Increasing access to fertility preservation for women with breast cancer: protocol for a stepped-wedge cluster randomized trial in France.

BACKGROUND: With the increase in the number of long-term survivors, interest is shifting from cancer survival to life and quality of life after cancer. These include consequences of long-term side effects of treatment, such as gonadotoxicity. Fertility preservation is becoming increasingly important in cancer management. International recommendations agree on the need to inform patients prior to treatments about the risk of fertility impairment and refer them to specialized centers to discuss fertility preservation. However, the literature reveals suboptimal access to fertility preservation on an international scale, and particularly in France, making information for patients and oncologists a potential lever for action. Our overall goal is to improve access to fertility preservation consultations for women with breast cancer through the development and evaluation of a combined intervention targeting the access and diffusion of information for these patients and brief training for oncologists. METHODS: Firstly, we will improve existing information tools and create brief training content for oncologists using a qualitative, iterative, user-centred and participatory approach (objective 1). We will then use these tools in a combined intervention to conduct a stepped-wedge cluster randomized trial (objective 2) including 750 women aged 18 to 40 newly treated with chemotherapy for breast cancer at one of the 6 participating centers. As the primary outcome of the trial will be the access to fertility preservation counselling before and after using the combined intervention (brochures and brief training for oncologists), we will compare the rate of fertility preservation consultations between the usual care and intervention phases using linear regression models. Finally, we will analyse our approach using a context-sensitive implementation analysis and provide key elements for transferability to other contexts in France (objective 3). DISCUSSION: We expect to observe an increase in access to fertility preservation consultations as a result of the combined intervention. Particular attention will be paid to the effect of this intervention on socially disadvantaged women, who are known to be at greater risk of inappropriate treatment. The user-centred design principles and participatory approaches used to optimize the acceptability, usability and feasibility of the combined intervention will likely enhance its impact, diffusion and sustainability. TRIAL REGISTRATION: Registry: ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT05989776. Date of registration: 7th September 2023. URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT05989776 . PROTOCOL VERSION: Manuscript based on study protocol version 2.0, 21st may 2023.

Migrants facing intersectional vulnerability to HIV and AIDS in Switzerland: an exploratory study.

An emerging body of evidence suggests that a significant number of HIV-positive migrants to Europe acquire HIV after arriving in their host country. There is an urgent need to rethink HIV and AIDS prevention for migrant populations and to acknowledge the specific vulnerability to HIV and AIDS that migrants face. This article uses empirical data collected in a qualitative sociological study conducted in Switzerland. We provide evidence for the heuristic value of articulating an intersectional approach within a multilevel (biographical, interactional and contextual) framework to capture the complexity of the vulnerability to HIV and AIDS. We show that migrants' specific vulnerability to HIV and AIDS results from social vulnerabilities related to many social and cultural dimensions, including migration status, socioeconomic conditions, gender and sexual identity, sexual norms, the relational context in which sex occurs, power relations and sociocultural structures of the receiving country. The three case studies presented illustrate how HIV-related processes of intersectional vulnerability are embedded in sexism, cisgenderism, and racism, and how they are closely linked to social inequalities in health. Effective HIV and AIDS prevention for migrants must take greater account of these power relations and sociocultural structures.

The effect of smoking initiation in adolescence on the subsequent smoking trajectories of people who smoke, and the role of adverse childhood experiences: Results from the 1958 British cohort study.

OBJECTIVE: To examine the association between smoking initiation in adolescence and subsequent different smoking trajectories of people who smoke, and to examine the combined effect of adverse childhood experiences (ACEs) and smoking initiation in adolescence on smoking trajectories of people who smoke. DESIGN AND SAMPLE: Data are from 8757 individuals in Great Britain from the birth cohort National Child Development Study and who reported being smokers or former smokers by age 23. MEASUREMENTS: Smoking initiation in adolescence was measured at 16 y and smoking trajectories were derived from smoking variables from ages 23 to 55. We modelled the relationship between smoking initiation in adolescence with or without ACEs and smoking trajectories. RESULTS: Individuals who initiated smoking in adolescence were more likely to quit later than quitting in twenties (RRR quitting in thirties  = 3.43 [2.40; 4.89] p < .001; RRR quitting in forties  = 5.25 [3.38; 8.14] p < .001; RRR quitting in fifties  = 4.48 [2.95; 6.79] p < .001), to relapse (RRR Relapse  = 3.66 [2.82; 4.76] p < .001) and to be persistent smokers (RRR persistent  = 5.25 [3.81; 7.25] p < .001) compared to those who had initiated smoking in young adulthood. These effects were particularly pronounced in case of ACEs. CONCLUSION: Smoking prevention programs aimed at reducing smoking initiation should be promoted to adolescents to limit the burden of smoking, especially for people who have suffered adversity during childhood.

