Injury is a leading cause of the global disease burden, accounting for 10 percent of all deaths worldwide. Despite 90 percent of these deaths occurring in low and middle-income countries (LMICs), the ...majority of trauma research and infrastructure development has taken place in high-income settings. Furthermore, although accessible services are of central importance to a mature trauma system, there remains a paucity of literature describing the spatial accessibility of emergency services in LMICs. Using data from the Service Provision Assessment component of the Demographic and Health Surveys of Namibia and Haiti we defined the capabilities of healthcare facilities in each country in terms of their preparedness to provide emergency services. A Geographic Information System-based network analysis method was used to define 5- 10- and 50-kilometer catchment areas for all facilities capable of providing 24-hour care, higher-level resuscitative services or tertiary care. The proportion of a country's population with access to each level of service was obtained by amalgamating the catchment areas with a population layer. A significant proportion of the population of both countries had poor spatial access to lower level services with 25% of the population of Haiti and 51% of the population of Namibia living further than 50 kilometers from a facility capable of providing 24-hour care. Spatial access to tertiary care was considerably lower with 51% of Haitians and 72% of Namibians having no access to these higher-level services within 50 kilometers. These results demonstrate a significant disparity in potential spatial access to emergency services in two LMICs compared to analogous estimates from high-income settings, and suggest that strengthening the capabilities of existing facilities may improve the equity of emergency services in these countries. Routine collection of georeferenced patient and facility data in LMICs will be important to understanding how spatial access to services influences outcomes.
Background
Routine screening mammography at two-year intervals is widely recommended for the prevention and early detection of breast cancer for women who are 50 years + . Racial and other ...sociodemographic inequities in routine cancer screening are well-documented, but less is known about how these long-standing inequities were impacted by the disruption in health services during the COVID-19 pandemic. Early in the pandemic, cancer screening and other prevention services were suspended or delayed, and these disruptions may have had to disproportionate impact on some sociodemographic groups. We tested the hypothesis that inequities in screening mammography widened during the pandemic.
Methods
A secondary analysis of patient data from a large state-wide, non-profit healthcare system in Washington State. Analyses were based on two mutually exclusive cohorts of women 50 years or older. The first cohort (
n
= 18,197) were those women screened in 2017 who would have been due for repeat screening in 2019 (prior to the pandemic’s onset). The second cohort (
n
= 16,391) were women screened in 2018 due in 2020. Explanatory variables were obtained from patient records and included race/ethnicity, age, rural or urban residence, and insurance type. Multivariable logistic regression models estimated odds of two-year screening for each cohort separately. Combining both cohorts, interaction models were used to test for differences in inequities before and during the pandemic.
Results
Significant sociodemographic differences in screening were confirmed during the pandemic, but these were similar to those that existed prior. Based on interaction models, women using Medicaid insurance and of Asian race experienced significantly steeper declines in screening than privately insured and white women (Odds ratios 95% CI of 0.74 0.58–0.95 and 0.76 0.59–0.97 for Medicaid and Asian race, respectively). All other sociodemographic inequities in screening during 2020 were not significantly different from those in 2019.
Conclusions
Our findings confirm inequities for screening mammograms during the first year of the COVID-19 pandemic and provide evidence that these largely reflect the inequities in screening that were present before the pandemic. Policies and interventions to tackle long-standing inequities in use of preventive services may help ensure continuity of care for all, but especially for racial and ethnic minorities and the socioeconomically disadvantaged.
