Inequalities in cesarean births between American Indian & Alaska Native people and White people

Objective

To explore population-level American Indian & Alaska Native-White inequalities in cesarean birth incidence after accounting for differences in cesarean indication, age, and other individual-level risk factors.

Data Sources and Study Setting

We used birth certificate data inclusive of all live births within the United States between January 1 and December 31, 2017.

Study Design

We calculated propensity score weights that simultaneously incorporate age, cesarean indication, and clinical and obstetric risk factors to estimate the American Indian and Alaska Native-White inequality.

Data Collection/Extraction Methods

Births to individuals identified as American Indian, Alaska Native, or White, and residing in one of the 50 US states or the District of Columbia were included. Births were excluded if missing maternal race/ethnicity or any other covariate.

Principal Findings

After weighing the American Indian and Alaska Native obstetric population to be comparable to the distribution of cesarean indication, age, and clinical and obstetric risk factors of the White population, the cesarean incidence among American Indian and Alaska Natives increased to 33.4% (95% CI: 32.0–34.8), 3.2 percentage points (95% CI: 1.8–4.7) higher than the observed White incidence. After adjustment, cesarean birth incidence remained higher and increased in magnitude among American Indian and Alaska Natives in Robson groups 1 (low risk, primary), 6 (nulliparous, breech presentation), and 9 (transverse/oblique lie).

Conclusions

The unadjusted lower cesarean birth incidence observed among American Indian and Alaska Native individuals compared to White individuals may be related to their younger mean age at birth. After adjusting for this demographic difference, we demonstrate that American Indian and Alaska Native individuals undergo cesarean birth more frequently than White individuals with similar risk profiles, particularly within the low-risk Robson group 1 and those with non-cephalic presentations (Robson groups 6 and 9). Racism and bias in clinical decision making, structural racism, colonialism, or other unidentified factors may contribute to this inequality.     

Equity of colorectal cancer screening: cross-sectional analysis of National Bowel Cancer Screening Program data for South Australia

Objective: The National Bowel Cancer Screening Program (NBCSP) is a population‐based screening program based on a mailed screening invitation and immunochemical faecal occult blood test. Initial published evidence from the NBCSP concurs with international evidence on similar colorectal cancer screening programs about the unequal participation by different population sub‐groups. The aim of the paper is to present an analysis of the equity of the NBCSP for South Australia, using the concept of horizontal equity, in order to identify geographical areas and population groups which may benefit from targeted approaches to increase participation rates in colorectal cancer screening. Method: De‐identified data from the NBCSP (February 2007 to July 2008) were provided by Medicare Australia. Univariate and multivariate statistical analyses were undertaken in order to identify the predictors of participation rates in the NBCSP. Results: The overall participation rate was 46.1%, although this was statistically significantly different (p<0.001) by gender (42.6% for males and 49.5% for females), socioeconomic status (40% in most deprived quintile through to 48.1% in most affluent quintile) and remoteness (45.6% for metropolitan, 46% for remote and 48.6% for rural areas). These findings were confirmed in multivariate analyses. Of the NBCSP participants, 0.24% (CI 95% 0.20–0.30) identified themselves as Indigenous and 8% (CI 95% 7.7–8.3) reported speaking a language other than English at home. Conclusion: Findings from this study suggest inequities in participation in the NBCSP on the basis of gender, geographical location, Indigenous status and language spoken at home.     

Meeting the challenge of falls prevention at the population level: a community-based intervention with older people in Australia

Older people form a large and growing segment of our population,experience disproportionately more illness and require moreuse of health services than any other group. This differentialis largely due to falls, which are the leading cause of injuryfor those aged 65 plus. The North Coast ‘Stay On YourFeet’ programme is a 4-year multi-strategic, community-basedintervention to address this problem among 80000 older residents.This paper presents key results of the first 18 months of theprogramme. It demonstrates potential achievements of this typeof intervention and examines some barriers. Programme effectwas measured quasi-experimentally by monitoring indicators ofawareness, knowledge, attitudes and risk factors via a telephonesurvey with random cohorts in intervention and control areas.After allowing for baseline covariates, the intervention wassignificantly associated with: raised awareness both of theproblem of falling and its preventability; improved knowledgeof the risk factors for falling; and a higher self-rated riskof falling. As expected, there is as yet no population changein falls rate. Initial changes shown in risk factors for fallingraise interesting challenges. A reduction in physical activitymay indicate that older people, now more aware of risk, arebeing advised to restrict their activities. An increase in proportionof older people taking medications which may cause unsteadinessalso presents a challenge. However, a concomitant decrease inreported dizziness may indicate that medications are now bettermanaged. This evaluation shows that in 18 months, a well-fundedand managed community-based falls prevention programme can achievechanges in awareness, knowledge and attitudes but that continuedintervention is required to substantially change behaviouralrisk factor profiles and the likelihood of an older person falling.     