Evaluation of the "Build your bike!" pilot project by and for disadvantaged youth: A school-based intervention to promote active mobility / Évaluation du projet pilote « Construis ton vélo ! ¼ par et pour les jeunes en milieu défavorisé : une intervention en contexte scolaire pour promouvoir la mobilité active

The densification of urban centers has driven individuals with low income toward more affordable suburban neighborhoods, thereby constraining transportation options due to car-centric planning and the difficulty for public transit systems to meet mobility needs. Recognizing that active cycling promotes travel autonomy, social participation, and physical and mental well-being, the promotion of such behavior through localized interventions stands as a critical objective to foster transport equity. In this context, in collaboration with the organization "Cyclo Nord-Sud," this study aims to explore the outcomes and favorable components of the "Build Your Bike!" pilot project offered as an extracurricular activity to high school students in a disadvantaged neighborhood. A qualitative, comprehensive approach with an inductive and phenomenological perspective was employed. We conducted a focus group at the end of the program and used conceptual categories to complete the analysis. The results revealed positive outcomes from the program related to: 1) well-being, 2) learning, 3) access to a bicycle, and 4) mobility. Favorable mechanisms encompassed: 1) the approach of adult mentors, 2) extracurricular involvement, 3) teamwork, 4) manual labor, and 5) bicycle ownership upon program completion. The mechanisms identified by the participants hold potential for improvement in future program iterations and can guide the development of similar interventions.

La densification des centres urbains a poussé les personnes à faible revenu vers des quartiers suburbains plus abordables, limitant les options en transport en raison de l'aménagement centré sur la voiture et de la difficulté pour le réseau de transports en commun de répondre aux besoins de mobilité. Étant donné que les déplacements actifs à vélo favorisent l'autonomie des déplacements, la participation sociale et sont source de bienfaits pour la santé physique et mentale, leur promotion par des interventions à l'échelle locale est un objectif essentiel pour favoriser l'équité en matière de transport. C'est dans ce cadre que, en collaboration avec l'organisme Cyclo Nord-Sud, cette étude vise à explorer les retombées et les composantes favorables du projet pilote « Construis ton vélo ! ¼ offert en parascolaire à des élèves du secondaire en milieu défavorisé. Une méthode qualitative de type compréhensive avec une approche inductive et phénoménologique a été utilisée. Elle a été complétée par un entretien de groupe à la fin du programme et une analyse par catégories conceptualisantes. Les résultats ont révélé que les retombées positives du programme se rapportent : 1) au bien-être ; 2) aux apprentissages ; 3) à l'accès à un vélo ; et 4) à la motilité. Les fonctionnements favorables sont : 1) l'approche des adultes encadrants, 2) le parascolaire, 3) le travail d'équipe, 4) le travail manuel et 5) le fait de posséder un vélo à la fin du programme. Les mécanismes identifiés par les jeunes pourront être valorisés dans les prochaines versions du programme et guider la création d'interventions similaires.

Socioeconomic disparities and concentration of the spread of the COVID-19 pandemic in the province of Quebec, Canada.

BACKGROUND: Recent studies suggest that the risk of SARS-CoV-2 infection may be greater in more densely populated areas and in cities with a higher proportion of persons who are poor, immigrant, or essential workers. This study examines spatial inequalities in SARS-CoV-2 exposure in a health region of the province of Quebec in Canada. METHODS: The study was conducted on the 1206 Canadian census dissemination areas in the Capitale-Nationale region of the province of Quebec. The observation period was 21 months (March 2020 to November 2021). The number of cases reported daily in each dissemination area was identified from available administrative databases. The magnitude of inequalities was estimated using Gini and Foster-Greer-Thorbecke (FGT) indices. The association between transmission and socioeconomic deprivation was identified based on the concentration of transmission in socially disadvantaged areas and on nonparametric regressions relating the cumulative incidence rate by area to ecological indicators of spatial disadvantage. Quantification of the association between median family income and degree of exposure of dissemination areas was supplemented by an ordered probit multiple regression model. RESULTS: Spatial disparities were elevated (Gini = 0.265; 95% CI [0.251, 0.279]). The spread was more limited in the less densely populated areas of the Quebec City agglomeration and outlying municipalities. The mean cumulative incidence in the subsample made up of the areas most exposed to the pandemic was 0.093. The spread of the epidemic was concentrated in the most disadvantaged areas, especially in the densely populated areas. Socioeconomic inequality appeared early and increased with each successive pandemic wave. The models showed that areas with economically disadvantaged populations were three times more likely to be among the areas at highest risk for COVID-19 (RR = 3.55; 95% CI [2.02, 5.08]). In contrast, areas with a higher income population (fifth quintile) were two times less likely to be among the most exposed areas (RR = 0.52; 95% CI [0.32, 0.72]). CONCLUSION: As with the H1N1 pandemics of 1918 and 2009, the SARS-CoV-2 pandemic revealed social vulnerabilities. Further research is needed to explore the various manifestations of social inequality in relation to the pandemic.

