Unequal Burden Research Articles

Abstract P069: Quantifying the UK Benefits of reducing dietary trans fats: Modelling study

Introduction: Coronary Heart Disease (CHD) disease remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans-fats represent a powerful CHD risk factor. However, UK efforts to reduce the dietary intake of trans-fats (currently 1% of daily energy) have been limited in comparison with some other nations. Furthermore, quantifying the potential outcomes of such measures, and the effects on health inequalities has rarely been researched. We therefore modelled the effect of specific reductions in trans fatty acid (TFA) intake on CHD mortality, CHD related admissions and its effect on socioeconomic inequalities up to 2030. Methods: We extended the previously validated IMPACT model, to estimate the potential effects of reductions in TFA intake by 1% and 0.5% of daily energy upon the England and Wales population aged 25 years and above. We stratified these estimates by age, sex and Socioeconomic circumstances(SEC). We estimated a reduction in expected CHD deaths in 2030 attributable to a modest reduction in TF intake (-0.5% energy) and a complete ban (-1% energy). Main output measures were deaths prevented or postponed (DPP), life years gained (LYGs) and hospital admissions. Results: Reducing trans-fat consumption in the English and Welsh population by 1% of daily energy intake would result in approximately 3,900 fewer deaths per year; 10,000 fewer hospital admissions; and 37,000 additional life years. Smaller TFA reductions of 0.5% would yield approximately 1,900 fewer deaths, 5,000 fewer hospital admissions, and gain approximately 18,000 life years. Further, reducing trans-fats consumption to 0.5% across all SECs would reduce health inequalities. Three times as many DPPs and LYGs would be observed in the most deprived compared with the most affluent groups. Conclusions: Reducing dietary trans-fat intakes could substantially decrease CHD mortality and hospital admissions, gaining thousands of life years. Crucially, this policy could also reduce health inequalities. Strategies should therefore aim to achieve the lowest possible trans-fats intakes, as successfully achieved in many other European countries. However, such policies currently remain underused in the UK, generating an avoidable and unequal burden on the health services and on society.

PM352 Responding to the unequal burden of cardiovascular disease in Australia: The role of a leading Non Government Organisation (NGO) in tackling health inequities

Introduction: Access to the right information at the right time is a challenge facing health professionals across the globe. HEART Online (www.heartonline.org.au) is a website designed to support the delivery of evidence based care for the prevention and rehabilitation of heart disease. It was developed by the Queensland Government and the National Heart Foundation of Australia and launched May 2013. Objectives: HEART Online’s mission is to be a leading web resource that links best evidence with practical clinical tools promoting delivery of multi-disciplinary care. Methods: HEART Online was developed through a consensus approach. Content Leads wrote content for the following seven areas: i) risk factors and symptoms, ii) medications, iii) psycho-social issues, iv) exercise, v) patient education, vi) behaviour change and, vii) program evaluation. Content Leads were supported by contributions from over 40 clinicians and academics. Content was independently reviewed by six experts, with revisions made based upon their feedback. Ongoing evaluation of the site has consisted of user surveys, google analytics including ‘bounce rates’ (where a person visits only one page) and feedback via the ‘contact us’ page on the site. As the first content to be completed was relevant to exercise professionals, initial user evaluation invited physiotherapists and exercise physiologists to review the site and to complete a survey. Results: Surveys were completed by 31 exercises professionals with mean age 36 yrs and 11yrs post graduate clinical experience. Responses ranged from 3.45 to 4.61 across all questions on the Likert scales (5 being a positive strongly agree). Google analytics report for May to September 2013 identified that there had been 9451 visitors with 65% being unique visitors. Bounce rates were 38% suggesting that the majority of visitors are exploring the content. Conclusion: Initial evaluation suggests that HEART Online is reaching a large audience which is engaged by the content. The content is considered trustworthy, useful to clinical practice, specifically with regards to clarity and accuracy of content. It is proving to be a useful clinical tool in clinical and has the potential to improve standards of practice. Disclosure of Interest: None Declared

Chemical and biological work-related risks across occupations in Europe: a review.