Interventions to reduce socioeconomic health differences: A review of the international literature

The objective of this study was to review information on evaluatedinterventions to reduce socioeconomic health differences (SEHD)and analyse studies to identify possible conditions for success.The analysed interventions were from published and unpublishedsources. They were evaluated in terms of socioeconomic healthoutcomes. Ninety-eight publications on actual interventionsto reduce SEHD and 31 so-called ‘grey literature’interventions were identified. Many of the interventions describedare reported to be effective. Many of the local experimentalinterventions, however, were not formally evaluated. Structuralmeasures appear to be effective most often, but cannot be takento affect all determinants. Interventions often Involve healtheducation. This, however, only appears to be successful if providinginformation is combined with personal support or structuralmeasures. Many very creative interventions to reduce SEHD havebeen reported. Several appear to be effective, but all addressonly a small aspect of health inequalities. Regrettably thelack of standardized measures and a common methodology hamperour ability to integrate and compare the results. However, allthe studies show that there is room for improvement in our existinghealth policies to reach everyone in our population to the samedegree of effectiveness.     

Experiences,perceptions and expectations of health services amongst marginalized populations in urban Australia: A meta‐ethnographic review of the literature

BackgroundPoor health outcomes amongst marginalized groups result in part from health inequities related to social and structural determinants of health. Marginalized people report higher incidences of comorbidities, chronic disease and adverse health behaviours than their nondisadvantaged peers. The objective of this review is to examine marginalized Australians'' experiences of and access to community‐based primary health services in urban locations.MethodsA systematic search incorporating related MeSH terms and synonyms pertaining to marginalized Australian populations and their health‐seeking was conducted across seven databases. We included qualitative studies that reported experiences of health‐seeking within community‐based primary health care in metropolitan Australia. Participant populations experiencing marginalization due to social stigma and isolation, early‐life disadvantage, poor health and/or financial hardship were included. A meta‐ethnographic framework was used to synthesize themes across selected studies and researcher triangulation was employed to develop higher‐order themes.ResultsSearch results revealed 26 studies included for critical appraisal and synthesis. Seven higher‐order themes were developed describing experiences of health service engagement amongst marginalized groups: (1) Understanding the patient within the context of family and community, (2) Health and cultural beliefs influence health‐seeking, (3) Lack of information and poor cultural competence limit utilization of services, (4) Motivation for treatment influences health service engagement, (5) Accessing services, a spectrum of experience—from discrimination to validation, (6) Navigating a complex system in a complex society, (7) Preferences for health care and expectations for systemic change.ConclusionMarginalized Australians experience health disadvantage across micro, meso and macro levels of health system navigation and commonalities in health‐seeking were identified across each of the distinct marginalized groups in our analysis. This review outlines important areas of consideration for health care provision and policy development essential to helping address health inequities for a diversity of marginalized populations.Patient or Public ContributionWhilst patient voices were reported across all studies included within this review, no further patient or public contribution applies to this study.     

HIV transmission from husbands to wives in Cambodia: a systematic review of the literature

HIV transmission in Cambodia has declined considerably in recent years, yet new incidents of HIV transmission within marital relationships have increased. Evidence suggests that the cause of this is transmission from HIV-positive men to their HIV-negative spouses. The objective of this paper is to develop an evidence-based model of HIV transmission from husbands to wives in Cambodia in a context of culture and society, drawing from the published literature. A critical analysis of peer reviewed literature, professional papers, policy reports and reference books identified four plausible factors influencing inter-spousal HIV transmission: (1) a hierarchical male-dominated society, (2) husbands' involvement with sex workers, (3) cultural values concerning the ideal Khmer woman and (4) unprotected sex between an HIV-infected husband and his uninfected wife. This evidence-based explanatory model can be used to inform future culturally appropriate HIV-education and prevention programmes.     