Considering social inequalities in health in COVID-19 response: insights from a French case study.

The COVID-19 pandemic highlighted the impact of social inequalities in health (SIH). Various studies have shown significant inequalities in mortality and morbidity associated with COVID-19 and the influence of social determinants of health. The objective of this qualitative case study was to analyze the consideration of SIH in the design of two key COVID-19 prevention and control interventions in France: testing and contact tracing. Interviews were conducted with 36 key informants involved in the design of the intervention and/or the government response to the pandemic as well as relevant documents (n = 15) were reviewed. We applied data triangulation and a hybrid deductive and inductive analysis to analyze the data. Findings revealed the divergent understandings and perspectives about SIH, as well as the challenges associated with consideration for these at the beginning stages of the pandemic. Despite a shared concern for SIH between the participants, an epidemiological frame of reference dominated the design of the intervention. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission. Although the COVID-19 health crisis highlighted the importance of SIH, it did not appear to be an opportunity to further their consideration in response efforts. This article provides original insights into consideration for SIH in the design of testing and contact-tracing interventions based upon a qualitative investigation.

The COVID-19 pandemic has highlighted the importance of social inequalities in health (SIH) and the disproportionate burden of the pandemic and its consequences related to socioeconomic status, ethnicity and race, among other determinants of health. Public health interventions are likely to increase SIH when they are not considered in the design phase. Through a qualitative case study, we analyzed the design of one of the first local initiative providing testing and contact tracing offer to the general population in the Île-de-France region (Paris region, France) in response to the COVID-19 pandemic. This article discusses the uncertainty and challenges associated with consideration for SIH in the intervention design. It explores the diverse understandings of SIH among the actors and the complexities of cross-sectoral partnerships addressing SIH in times of health crisis. Despite a consensual concern for this issue among the respondents, an epidemiological frame of reference dominated the intervention design. It resulted in a model in which consideration for SIH appeared as a complement, with a clinical goal of the intervention: breaking the chain of COVID-19 transmission.

Associations of adverse childhood experiences with smoking initiation in adolescence and persistence in adulthood, and the role of the childhood environment: Findings from the 1958 British birth cohort.

Adverse childhood experiences (ACEs) have been identified as a strong determinant of smoking. We aimed to examine the association between ACEs and early smoking initiation and subsequent persistence and the contribution of five pathways including family factors, parental involvement, material living conditions, social activities and conscientiousness. Data are from 7414 individuals born in 1958 in Great Britain included in the National Child Development Study. ACEs were measured at ages 7, 11, and 16. Smoking initiation was derived from smoking variables from ages 16 to 42 and persistent smoking was derived from smoking variables from ages 23 to 42. We modelled the relationship between ACEs and smoking, and further assessed the contribution of each pathway using multinomial logistic regressions. During childhood, 20.9% of respondents experienced one ACE and 6.4% two or more. Those who experienced ACEs had a higher risk of initiating smoking by age 16 and of persistent smoking (RRR initiation by 16y = 1.89 [1.62; 2.20] for one ACE; RRR initiation by 16y = 2.36 [1.81; 3.08] for two or more ACEs, and RRR persistent smoking = 2.07 [1.73; 2.47] for one ACE, RRR persistent smoking = 2.59 [1.92; 3.49] for two or more ACEs). The factors that contributed most to explaining these associations were parental smoking, sibling order and conscientiousness. ACEs remained associated with persistent smoking after further adjusting for young adulthood variables. Smoking prevention measures may need to be tailored when considering adolescents from communities where ACEs are more prevalent to curtail initiation, intensity and persistence. FUNDING: This work was supported by the Institut National du Cancer & the Institut de recherche en santé publique (grant agreement: No. [2019-204]).