BackgroundWork-related health inequalities are determined to some extent by an unequal exposure to chemical and biological risk factors of disease. Although their potential economic burden in the European Union (EU-25) might be substantial, comprehensive reviews focusing on the distribution of these risks across occupational groups are limited. Thus, the main objective of this review is to provide a synopsis of the exposure to chemical and biological hazards across occupational groups. In addition, main industrial applications of hazardous substances are identified and some epidemiological evidence is discussed regarding societal costs and incidence rates of work-related diseases.MethodsAvailable lists of carcinogens, sensitisers, mutagens, reprotoxic substances and biological hazards were consulted. For each work-related hazard the main industrial application was identified in order to assess which ISCO occupational groups may be associated with direct exposure. Where available, information on annual tonnage production, risk assessment of the substances and pathogens, and other relevant data were collected and reported.ResultsAltogether 308 chemical and biological hazards were identified which may account to at least 693 direct exposures. These hazards concentrate on the following major occupational groups: technicians (ISCO 3), operators (ISCO 8), agricultural workers (ISCO 6) and workers in elementary occupations (ISCO 9). Common industrial applications associated with increased exposure rates relate among others to: (1) production or application of pigments, resins, cutting fluids, adhesives, pesticides and cleaning products, (2) production of rubber, plastics, textiles, pharmaceuticals and cosmetics, and (3) in agriculture, metallurgy and food processing industry, Societal costs of the unequal distribution of chemical and biological hazards across occupations depend on the corresponding work-related diseases and may range from 2900 EUR to 126000 EUR per case/year.ConclusionsRisk of exposure to chemical and biological risks and work-related disease incidence are highly concentrated on four occupational groups. The unequal burden of exposure across occupations is an important contributing factor leading to health inequalities in society. The bulk of societal costs, however, are actually being borne by the workers themselves. There is an urgent need of taking into account the health impact of production processes and services on workers’ health.

A Radical Agenda for Men's Caregiving

The gender equality agenda has long discussed the unequal burden of care work for women and girls. But this debate has seldom focused on how to create the conditions necessary for men and boys to do more care work and be part of a global effort to value care work, regardless of who carries it out. In this analysis of global data and trends, the author argues for a radical shifting of the conversation to understand the resistance to men's care work, the benefits to men of greater participation in care work, and provides a set of policy recommendations for how to promote this change. The article also argues that the benefits of men's caregiving may be the impetus to move from a limited and zero-sum notion of the ‘patriarchal dividend’ to a ‘gender equality dividend’ with benefits for women, children and men themselves.

Metabolic Equivalent Determination in the Cultural Dance of Hula

Ethnic minorities share an unequal burden of cardiometabolic syndrome. Physical activity (PA) has been shown to be an important factor for improving the outcomes of these diseases. While metabolic equivalents (METs) have been calculated for diverse activities, most cultural activities have not been evaluated. Hula, the traditional dance of Native Hawaiians, is practiced by men and women of all ages but its MET value is unknown. To our knowledge, this is the first scientific evaluation of energy expenditure of hula. 19 competitive hula dancers performed 2 dance sets of low- and high-intensity hula. METs were measured with a portable indirect calorimetry device. Mean and standard deviations were calculated for all the variables. A 2-way ANOVA was conducted to identify differences for gender and intensity. The mean MET were 5.7 (range 3.17-9.77) and 7.55 (range 4.43-12.0) for low-intensity and high-intensity, respectively. There was a significant difference between intensities and no significant difference between genders. This study demonstrates that the energy expenditure of both low- and high-intensity hula met the recommended guidelines for moderate and vigorous intensity exercise, respectively, and that hula can be utilized as a prescribed PA.

Geographic and Racial Disparities in Breast Cancer–Related Outcomes in Georgia

To measure the effects of race/ethnicity, area measures of socioeconomic status (SES) and geographic residency status, and health care supply (HCS) characteristics on breast cancer (BC)-related outcomes. Female patients in Georgia diagnosed with BC in the years 2000-2009. Multilevel regression analysis with adjustment for variables at the county, census tract (CT), and individual level. The county represents the spatial unit of analysis for HCS. SES and geographic residency status were grouped at the CT level. Even after controlling for area-level characteristics, racial and ethnic minority women suffered an unequal BC burden. Despite inferior outcomes for disease stage and receipt of treatment, Hispanics had a marginally significant decreased risk of death compared with non-Hispanics. Higher CT poverty was associated with worse BC-related outcomes. Residing in small, isolated rural areas increased the odds of receiving surgery, decreased the odds of receiving radiotherapy, and decreased the risk of death. A higher per-capita availability of BC care physicians was significantly associated with decreased risk of death. Race/ethnicity and area-level measures of SES, geographic residency status, and HCS contribute to disparities in BC-related outcomes.