Mobility among sex workers has been linked not only to improved economic and social opportunities, but also to concerns regarding displacement, criminalization, and violence. In 2014, new ...“end-demand” legislation criminalized new aspects of sex work in Canada (e.g., third-party advertising, purchasing) while leaving the sale of sex legal. Utilizing data from a longitudinal community-based cohort of women sex workers in Metro Vancouver (An Evaluation of Sex Workers Health Access AESHA, 2010-2016), we used kernel density mapping to understand and identify geographic patterns of workplace neighborhood mobility (i.e., changing the primary neighborhood in which one worked in the last 6 months); multivariable logistic regression using generalized estimating equations was also used to model contextual (policing, violence, and safety) and individual correlates of workplace mobility among sex workers over the 6-year period, including potential changes in mobility patterns pre- and post-end-demand criminalization. A total of 543 sex workers were included in analyses, contributing 2,199 observations. A total of 402 (74.0%) experienced workplace neighborhood mobility during the study period. Neighborhood mobility was negatively correlated with age (adjusted odds ratio AOR = 0.98/year older, 95% confidence interval CI = 0.97, 0.99) and positively correlated with homelessness (AOR = 1.43, 95% CI = 1.12, 1.82), identifying as a gender/sexual minority (AOR = 1.31, 95% CI = 1.04, 1.70), and servicing clients primarily outdoors (vs. informal indoor or in-call venues; AOR = 1.48, 95% CI = 1.21, 1.81); police harassment (AOR = 1.19, 95% CI = 0.96, 1.48, p = .11) and changing one’s neighborhood of work due to safety concerns (AOR = 1.37, 95% CI = 0.94, 2.00, p = .09) were both marginally correlated. Steps to promote safer working conditions for marginalized women in urban environments remain urgently needed, including shifts away from criminalized enforcement toward community-led initiatives and promoting access to safer indoor workspaces.
To examine the effects of poor sanitation and hygiene on the prevalence of antimicrobial-resistant bacteria, we surveyed households in two rural and two urban communities in Guatemala (N = 196 ...randomly selected households). One adult (≥ 18-years old) and, when available, one child (≤ 5 years-old) provided a stool sample. Up to 48 presumptive Escherichia coli isolates were collected from each stool sample (n = 21,256 total) and were subjected to breakpoint assays for ten antibiotics. Mixed-effects logistic models were used to identify potential factors influencing the likelihood of harboring antibiotic-resistant bacteria. For nine out of ten antibiotics, the odds of detecting resistant bacteria decreased by ~ 32% (odds ratios, OR 0.53-0.8, P < 0.001) for every unit of improvement of a hygiene scale. Hygiene differences between households had a greater impact on prevalence compared to antibiotic use differences. The likelihood of detecting resistant isolates was lower for five antibiotics among households that boiled raw milk before consumption (OR 0.31-0.69), and higher for nine antibiotics in urban households (OR > 1.89-9.6). Poor hygiene conditions likely obscure effects of individual antibiotic use, presumably due to enhanced microbial transmission. Consequently, efforts to improve antibiotic stewardship should be coupled with improving hygiene conditions.
Socio economic inequities in obesity have been attributed to individuals’ psychosocial and behavioral characteristics. School environment, where children spend a large part of their day, may play an ...important role in shaping their health. This study aims to assess whether prevalence of overweight and obesity among elementary school students was associated with the school’s social and built environments. Analyses were based on 28 public elementary schools serving a total of 10,327 children in the city of Spokane, Washington. Schools were classified by percentage of students eligible for free and reduced meals (FRM). Crime rates, density of arterial roads, healthy food access, and walkability were computed in a one-mile walking catchment around schools to characterize their surrounding neighborhood. In the unadjusted multilevel logistic regression analyses, age, sex, percentage of students eligible for FRM, crime, walkability, and arterial road exposure were individually associated with the odds of being overweight or obese. In the adjusted model, the odds of being overweight or obese were higher with age, being male, and percentage of students eligible for FRM. The results call for policies and programs to improve the school environment, students’ health, and safety conditions near schools.
Introduction
Studies have shown that cancer screenings dropped dramatically following the onset of the coronavirus diseases 2019 (COVID‐19) pandemic. In this study, we examined differences in rates ...of cervical and colorectal cancer (CRC) screening and diagnosis indicators before and during the first year of the COVID‐19 pandemic.