The Every Woman Every Child initiative: supporting countries in Latin America and the Caribbean to reduce social inequalities in health.

The Every Woman Every Child Latin America and the Caribbean (EWEC-LAC) initiative was established in 2017 as a regional inter-agency mechanism. EWEC-LAC coordinates the regional implementation of the Global Strategy for Women's, Children's and Adolescents' Health in Latin America and the Caribbean (LAC), including adaptation to region specific needs, to end preventable deaths, ensure health and well-being and expand enabling environments for the health and well-being of women, children and adolescents. To advance the equitable achievement of these objectives, EWEC-LAC's three working groups collectively support LAC countries in measuring and monitoring social inequalities in health, advocating for their reduction, and designing and implementing equity-oriented strategies, policies and interventions. This support for data-driven advocacy, capacity building, and policy and program solutions toward closing current gaps ensures that no one is left behind. Members of EWEC-LAC include PAHO, UNAIDS, UNFPA, UNICEF, UN WOMEN, the World Bank, the Inter-American Development Bank, USAID, LAC Regional Neonatal Alliance, and the LAC Regional Task Force for the Reduction of Maternal Mortality. To date, EWEC-LAC has developed and collected innovative tools and resources and begun to engage with countries to utilize them to reduce equity gaps. These resources include a framework for the measurement of social inequalities in health, data use and advocacy tools including a data dashboard to visualize trends in social inequalities in health in LAC countries, a methodology for setting targets for the reduction of inequalities, and a compendium of tools, instruments and methods to identify and address social inequalities in health. EWEC-LAC has also engaged regionally to emphasize the importance of recognizing these inequalities at social and political levels, and advocated for the reduction of these gaps. Attention to closing health equity gaps is ever more critical in the face of the COVID-19 pandemic which has exploited existing vulnerabilities. More equitable health systems will be better prepared to confront future health shocks.

RESUMEN: La iniciativa Todas las mujeres, Todos los niños América Latina y el Caribe (EWEC-LAC, por su sigla en inglés) se estableció en 2017 como un mecanismo interinstitucional regional. Coordina la implementación regional de la Estrategia Mundial para la Salud de la Mujer, el Niño y el Adolescente en América Latina y el Caribe (ALC), incluyendo la adaptación a necesidades específicas de la región, para poner fin a muertes evitables, garantizar la salud y el bienestar y ampliar entornos propicios para la salud y el bienestar de mujeres, niños, niñas y adolescentes. Para promover el logro equitativo de estos objetivos, los tres grupos de trabajo de EWEC-LAC colectivamente apoyan a los países de ALC en la medición y monitoreo de las desigualdades sociales en salud, la abogacía por la disminución de estas y el diseño e implementación de estrategias, políticas e intervenciones orientadas a la equidad. Este apoyo para cerrar brechas actuales asegura que nadie se quede atrás. Miembros de EWEC-LAC incluyen FPNU, OPS, ONU Mujeres, ONUSIDA, UNICEF, el Banco Mundial, el Banco Interamericano de Desarrollo, USAID, la Alianza Regional Neonatal para ALC, y el Grupo de Trabajo Regional para la Reducción de la Mortalidad Materna. A la fecha, EWEC-LAC ha desarrollado y recopilado herramientas y recursos innovadores y ha comenzado a colaborar con los países para utilizarlos a fin de reducir brechas de equidad. Estos incluyen un marco de medición de desigualdades sociales en salud, herramientas de promoción de datos incluyendo un tablero de datos para visualizar tendencias en desigualdades sociales en salud, una metodología para establecer metas en la disminución de las desigualdades y un compendio de herramientas y métodos para identificar y abordar las desigualdades sociales en salud. EWEC-LAC ha trabajado en la región para enfatizar la importancia de reconocer estas desigualdades a niveles sociales y políticos, y ha abogado por la disminución de éstas. La atención para cerrar las brechas de equidad en salud es cada vez más crítica frente a la pandemia de COVID-19, que ha agudizado las vulnerabilidades existentes. Sistemas de salud más equitativos estarán mejor preparados para hacer frente a futuras crisis de salud.

Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey.

BACKGROUND: Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire. METHODS: A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient. RESULTS: The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60. CONCLUSION: Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Considering social inequalities in health in large-scale testing for COVID-19 in Montréal: a qualitative case study.