HPV Awareness and Vaccine Acceptability in Hispanic Women Living Along the US-Mexico Border

Despite advances in prevention of cervical cancer in the US, women of Hispanic origin still bear an unequal burden in cervical cancer incidence, morbidity and mortality. Our objective was to determine the HPV vaccine knowledge and acceptability in a group of mostly Hispanic females. In this cross sectional survey, 62% of participants heard of HPV; 34.9% identified HPV as a cause of cervical cancer. 63% of participants reported willingness to receive vaccine and 77% were willing to vaccinate daughters. Those with previous abnormal PAPs were more likely to have heard of HPV and Vaccine. No other factors examined showed association with willingness to get vaccine or administer to daughters. Knowledge level remains low in this high risk population. Willingness to receive vaccine is high despite lack of access to care. Increased targeted community based education and vaccination programs may be useful in closing disparity in cervical cancer morbidity.

Civic Environmentalism and the Politics of Marginalized People: A Case Study from Megacity Dhaka, Bangladesh

Abstract Civic environmentalism is gaining new momentum in the Global South in response to the state's structural failure to provide its citizens with urban environmental services and social justice. Dhaka, one of the world's biggest megacities, suffers from a large poverty stricken population, which leads to a gap in environmental services for poor and rich. In recent years, Dhaka has experienced a growing momentum with the environmental justice movement particularly led by poor marginalized people demanding their environmental rights and justice. A confrontational situation arises when the state and the citizens stand against each other. This article illustrates the process of unequal environmental burden placed on the poor marginalized citizens and their subsequent mobilization demanding urban environmental justice in megacity Dhaka.

Debunking ‘Race’ and Asserting Social Determinants as Primary Causes of Cancer Health Disparities: Outcomes of a Science Education Activity for Teens

Cancer health disparities are often described as the unequal burden of cancer deaths in one racial/ethnic group compared to another. For example, national cancer statistics in the USA shows that Blacks die the most for 9 of the top 10 cancers in men and women. When asked about the underlying causes for this disparity, teen participants speculated that it is primarily due to genetics or biology. This speculation appears to be based on a false concept of 'race.' A science activity was created to counter the false concept that genetics/biology underlie the categorization of humans into different 'races.' This activity provided teen participants with first-hand evidence of how they are all related at one genetic locus, and how they are more genetically related across racial/ethnic groups than within them. Results of surveys given before and after the activity show that they change their perceptions of 'race.' Before the activity, they view themselves as most related at the genetic level to 1-2 well-known individuals (i.e., celebrities) who they perceive as members of their own 'race' mainly because of similar appearance. After the activity, they view themselves as related to more/all the celebrities or they state that they do not know to whom they are most related. This increased awareness of the uncertainty between the apparent 'race' of an individual and their genetics drives teens to dismiss genetics or biology as the primary cause of racial/ethnic disparities in cancer outcomes. Instead, they consider the unequal distribution of the social determinants of health as the primary cause of cancer disparities.

Unequal Burden of Disease, Unequal Participation in Clinical Trials: Solutions from African American and Latino Community Members

African Americans and Latinos are underrepresented in clinical trials. The purpose of this study was to elicit solutions to participation barriers from African Americans and Latinos. Fifty-seven adults (32 African Americans, 25 Latinos) ages 50 years and older participated. The Institute of Medicine's Unequal Treatment conceptual framework was used. Six racially/ ethnically homogenous focus groups were conducted at five sites in three counties. Themes within groups and cross-cutting themes were identified. The NVIVO program was used for data classification. The data were reviewed for final coding and consensus. Shared solutions included addressing costs, recruiting in community contexts, conducting community and individualized patient education, and sharing patient safety information. Participants were unanimously in favor of clinical trials navigation recruitment interventions. Solutions specific to African Americans included diversifying research teams, recognizing past research abuses, and increasing community trust. Solutions specific to Latinos included providing low-literacy materials, providing Spanish-speaking clinicians and advocates, and clarifying that immigration status would neither be documented nor prevent participation. Solutions from African Americans and Latinos reflect their cultural backgrounds and historical experiences. The results suggest the importance of developing a tailored, barriers-focused navigation intervention to improve participation among diverse racial and ethnic populations.

