported greater unwillingness to vaccinate vs. White parents (aPD = 10.3; 95% CI: 1.5, 19.1). Vaccine-eligible adolescents from the most deprived neighbourhood were half as likely to be vaccinated compared to those from the least deprived neighbourhood (aPR = 0.48; 95% CI: 0.18 to 0.77).Interpretation.This study identified marked social inequalities in COVID-19 vaccine acceptance and uptake for children and adolescents. Efforts are needed to reach disadvantaged and marginalized populations with tailored strategies that promote informed decision making and facilitate access to vaccination.

Socioeconomic inequalities in COVID-19 DALYs in Scotland, 2020

AimOur aim was to estimate the overall, and inequalities in the, population health impact of COVID-19 in Scotland, measured by disability-adjusted life years (DALYs) in 2020.MethodsNational deaths and daily case data were input into the consensus model outlined by the European Burden of Disease Network, to estimate DALYs. Total Years of Life Lost (YLL) were estimated, and for each deprivation quintile of the Scottish population. Years Lived with Disability (2% of all DALYs) were proportionately distributed to deprivation quintiles, based on YLL estimates. Socioeconomic inequalities were measured by the Relative Index of Inequality (RII), Slope Index of Inequality (SII), and attributable DALYs were estimated by using the least deprived quintile as a reference. Results were presented as a range, using a sensitivity based on YLL estimates using: cause-specific; and COVID-19 related deaths.ResultsCOVID-19 DALYs ranged from 96,500 to 108,200 in 2020, representing the second leading cause of disease/injury in Scotland, in 2020. Marked socioeconomic inequalities were observed across several measures. The difference between the most and least deprived areas, measured by SII, was 2,048 to 2,289 DALYs per 100,000. The RII was 1.16, meaning that the rate in the most deprived areas was around 58% higher than the mean rate of the population. DALYs attributable to differences in socioeconomic status accounted for 40% of total COVID-19 DALYs.ConclusionsThe direct population health impact of COVID-19 in 2020 was substantial. Despite unprecedented mitigation efforts, in Scotland, a single case in early 2020 developed to having an impact second only to ischaemic heart disease. This impact was not shared equally, and socioeconomically deprived areas were hit hardest, a result confirmed across all measures of inequality. DALY estimation on both the ongoing direct, and indirect, pandemic harms will evidence the extent of impact on overall, and inequalities in, population health.Key messages The population impact of COVID-19 has been highly damaging. When measured by DALYs, the population health impact of COVID-19 in Scotland, during 2020, was second only to ischaemic heart disease.The population health impact of COVID-19 has not been shared equally, a result confirmed across all measures of socioeconomic inequality.

Vaccination intentions generate racial disparities in the societal persistence of COVID-19

We combined survey, mobility, and infections data in greater Boston, MA to simulate the effects of racial disparities in the inclination to become vaccinated on continued infection rates and the attainment of herd immunity. The simulation projected marked inequities, with communities of color experiencing infection rates 3 times higher than predominantly White communities and reaching herd immunity 45 days later on average. Persuasion of individuals uncertain about vaccination was crucial to preventing the worst inequities but could only narrow them so far because 1/5th of Black and Latinx individuals said that they would never vaccinate. The results point to a need for well-crafted, compassionate messaging that reaches out to those most resistant to the vaccine.

The Covid-19 Pandemic and the Bioethics of Care

"The lecture illustrates how three fundamental dimensions of the human condition (vulnerability, interdependence, uncertainty), highlighted by the pandemic, are also at the root of the bioethics of care. In the first model proposed by Warren T. Reich, the bioethics of care is, in fact, based on Heidegger’s concept of Care and its link with vulnerability. It is proposed that two fundamental principles that remain implicit in the bioethics of care derive from this link: the principle of responsibility and the principle of solidarity. In the first part of the lecture, the theme-problem of preparedness is viewed in light of the principle of responsibility. Dwelling on Hans Jonas’s ideas on responsibility, I examine the duty of fore-seeing and its implications: the heuristics of fear, the difficulty of the shift from individual to collective responsibility, ultimately opposing the parental paradigm of responsibility proposed by Jonas with the paradigm of fraternity. In the second part, the relationship of interdependence between individual health and public health is examined, highlighting the marked inequalities that remain. Starting with some reflections on the principle of solidarity and its relationship with responsibility, the shift from the “fact” of interdependence to the ethical principle of solidarity is retraced, also through the rereading of an opinion issued by Italy’s National Bioethics Council (CNB) in 2020. This shift is seen in conclusion as both utopian and necessary if we are to re-interpret the pandemic emergency as a crisis that may result in a new beginning. "