Modifiable health risk factors,related counselling,and treatment among patients in health centres

Chronic disease burden and its related health risk factors are especially concentrated among the poor. Community health centres reach the nation's most vulnerable population. This study explored the prevalence, racial/ethnic, and gender disparities of five modifiable health risk factors and the receipt of related counselling and treatment among patients in U.S. federally qualified health centres. The 2014 Health Center Patient Survey was used for this study. We performed a cross‐sectional study. Measures included tobacco use, excessive alcohol consumption, obese/overweight, high blood pressure, high blood cholesterol, and five related counselling/treatment measures. Logistic regression models were conducted to examine the multivariable‐adjusted putative associations of several sociodemographic and health‐related factors with modifiable health risk and counselling/treatment measures. Preliminary findings revealed differences in modifiable health risk factors across different racial/ethnic groups, while few racial/ethnic differences existed in related counselling/treatment measures. In the multivariable‐adjusted logistic regression models, these differences in health risk factors were still apparent, while associations between race/ethnicity status and counselling/treatment measures were not detected. Gender was also a predictor for four types of health risk measures and two types of counselling/treatment measures. Health centre patients had high rates of modifiable health risk factors. The rates were different across race/ethnicity groups, and the differences found did not always favour non‐Hispanic Whites. However, the findings reveal equitable access to related counselling/treatment service among patients across race/ethnicity groups.     

Risk and protective factors that affect adolescent reproductive health in developing countries: A structured literature review

Abstract

The primary focus of this article is to determine which risk and protective factors are most important to adolescent reproductive health in developing countries. A comprehensive and systematic literature search was conducted on studies that examined factors in relation to the following outcomes: ever had premarital sex, condom use, pregnancy, early childbearing, sexually transmitted infections, and HIV. While the search identified over 11,000 publications, only 61 were retained for the final analysis. The results show that factors which were significantly associated to the outcomes were primarily related to the adolescents themselves. In fact, very few factors outside the individual were found to be related to sexual risk behaviours. This contrasts to similar research conducted among youth samples in the US. While this review confirms the strong need for a broader research base on the risk and protective factors related to adolescent sexual and reproductive health in developing countries, it also does identify key factors that can be addressed through innovative programmes and policies to help improve adolescent reproductive health in the developing world.     

1 000名老年人卫生服务需求及社区卫生服务意向研究

目的　为了了解老年人的卫生需求,更好地开展社区卫生服务。方法　采用整群随机抽样并进行入户调查的方法,对１ ０００ 名６０ 岁及以上老年人进行了调查。结果　老年人的２ 周患病率为４６７－０ ‰;患有慢性病者占６４－８ ％ ,其中３５－７ ％ 的患有２ 种或２ 种以上慢性病;残疾率占９－５ ％ ,８５ 岁以上者残疾率达３７－９ ％ ,１０－１ ％ 的人的生活活动能力失能;２３－８ ％ 的对卫生服务最为迫切;６２－８ ％ 的老人愿意到社区接受卫生服务,因经济困难应住院而未住院占５８－３ ％ 。结论　社区卫生服务应尽快建立并完善,尤其应针对目前老年人的需求和经济状况,开展一些老年人需要的且能接受的社区卫生服务     

Writing the risk of cancer: Cancer risk in public policy

In this paper we examine how cancer risk is written in cancer policy documents from the English speaking OECD nations. We offer an audit of the multiple ways in which cancer risk is conceptualised and presented in health policy and professional contexts with the long term aim of comparing this with lay conceptualisations. Our study sampled cancer policy documents produced by six nations, the World Health Organization and the International Union for Cancer Control since 2000 and analysed them iteratively through questions and codes. Whilst the documents contained a comprehensive range of concepts and locations for cancer risk, our analysis found two predominant representations: firstly, well established metaphors that depict cancer as uniformly dreadful and life threatening; and secondly, through a concentration on five behavioural risk factors (tobacco smoking, drinking alcohol, inadequate nutrition, sun exposure and physical inactivity) and one bodily state (overweight). We discuss the implications of this dual focus and of other tensions within ideas about cancer risk that we identified for risk communication.     

A systematic review of the evidence that swimming pools improve health and wellbeing in remote Aboriginal communities in Australia

Objective : To provide an overview of the evidence for health and wellbeing benefits associated with swimming pools in remote Aboriginal* communities in Australia. Methods : Peer‐reviewed and grey literature from 1990 to 2014 was searched to identify studies set in remote Australia that evaluated health and wellbeing benefits that have been associated with swimming pools. Studies were categorised using an evidence classification scale. Results : Twelve studies met our search criteria. All prospective studies that collected data on skin infections found access to swimming pools to be associated with a drop of skin sore prevalence and ‐where measured‐ severity. Studies documenting ear and eye infections showed mixed outcomes. Many wider community and wellbeing benefits were documented in various studies, although many of these were primarily anecdotal in nature. Conclusions : Although a case can be made regarding skin infections and the broader wellbeing benefits that swimming pools may bring to remote Aboriginal communities, the benefit to ear and eye health remains unresolved. Implications : The decision to provide swimming pools to remote Aboriginal communities should not hinge on the demonstration of direct health benefits alone. Equity considerations and the potential broader benefits such amenities may entail are equally important.