Unequal Burden of Diabetes and Hypertension in the Adult Population of the San Juan Metropolitan Area of Puerto Rico

Objective: The study describes critical information gaps regarding diabetes, hypertension, prediabetes, prehypertension and its comorbidities in a representative sample of the Hispanic adult population living in Puerto Rico. Research design and methods: A representative sample of non-institutionalized Puerto Ricans adults aged 18-79 years residing in the San Juan metropolitan area participated in a face-to-face interview, anthropometric measurements and blood draws. Prevalence of diabetes, hypertension, prediabetes, prehypertension were estimated using logistic regression. Levels of awareness, treatment, adherence to medications, and control of these conditions were assessed. Results: Of 452 participants, 15.2% had diabetes, 35.3% had pre-diabetes, 39.9% had hypertension and 44.9% had pre-hypertension. Females were more likely to have diabetes, except those aged 18-64 years. Prevalence of diabetes, pre-diabetes, hypertension and pre-hypertension increased significantly with age in both sexes. Prehypertension was more prevalent among males in all age groups. Only 35% of those diagnosed with diabetes and 52.5% of those diagnosed with hypertension were controlled on pharmacotherapy. Conclusions: There is an unequal burden of diabetes, pre-diabetes, hypertension and pre-hypertension in Puerto Rico. The prevalence is high, increased significantly with age, and although the vast majority of participants with diabetes and hypertension were under treatment, control rates are suboptimal. These findings underscore the need for continued physician’s efforts to improve control rates in our population.

Introduction

Introduction Stephen Olufemi Sodeke, PhD, MT(ASCP), MA (bio) The manuscripts in this Supplemental Issue of the Journal of Health Care for the Poor and the Underserved are from the First Bioethics Conference on Cancer Health Disparities Research held at Tuskegee University in Tuskegee, Alabama from January 18 to 20, 2012. This conference was based on our belief that cancer health disparities are a bioethics issue because they reflect an injustice due to the unequal burden of suffering and cancer deaths in minority populations.1 Because bioethics is a life-affirming field, issues of disparities in health and wellbeing, justice, and equity are of serious concern, as highlighted in various reports.2,3,4 We are confident that scientific researchers are hard at work and their progress must be celebrated, but their research efforts in cancer health disparities raise many ethical issues that must be addressed. Therefore, the Bioethics Shared Resource Core of the Morehouse School of Medicine/Tuskegee University/University of Alabama at Birmingham Comprehensive Cancer Center Partnership recognized the need to collaborate with the research community to create the necessary reflective space and organize a program that could make this possible using a holistic approach. But why was a holistic approach critical? And, how did we make it happen? We reasoned that, since issues related to cancer health disparities research are contextual and cannot be ignored, an integrative bioethics approach that is responsive to issues of the race, ethnicity, gender, class, and spirituality of research participants as well as those of the investigators is required to address relevant issues. Such a holistic approach welcomes and accords credibility to different ways of thinking, knowing, experiencing, and understanding the interconnectedness of all stakeholders in cancer health matters affecting personal and community well-being. Our intention was to ensure that the scientific community and those who volunteer for research could, after learning from one another in the supportive environment of the conference, perform their work according to better bioethical standards. The conference had three parts. The first part dealt with cancer narratives and the duty not to harm. It opened with a theatrical production of the story of Henrietta Lacks by two professional actresses, Jamila Turner and Cynthia Wilson, who were supported by six Tuskegee University students. The synopsis of the play, written by Jamila Turner, is reproduced below: [End Page 1] HeLa*: Cellvation Meet Henrietta Lacks! She could be your mother, your wife, your sister, your daughter, your best friend, or your neighbor. But can a person’s life be summed up in just those relationships? She could have been any one of us. Any one of us could have had her story, but we didn’t. And because of her forced contribution to society, the world has greatly benefited in terms of scientific discovery, from a better understanding of the intricacies of cancer to the development of the polio vaccine that protected millions. No one can deny the importance of the HeLa cell to the revolution taking place in modern medicine cancer, however, what about the importance of the woman whose cells we revere? The play HeLa*: Cellvation is an attempt to tell Henrietta Lacks’ story through her perspective from the time of her diagnosis to her untimely death. The play is based on Rebecca Skloot’s book, The Immortal Life of Henrietta Lacks. It is the most intimate account of Henrietta’s life, as it is derived from accounts of her family and friends. This play is dedicated to humanizing her in a way that allows the audience to venture beyond the cells, which have made her known around the world as the immortal cancer cells known as “HeLa.” Henrietta’s story raises questions about the ethics of the acquisition, without consent, of human biological samples for use in research. Sit back and expand your focus from a single cell to clearly see a living, breathing person; a woman that loved and was loved, a woman that respected and was respected. Then, and only then, you will be able to experience the real Henrietta Lacks. (Jamila Turner) The discussion of bioethical issues was facilitated by Dr. Roland Pattilo, Professor of Gynecological Oncology, Morehouse School of Medicine in Atlanta...