Announcing the Lancet Psychiatry Commission on Psychoses in Global Context

Psychoses affect more than 20 million people worldwide1 and are associated with substantial impoverishment,2 premature mortality,3 stigma,4 and human rights violations.5,6 In high-income countries, for example, social outcomes for those with psychoses are poor and include high levels of unemployment, poverty, and homelessness in the decades after the initial contact with mental health services.2 In addition, there are marked inequities in outcomes and involvement with services by ethnic group (eg, high rates of compulsory admissions among Black populations in several countries).

Marked Inequalities in COVID-19 Vaccination by Racial/Ethnic, Socioeconomic, Geographic, and Health Characteristics, United States, January 6 – February 15, 2021

Background: The COVID-19 pandemic has had a substantial adverse impact on the health and wellbeing of populations in the United States (US) and globally. Since the availability of COVID-19 vaccines in December 2020, efforts have been underway to vaccinate priority populations who are at increased risks of COVID-19 infections, morbidity, and mortality, but rigorous and analytical national data on vaccination rates are lacking. Using the latest nationally representative data, we examine disparities in COVID-19 vaccination among US adults aged 18 years and older by a wide range of social determinants. Methods: Using three consecutive rounds of the US Census Bureau’s Household Pulse Survey from January 6 to February 15, 2021 (N=224,458), disparities in vaccination rates by race/ethnicity, socioeconomic status, health insurance, health status, and metropolitan area were modeled by multivariate logistic regression. Results: An estimated 33.6 million or 13.6% of US adults received COVID-19 vaccination. Vaccination rates varied 5-fold across the age range, from a low of 5.8% for adults aged 18-24 to 19.1% for those aged 65-74, and 29.0% for those aged ≥75 years. Males, non-Hispanic Blacks, Hispanics, divorced/separated and single individuals, those with lower education and household income levels, renters, not-employed individuals, the uninsured, and individuals with higher depression levels reported significantly lower rates of vaccination. Controlling for covariates, non-Hispanic Blacks had 11% lower odds and Asians had 50% higher odds of receiving vaccination than non-Hispanic Whites. Adults with less than a high school education had 64% lower adjusted odds of receiving vaccination than those with a Master’s degree. Adults with an annual income of &lt;$25,000 had 33% lower adjusted odds of vaccination than those with a ≥$200,000. Vaccination rates ranged from 10.7% in Riverside-San Bernardino, California to 16.1% in Houston, Texas. Conclusion and Implications for Translation: Ethnic minorities, socioeconomically-disadvantaged individuals, uninsured adults, and those with serious depression reported significantly lower vaccination rates. Equitable vaccination coverage is critical to reducing inequities in COVID-19 health outcomes. Copyright © 2021 Singh. et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in this journal, is properly cited.

Physical health monitoring of patients prescribed depot antipsychotic medication in north west Edinburgh community mental health team

AimsTo monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.BackgroundAntipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.MethodThe records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.ResultWe identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.ConclusionThere is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.

EXPRESS: COVID-19 AND STROKE â UNDERSTANDING THE RELATIONSHIP AND ADAPTING SERVICES. A GLOBAL WORLD STROKE ORGANISATION PERSPECTIVE.

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review we consider a year later where we are now, what the future holds, and what the long term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalised with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggests that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly the pandemic has had a major impact on stroke research and funding, although it has also emphasised the importnace of large scale collaborative research initiatives.

COVID-19, activity and mobility patterns in Bogotá. Are we ready for a ‘15-minute city’?