BACKGROUND: Evidence continues to demonstrate that certain marginalised populations are disproportionately affected by COVID-19. While many studies document the impacts of COVID-19 on social inequalities in health, none has examined how public health responses to the pandemic have unfolded to address these inequities in Canada. The purpose of our study was to assess how social inequalities in health were considered in the design and planning of large-scale COVID-19 testing programs in Montréal (Québec, Canada). METHODS: Part of the multicountry study HoSPiCOVID, this article reports on a qualitative case study of large-scale testing for COVID-19 in Montréal. We conducted semi-structured interviews with 19 stakeholders involved in planning large-scale testing or working with vulnerable populations during the pandemic. We developed interview guides and a codebook using existing literature on policy design and planning, and analysed data deductively and inductively using thematic analysis in NVivo. RESULTS: Our findings suggest that large-scale COVID-19 testing in Montréal did not initially consider social inequalities in health in its design and planning phases. Considering the sense of urgency brought by the pandemic, participants noted the challenges linked to the uptake of an intersectoral approach and of a unified vision of social inequalities in health. However, adaptations were gradually made to large-scale testing to improve its accessibility, acceptability, and availability. Actors from the community sector, among others, played an important role in supporting the health sector to address the needs of specific subgroups of the population. CONCLUSIONS: These findings contribute to the reflections on the lessons learned from COVID-19, highlighting that public health programs must tackle structural barriers to accessing healthcare services during health crises. This will be necessary to ensure that pandemic preparedness and response, including large-scale testing, do not further increase social inequalities in health.

Ability of municipality-level deprivation indices to capture social inequalities in perinatal health in France: A nationwide study using preterm birth and small for gestational age to illustrate their relevance.

BACKGROUND: Evidence-based policy-making to reduce perinatal health inequalities requires an accurate measure of social disparities. We aimed to evaluate the relevance of two municipality-level deprivation indices (DIs), the French-Deprivation-Index (FDep) and the French-European-Deprivation-Index (FEDI) in perinatal health through two key perinatal outcomes: preterm birth (PTB) and small-for-gestational-age (SGA). METHODS: We used two data sources: The French National Perinatal Surveys (NPS) and the French national health data system (SNDS). Using the former, we compared the gradients of the associations between individual socioeconomic characteristics (educational level and income) and "PTB and SGA" and associations between municipality-level DIs (Q1:least deprived; Q5:most deprived) and "PTB and SGA". Using the SNDS, we then studied the association between each component of the two DIs (census data, 2015) and "PTB and SGA". Adjusted odds ratios (aOR) were estimated using multilevel logistic regression with random intercept at the municipality level. RESULTS: In the NPS (N = 26,238), PTB and SGA were associated with two individual socioeconomic characteristics: maternal educational level (≤ lower secondary school vs. ≥ Bachelor's degree or equivalent, PTB: aOR = 1.43 [1.22-1.68], SGA: (1.31 [1.61-1.49]) and household income (< 1000 € vs. ≥ 3000 €, PTB: 1.55 [1.25-1.92], SGA: 1.69 [1.45-1.98]). For both FDep and FEDI, PTB and SGA were more frequent in deprived municipalities (Q5: 7.8% vs. Q1: 6.3% and 9.0% vs. 5.9% for PTB, respectively, and 12.0% vs. 10.3% and 11.9% vs. 10.2% for SGA, respectively). However, after adjustment, neither FDep nor FEDI showed a significant gradient with PTB or SGA. In the SNDS (N = 726,497), no FDep component, and only three FEDI components were significantly associated (specifically, the % of the population with ≤ lower secondary level of education with both outcomes (PTB: 1.5 [1.15-1.96]); SGA: 1.25 [1.03-1.51]), the % of overcrowded (i.e., > 1 person per room) houses (1.63 [1.15-2.32]) with PTB only, and unskilled farm workers with SGA only (1.52 [1.29-1.79]). CONCLUSION: Some components of FDep and FEDI were less relevant than others for capturing ecological inequalities in PTB and SGA. Results varied for each DI and perinatal outcome studied. These findings highlight the importance of testing DI relevance prior to examining perinatal health inequalities, and suggest the need to develop DIs that are suitable for pregnant women. .

The role of pension contributions in explaining inequalities in depressive symptoms. Results from SHARE.