Methodology
We used retrospective data from a large healthcare system in Washington State. Targeted screening data included completed cancer screenings for both CRC (colonoscopy) and cervical cancer (Papanicolaou test (Pap test)). We analyzed and compared the rate of uptake of colorectal (colonoscopies) and cervical cancer (Pap) screenings done pre‐COVID‐19 (April 1, 2019–March 31, 2020) and during the pandemic (April 1, 2020–March 31, 2021).
Results
A total of 26,081 (12.7%) patients underwent colonoscopies in the pre‐COVID‐19 period, compared to only 15,708 (7.4%) patients during the pandemic, showing a 39.8% decrease. A total of 238 patients were referred to medical oncology for CRC compared to only 155 patients during the first year of the pandemic, a reduction of 34%. In the pre‐COVID‐19 period, 22,395 (10.7%) women were administered PAP tests compared to 20,455 (9.6%) women during the pandemic, for a 7.4% reduction. period 1780 women were referred to colposcopy, compared to only 1680 patients during the pandemic, for a 4.3% reduction.
Conclusion
Interruption in screening and subsequent delay in diagnosis during the pandemic will likely lead to later‐stage diagnoses for both CRC and cervical cancer, which is known to result in decreased survival.
Impact
The results emphasize the need to prioritize cancer screening, particularly for those at higher risk.
Studies are showing that COVID‐19 had an impact on access to colorectal and cervical cancer screening. However, only limited number of studies focused on inequities in colorectal and cervical cancer screening during the pandemic and little has been reported on the impact on diagnosis. This study shows lower screening and diagnosis during COVID‐19, particularly for patients residing in rural areas.
British Columbia, Canada is a geographically large jurisdiction with varied environmental and socio-cultural contexts. This cross-sectional study examined variation in motor vehicle crash rates ...across 100 police patrols to investigate the association of crashes with key explanatory factors.
Eleven crash outcomes (total crashes, injury crashes, fatal crashes, speed related fatal crashes, total fatalities, single-vehicle night-time crashes, rear-end collisions, and collisions involving heavy vehicles, pedestrians, cyclists, or motorcyclists) were identified from police collision reports and insurance claims and mapped to police patrols. Six potential explanatory factors (intensity of traffic law enforcement, speed limits, climate, remoteness, socio-economic factors, and alcohol consumption) were also mapped to police patrols. We then studied the association between crashes and explanatory factors using negative binomial models with crash count per patrol as the response variable and explanatory factors as covariates.
Between 2003 and 2012 there were 1,434,239 insurance claim collisions, 386,326 police reported crashes, and 3,404 fatal crashes. Across police patrols, there was marked variation in per capita crash rate and in potential explanatory factors. Several factors were associated with crash rates. Percent roads with speed limits ≤ 60 km/hr was positively associated with total crashes, injury crashes, rear end collisions, and collisions involving pedestrians, cyclists, and heavy vehicles; and negatively associated with single vehicle night-time crashes, fatal crashes, fatal speeding crashes, and total fatalities. Higher winter temperature was associated with lower rates of overall collisions, single vehicle night-time collisions, collisions involving heavy vehicles, and total fatalities. Lower socio-economic status was associated with higher rates of injury collisions, pedestrian collisions, fatal speeding collisions, and fatal collisions. Regions with dedicated traffic officers had fewer fatal crashes and fewer fatal speed related crashes but more rear end crashes and more crashes involving cyclists or pedestrians. The number of traffic citations per 1000 drivers was positively associated with total crashes, fatal crashes, total fatalities, fatal speeding crashes, injury crashes, single vehicle night-time crashes, and heavy vehicle crashes. Possible explanations for these associations are discussed.
There is wide variation in per capita rates of motor vehicle crashes across BC police patrols. Some variation is explained by factors such as climate, road type, remoteness, socioeconomic variables, and enforcement intensity. The ability of explanatory factors to predict crash rates would be improved if considered with local traffic volume by all travel modes.