An unequal burden: Risk factors for severe complications following unsafe abortion in Tigray, Ethiopia

Unsafe abortion is a leading cause of maternal mortality and morbidity worldwide. A total of 266 women seeking care at health facilities for the treatment of incomplete abortion in Tigray, Ethiopia were studied, and factors associated with severe complications related to unsafe abortion were assessed. Women had significantly higher odds of experiencing severe clinical complications if they were married compared with unmarried (odds ratio 3.98; 95% confidence interval, 1.75–9.04) or were seen in a mid- or low-level health facility (a health center or health post) compared with a high-level facility (a hospital) (odds ratio 4.77; 95% confidence interval, 1.87–12.19). The findings support the need to provide family planning programs that involve men and the need to expand access to confidential, safe abortion services by mid-level providers so that pregnancy termination no longer means placing women's lives and health in danger.

Recent UK trends in the unequal burden of coronary heart disease

IntroductionThe burden of coronary heart disease (CHD) in the UK is substantial. However, recent trends and associated socioeconomic inequalities are not well studied. We aim to identify and analyse these...

Equal Opportunity to Harass, Unequal Burdens of Proof: Affirming the Equal Opportunity Defense

Equal Opportunity to Harass, Unequal Burdens of Proof: Affirming the Equal Opportunity Defense

Race and Unequal Burden of Perioperative Pain and Opioid Related Adverse Effects in Children

Interindividual variability in pain perception and analgesic response is a major problem in perioperative practice. Adult studies suggest pain management is influenced by patient's race. The objective of this study is to evaluate the influence of race on perioperative pain treatment in children. Prospective observational study evaluating effect of race on analgesia and opioid related adverse effects after tonsillectomy in African American and Caucasian children. A sample of 194 healthy children between 6 and 15 years of age were included. Race was self-identified by parents. All participants received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine. Analgesia outcomes included maximum postoperative pain scores, postoperative opioid requirement, and analgesic interventions. Safety outcomes included incidences of opioid related adverse effects. African American children experienced significantly more postoperative pain than Caucasian children as measured by postoperative opioid requirement (P = .0011), maximum postoperative pain scores (P < .0001), and analgesic interventions (P < .0001) in the recovery room. Although Caucasian children received relatively less opioids perioperatively, they had significantly higher opioid related adverse effects (P = .039). African American children with obstructive sleep apnea were more likely to have prolonged post anesthesia recovery unit stay due to inadequate pain control. After similar uses of intraoperative morphine for tonsillectomy, there was an unequal burden of increased pain in African American children and increased opioid adverse effects in Caucasian children in the recovery room. Though Caucasian children received relatively less opioids perioperatively, they had higher incidences of opioid related adverse effects than African American children.