Aims: Research has established solid evidence that socioeconomic position impacts health. It is, however, still debated to what extent characteristics of entire employment histories are associated with health inequalities later on. This study investigates associations between contributing to pension schemes throughout entire employment histories and depressive symptoms in older men and women. Methods: We use retrospective life history data from the Survey of Health, Ageing and Retirement in Europe (SHARE), collected in 2008-2009 from retired men and women. Data include detailed information on previous employment histories (between age 25 and 60 years) that allows us to measure labour market involvements and pension contributions during past working lives. In addition, we measure elevated depressive symptoms using EURO-D. Results: We observe that employed work without contributing to pension schemes is associated with elevated depressive symptoms for women, even when taking the current household income into consideration. For men (but not for women), self-employed work without pension contributions is linked to elevated depressive symptoms. Conclusions: Our results indicate that studies linking previous employment participation to health after labour market exit should not only consider whether a person worked, but also whether he or she contributed to a pension scheme. In addition, our study points to interesting gender differences, where pension contributions matter most for women in employed work and for men in self-employed work.

Racial/ethnic disparities in the association between fine particles and respiratory hospital admissions in San Diego county, CA.

Ambient air pollution exposure is associated with exacerbating respiratory illnesses. Race/ethnicity (R/E) have been shown to influence an individual's vulnerability to environmental health risks such as fine particles (PM 2.5). This study aims to assess the R/E disparities in vulnerability to air pollution with regards to respiratory hospital admissions in San Diego County, California where most days fall below National Ambient Air Quality Standards (NAAQS) for daily PM 2.5 concentrations. Daily PM 2.5 levels were estimated at the zip code level using a spatial interpolation using inverse-distance weighting from monitor networks. The association between daily PM 2.5 levels and respiratory hospital admissions in San Diego County over a 15-year period from 1999 to 2013 was assessed with a time-series analysis using a multi-level Poisson regression model. Cochran Q tests were used to assess the effect modification of race/ethnicity on this association. Daily fine particle levels varied greatly from 1 µg/m3 to 75.86 µg/m3 (SD = 6.08 µg/m3) with the majority of days falling below 24-hour NAAQS for PM 2.5 of 35 µg/m3. For every 10 µg/m3 increase in PM 2.5 levels, Black and White individuals had higher rates (8.6% and 6.2%, respectively) of hospitalization for respiratory admissions than observed in the county as a whole (4.1%). Increases in PM 2.5 levels drive an overall increase in respiratory hospital admissions with a disparate burden of health effects by R/E group. These findings suggest an opportunity to design interventions that address the unequal burden of air pollution among vulnerable communities in San Diego County that exist even below NAAQS for daily PM 2.5 concentrations.

Coronavirus biopolitics: the paradox of France's Foucauldian heritage.

In this short paper we analyse some paradoxical aspects of France's Foucauldian heritage: (1) while several French scholars claim the COVID-19 pandemic is a perfect example of what Foucault called biopolitics, popular reaction instead suggests a biopolitical failure on the part of the government; (2) One of these failures concerns the government's inability to produce reliable biostatistical data, especially regarding health inequalities in relation to COVID-19. We interrogate whether Foucaldianism contributed, in the past as well today, towards a certain myopia in France regarding biostatistics and its relation to social inequalities in health. One might ask whether this very data could provide an appropriate response to the Foucauldian question: What kind of governance of life is the pandemic revealing to us?

Patterning of educational attainment across inflammatory markers: Findings from a multi-cohort study.

BACKGROUND: Evidence suggests that the inflammatory reaction, an adaptive response triggered by a variety of harmful stimuli and conditions involved in the risk and development of many chronic diseases, is a potential pathway through which the socioeconomic environment is biologically embedded. Difficulty in interpreting the role of the inflammatory system in the embodiment dynamic arises because of heterogeneity across studies that use a limited but varied number of inflammatory markers. There is no consensus in the literature as to which inflammatory markers beyond the C-reactive protein and to a lesser extent interleukin 6 are related to the social environment. Accordingly, we aimed to investigate the association between educational attainment, and several markers of inflammation - C-reactive protein, fibrinogen, interleukin 6, interleukin 1ß and tumor necrosis factor α- in 6 European cohort studies. METHODS: Up to 17,470 participants from six European cohort studies with data on educational attainment, health behaviors and lifestyle factors, and at least two different inflammatory markers. Four sub-datasets were drawn with varying numbers of participants to allow pairwise comparison of the social patterning of C-reactive protein and any other inflammatory markers. To evaluate within each sub-dataset the importance of the context and cohort specificities, linear regression-based analyses were performed separately for each cohort and combined in a random effect meta-analysis to determine the relationship between educational attainment and inflammation. RESULTS: We found that the magnitude of the relationship between educational attainment and five inflammatory biomarkers (C-reactive protein, fibrinogen, interleukin 6 and 1ß and tumor necrosis factor α) was variable. By far the most socially patterned biomarker was C-reactive protein, followed by fibrinogen and to lesser extent interleukin 6, where a low educational attainment was associated with higher inflammation even after adjusting for health behaviours and body mass index. No association was found with interleukin 1ß and tumor necrosis factor α. CONCLUSIONS: Our study suggests different educational patterning of inflammatory biomarkers. Further large-scale research is needed to explore social differences in the inflammatory cascade in greater detail and the extent to which these differences contribute to social inequalities in health.