Worldwide, Indigenous people have disproportionately higher rates of transport injuries. We examined disparities in injury-related hospitalizations resulting from transport incidents for three ...population groups in British Columbia (BC): total population, Aboriginal off-reserve, and Aboriginal on-reserve populations. We also examined sociodemographic, geographic and ethnic risk markers for disparities.
We identified Aboriginal people through BC's universal health care insurance plan insurance premium group and birth and death record notations. We calculated crude incidence rate and Standardized Relative Risk (SRR) of hospitalization for unintentional transport injury, standardized for age, gender and Health Service Delivery Area (HSDA), relative to the total population of BC. We tested hypothesized associations of geographic, socio-economic, and employment-related characteristics of Aboriginal communities with SRR of transport injury by multivariable linear regression.
During the period 1991-2010, the SRR for the off-reserve Aboriginal population was 1.77 (95% CI: 1.71 to 1.83); and 2.00 (95% CI: 1.93 to 2.07) among those living on-reserve. Decline in crude rate and SRRs was observed over this period among both the Aboriginal and total populations of BC, but was proportionally greater among the Aboriginal population. The best-fitting multivariable risk marker model was an excellent fit (R2 = 0.912, p<0.001), predicted SRRs very close to observed values, and retained the following terms: urban residence, population per room, proportion of the population with a high school certificate, proportion of the population employed; and multiplicative interactions of Aboriginal ethnicity with population per room and proportion of the population employed.
Disparities in risk of hospitalization due to unintentional transport injury have narrowed. Aboriginal ethnicity modifies the effects of socioeconomic risk factors. Continued improvement of socioeconomic conditions and implementation of culturally relevant injury prevention interventions are needed.
Epidemiologic studies have consistently reported associations between outdoor fine particulate matter (PM
2.5
) air pollution and adverse health effects. Although Asia bears the majority of the ...public health burden from air pollution, few epidemiologic studies have been conducted outside of North America and Europe due in part to challenges in population exposure assessment. We assessed the feasibility of two current exposure assessment techniques, land use regression (LUR) modeling and mobile monitoring, and estimated the mortality attributable to air pollution in Ulaanbaatar, Mongolia. We developed LUR models for predicting wintertime spatial patterns of NO
2
and SO
2
based on 2-week passive Ogawa measurements at 37 locations and freely available geographic predictors. The models explained 74% and 78% of the variance in NO
2
and SO
2
, respectively. Land cover characteristics derived from satellite images were useful predictors of both pollutants. Mobile PM
2.5
monitoring with an integrating nephelometer also showed promise, capturing substantial spatial variation in PM
2.5
concentrations. The spatial patterns in SO
2
and PM, seasonal and diurnal patterns in PM
2.5
, and high wintertime PM
2.5
/PM
10
ratios were consistent with a major impact from coal and wood combustion in the city’s low-income traditional housing (ger) areas. The annual average concentration of PM
2.5
measured at a centrally located government monitoring site was 75 μg/m
3
or more than seven times the World Health Organization’s PM
2.5
air quality guideline, driven by a wintertime average concentration of 148 μg/m
3
. PM
2.5
concentrations measured in a traditional housing area were higher, with a wintertime mean PM
2.5
concentration of 250 μg/m
3
. We conservatively estimated that 29% (95% CI, 12–43%) of cardiopulmonary deaths and 40% (95% CI, 17–56%) of lung cancer deaths in the city are attributable to outdoor air pollution. These deaths correspond to nearly 10% of the city’s total mortality, with estimates ranging to more than 13% of mortality under less conservative model assumptions. LUR models and mobile monitoring can be successfully implemented in developing country cities, thus cost-effectively improving exposure assessment for epidemiology and risk assessment. Air pollution represents a major threat to public health in Ulaanbaatar, Mongolia, and reducing home heating emissions in traditional housing areas should be the primary focus of air pollution control efforts.
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