Social distancing and economic lockdown measures implemented in Global North countries have been mimicked in the Global South to contain the spread of COVID-19. However, the consequences of such measures on activity and mobility patterns among social groups in Global South cities remain unclear. This paper seeks to provide reliable evidence from changes in behaviors across income groups at the urban scale. We report a detailed analysis from a web-based survey to understand the effects of the early and complete lockdown adopted to contain the COVID-19 spread on activity and travel patterns in Bogotá. We also performed a geographical proximity analysis of non-work services and facilities located around surveyed households to challenge the rhetoric about the ‘15-minute’ city. We found that low-income people are more socially exposed to contagion being forced to go out to find their daily sustenance and having adverse economic and travel effects than other income groups. However, even though Bogotá is not so far from meeting the goal of 15 min proximity, particularly for non-work-related activities, we found marked inequalities among income groups regarding access to essential services in proximity. The paper’s findings serve as a reminder that travel behavior and accessibility are not the remits of only urban transport planning and that land-use and urban planning play a determining role in redressing social and spatial inequalities in a city.

Determinants of anterior tooth loss in Chilean adults: data from the Chilean National Health Survey 2016-2017.

To describe prevalence of anterior tooth loss and its determinants among Chilean people aged over 15 years. Cross-sectional study, using the sampling frame of the Chilean National Health Survey 2016-2017 (n=5473 participants). Multivariate logistic regressions were performed to obtain the prevalence and odds ratio (OR) for anterior tooth loss using a complex sampling method. We described anterior tooth loss affecting each jaw according to sex, age, educational level, urban/rural residence and having health insurance. The odds of anterior tooth loss were 7.11 (95%CI: 4.57 - 10.78) and 4.84 (95%CI: 3.02 - 7.72) times higher for low-educated subjects compared to those with more educational, for the upper and lower jaw respectively. Also, the odds of anterior tooth loss for the upper jaw was 1.34 (CI 95%: 1.07 - 1.66) times higher in women, whereas for the lower jaw, no significant differences by sex were found (p-value 0.14). Adults having only the National Health Fund B insurance (FONASA B) had odds of losing one or more anterior teeth 2.43 (CI 95%: 1.34 - 4.39) times higher in the upper jaw and 2.08 (CI 95%: 1.03 - 4.20) in the lower jaw compared with those having Health Insurance Institutions (ISAPREs). Our study showed for the first time that anterior tooth loss is a widespread condition in Chile, with marked inequities by sex, age, educational level, and geographical area. People in the public health insurance system have a higher odds of anterior tooth loss.

COVID-19 and stroke-Understanding the relationship and adapting services. A global World Stroke Organisation perspective.

A year ago the World Stroke Organisation (WSO) highlighted the enormous global impact of the COVID-19 pandemic on stroke care. In this review, we consider a year later where we are now, what the future holds, and what the long-term effects of the pandemic will be on stroke. Stroke occurs in about 1.4% of patients hospitalized with COVID-19 infection, who show an excess of large vessel occlusion and increased mortality. Despite this association, stroke presentations fell dramatically during the pandemic, although emerging data suggest that total stroke mortality may have risen with increased stroke deaths at home and in care homes. Strategies and guidelines have been developed to adapt stroke services worldwide, and protect healthcare workers. Adaptations include increasing use of telemedicine for all aspects of stroke care. The pandemic is exacerbating already marked global inequalities in stroke incidence and mortality. Lastly, the pandemic has had a major impact on stroke research and funding, although it has also emphasized the importance of large scale collaborative research initiatives.

A new two-nested-game approach: linking micro- and macro-scales in international environmental agreements

This study investigates the effectiveness of international environmental agreements (IEAs) and how it might be affected by the development of pro-environmental behaviour among households and firms. We propose a new framework based on a two-nested-game approach composed by: (1) a one-shot game with two asymmetric countries that negotiate the international abatement target, and (2) an evolutionary game which describes the economic structure resulting from agents’ interactions. These two games are nested because the initial economic structure determines the welfare of each country, and thus the outcome of Game 1 which, in turn, is embedded in Game 2, modifies the agents’ pay-off and the economic structure thereof. Numerical simulation outcomes suggest three key messages. First, we find that global solutions do not automatically produce the expected effects irrespective of any free-riding assumption. Second, extreme climate risks might not lead to a high abatement target in the event of marked cross-country inequality. Third, adverse consumers’ environmental attitudes might hamper the success of an IEA. The above observations entail that governments should not simply impose environmental laws. Rather, top-down policies and bottom-up interventions should be coordinated; otherwise, they might fail if undertaken in isolation.Graphic abstract