Overcoming adversity: a grounded theory of health management among middle-aged and older gay men.

This article presents findings from a grounded theory study in which we explored how self-identifying gay men between 40 and 76 years of age manage their health in the context of homophobia, heteronormativity and discrimination. Data were collected with 25 men over a 6-month period in a large urban setting in Western Canada. A preliminary theory of health management is discussed, consisting of the central phenomenon of overcoming adversity. Three thematic processes are considered that illustrate how adversity and health management are situated within the interrelationships of historical and ongoing discrimination inclusive of and external to the healthcare encounter, the complexity of men's illnesses, and the temporal aspects of HIV epidemics and treatments that occurred throughout their lives. These themes include: advocating for health needs, knowing about health issues and treatments, and engaging in health promoting practices. These findings help to address a gap in knowledge concerning health management among older gay men and support that initiatives aimed at health care with gay men must appreciate the systemic role of discrimination, while supporting men's individual efforts in actively managing their health.

'Ingredients' of a supportive web of caring relationships at the end of life: findings from a community research project in Austria.

In accordance with the pluralisation of life plans in late modernity, the societal organisation of care at the end of life is diverse. Although the public discourse in western societies is dominated by questions about optimising specialised palliative care services, public health approaches, which take into account the social determinants and inequalities in end-of-life care, have gained in importance over the last decade. Conceptual aspects, dimensions of impact and benefit for the dying and their communities are well discussed in the public health end-of-life care research literature. Our research focuses on the preconditions of a supportive caring web in order to understand how communities can build on their social capital to deal with existential uncertainty. As part of a large-scale community research project, we carried out focus groups and interviews with community members. Through dispositive analysis, we generated a set of care-web 'ingredients', which constitute and foster a caring community. These 'ingredients' need to be cultivated through an ongoing process of co-creation. This requires: (i) a focus on relationships and social systems; (ii) the creation of reflective spaces; and (iii) the strengthening of social capital, and d) the addressing of inequalities in care.

Socioeconomic inequalities in survival of children with acute lymphoblastic leukemia insured by social security in Mexico: a study of the 2007-2009 cohorts.

BACKGROUND: Although acute lymphoblastic leukemia (ALL) 5 years survival in minors has reached 90%, socioeconomic differences have been reported among and within countries. Within countries, the difference has been related to the socioeconomic status of the parents, even in the context of public health services with universal coverage. In Mexico, differences in the mortality of children with cancer have been reported among sociodemographic zones. The Instituto Mexicano del Seguro Social (IMSS), the country's main social security institution, has reported socioeconomic differences in life expectancy within its affiliated population. Here, the socioeconomic inequalities in the survival of children (< 15 years old) enrolled in the IMSS were analyzed. METHODS: Five-year survival data were analyzed in cohorts of patients diagnosed with ALL during the period 2007-2009 in the two IMSS networks of medical services that serve 7 states of the central region of Mexico. A Cox proportional risk model was developed and adjusted for the socioeconomic characteristics of family, community of residence and for the clinical characteristics of the children. The slope of socioeconomic inequality of the probability of dying within five years after the diagnosis of ALL was estimated. RESULTS: For the 294 patients studied, the 5 years survival rate was 53.7%; the median survival was 4.06 years (4.9 years for standard-risk diagnosis; 2.5 years for high-risk diagnosis). The attrition rate was 12%. The Cox model showed that children who had been IMSS-insured for less than half their lives had more than double the risk of dying than those who had been insured for their entire lives. CONCLUSIONS: We did not find evidence of socioeconomic inequalities in the survival of children with ALL associated with family income, educational and occupational level of parents. However, we found a relevant gradient related social security protection: the longer children's life insured by social security, the higher their probability of surviving ALL was. These results add evidence of the effectiveness of social security, as a mechanism of wealth redistribution and a promoter of social mobility. Extending these social security benefits to the entire Mexican population could promote better health outcomes.