Race and Unequal Burden of Perioperative Pain and Opioid Related Adverse Effects in Children

Race and Unequal Burden of Perioperative Pain and Opioid Related Adverse Effects in Children

Abstract 4439: Childhood cancer late effects: Knowledge base and meaningful resources from a community perspective

Abstract Each year, cancer kills more children between 1 and 20 years of age than asthma, diabetes, cystic fibrosis, and AIDS combined, and remains the leading cause of death in children. Over 80% of children with cancer will survive, due to ongoing research and treatment in pediatric cancer. While long-term survival rates for pediatric cancer are fairly high, more than 3/4 of survivors experience late effects–complications, disabilities or other adverse outcomes as a result of the disease, its treatment, or both. The development of a website focusing on pediatric cancer late effects for diverse patients and the public is currently underway. The process is guided by community based participatory components. As part of the needs assessment we conducted a series of four focus group discussions. A total of 39 adults participated, including 7 to 12 participants per group. All group discussions were conducted in community sites and lasted up to two hours. Participants of diverse background from the local underserved communities were recruited. Gender and language of preference (English-Spanish) was used to breakdown the group discussions into 4 homogeneous groups. All groups conducted in Spanish included individuals from Latino descent. In addition, primarily African Americans, Asian Americans, Native Hawaiians and Pacific Islanders, and Latinos participated in the groups conducted in English. The results indicated that knowledge about childhood cancer based on other than personal experience was extremely limited. Participants across the groups consistently referred to TV ads as the only source of information. In addition, participants across the groups expressed that they lacked information about cancer in general. Personal experience varied greatly among the groups and included experience through close family members. Notably, the groups including women expressed greater direct experience with families, friends, or acquaintances and were more proactive sharing details of the experiences and hardships related to childhood cancer. Unfortunately often the information shared during the discussions pointed out to the premature deaths of strong exemplary children and the devastation in their families. Another common theme was the complete lack of information about the topic that the families confronted when the disease was diagnosed. Written resources and information distributed at community group meetings were identified across all groups as necessary to increase awareness about childhood cancer (and cancer in general), including late effects. Websites were also discussed as potential sources of information. Given the unequal burden of pediatric cancer on underserved communities, the results are important to guide the development of community programs addressing pediatric cancer knowledge and late effects awareness. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4439. doi:1538-7445.AM2012-4439

Ancient Virtues, Contemporary Practices

Earlier discussions of care have both insisted on its importance to political life and decried the unequal burden borne by women in care work. Yet they have failed to demonstrate why for reasons above and beyond the instrumental ends it serves. We ought to make the cultivation of an ongoing practice of caregiving a political priority. This article redefines and reframes care as a thoroughly critical and deeply embodied practice that is central to the flourishing of human beings. By way of Aristotle, I situate philia and embodied practices of care at the center of the shaping of the citizen and demonstrate a deeper significance of relations of care to our political life. When this is done alongside attention to habituation to right action and thinking, we can see more clearly how a particular kind of embodied politics can activate and sustain an ethic that cultivates citizens’ capacities and desires to care.

Access to general practitioner services amongst underserved Australians: a microsimulation study.

BackgroundOne group often identified as having low socioeconomic status, those living in remote or rural areas, are often recognised as bearing an unequal burden of illness in society. This paper aims to examine equity of utilisation of general practitioner services in Australia.MethodsUsing the 2005 National Health Survey undertaken by the Australian Bureau of Statistics, a microsimulation model was developed to determine the distribution of GP services that would occur if all Australians had equal utilisation of health services relative to need.ResultsIt was estimated that those who are unemployed would experience a 19% increase in GP services. Persons residing in regional areas would receive about 5.7 million additional GP visits per year if they had the same access to care as Australians residing in major cities. This would be a 18% increase. There would be a 20% increase for inner regional residents and a 14% increase for residents of more remote regional areas. Overall there would be a 5% increase in GP visits nationally if those in regional areas had the same access to care as those in major cities.ConclusionParity is an insufficient goal and disadvantaged persons and underserved areas require greater access to health services than the well served metropolitan areas due to their greater poverty and poorer health status. Currently underserved Australians suffer a double disadvantage: poorer health and poorer access to health services.