Small-area socioeconomic deprivation indices in Cyprus: development and association with premature mortality.

BACKGROUND: Area-level measures of socioeconomic deprivation are important for understanding and describing health inequalities. The aim of this study was the development and validation of a small-area index of socioeconomic deprivation for Cypriot communities and the investigation of its association with the spatial distribution of all-cause premature adult mortality. METHODS: Six area-level socioeconomic indicators were used from the 2011 national population census (low educational attainment, unemployment, not owner occupied household, single-person household, divorced or widowed and single-parent households). After normalization and standardization of the geographically smoothed indicators, Principal Component Analysis (PCA) was used to construct indicator weights. The association between deprivation indices and the spatial distribution of all-cause premature adult mortality was estimated in Poisson log-linear spatial models. RESULTS: PCA resulted in two principal components explaining the 65.7% of the total variance. The first principal component included four indicators (low educational attainment, single-person households, divorced or widowed and single-parent households, the latter however with a negative loading) and it thought more likely to capture rural-related aspects of deprivation. The second principal component included the other two indicators (unemployment and not owner occupied households) and it is more likely to capture urban-related aspects of material deprivation. Restricting the analysis in the metropolitan areas of the island resulted in a different set of indicators for the urban-specific deprivation index. All developed indices were linearly associated with all-cause premature adult mortality. The all-cause premature adult mortality increased by 17% per 1 standard deviation (SD) increase in rural-related socioeconomic deprivation (95% CrI: 8-27%) and 8% per 1 SD increase in urban-related aspects of material deprivation (95% CrI: 3-15%) in the nationwide analysis and 9% per 1 SD increase in urban-specific socioeconomic deprivation (95% CrI: 4-15%) across metropolitan areas. CONCLUSIONS: The results of this study demonstrate that a set of small-area indices of socioeconomic deprivation across Cypriot communities have good construct and predictive validity. However, the study indicates that different aspects of socioeconomic deprivation may be important in rural and urban areas in Cyprus. The developed socioeconomic deprivation indices could offer a valid new tool for Cypriot public health research and policy in terms of identifying areas in greatest need, guiding resource allocation and developing area-targeted public health programmes and policies.

From prospective clinical trial to reducing social inequalities in health: The DESSEIN trial, concept and design of a multidisciplinary study in precarious patients with breast cancer.

BACKGROUND: In France during the last 15 years, precariousness among women has increased. In breast cancer, precariousness has been associated with an increase in mortality, but the links between precariousness, stage at diagnosis and care pathway are little explored. Our study aims to evaluate the impact of precariousness on care pathways, treatment and recovery phase according to a multidisciplinary analysis. METHODS AND DESIGN: Comparative prospective observational multicenter study of exposed / unexposed category. Patients with breast cancer are recruited in the Ile de France area. Three scores are used to identify precarious patients. Precarious patients are matched to non-precarious patients by age group. Questionnaires are distributed to patients at different times of care. The main objective is to compare the stage of the disease at diagnosis between two groups. The secondary objectives are: comparison of socio-economic and geographical characteristics, direct and indirect costs, personal trajectories of care and health. Analysis include multidisciplinary approaches. A geographical information systems method will evaluate the accessibility to health facilities and the characteristics of the places of residence of the patients. An anthropological analysis will be conducted through observation of consultations and semi-directed interviews with patients. These methods will allow to analyze the diagnostic and therapeutic routes, placing it in a life history and an economic, socio-cultural and health environment. The economic analysis will include a comparison of direct, indirect costs and out-off pocket costs, from the patient's point of view and from the societal perspective. DISCUSSION: Conducted in a clinical setting and coupled with a qualitative study, this study will provide a better understanding of how contextual factors, combined with individual factors, can influence the course of health and thus the stage of the disease at diagnosis. The multidisciplinary approach, involving clinicians, geographers, an anthropologist, an economist and a health epidemiologist, will allow a multidimensional approach to the impact of precariousness on breast cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02948478 registered October 28, 2016. ID RCB: 2016-A00589-42. protocol version: 2.1. decembre 13, 2018.