[Selected aspects regarding social factors in skin diseases]. / Ausgewählte Aspekte sozialer Faktoren bei Hautkrankheiten.

Skin diseases are complex and cannot be explained solely by genetic or environmental factors but are also significantly shaped by social influences. This review illuminates the bidirectional relationship between social factors and skin diseases, demonstrating how social determinants such as socioeconomic status, living environment, and psychosocial stress can influence the onset and progression of skin conditions. Simultaneously, it explores how skin diseases can affect individuals' social lives and work capability, leading to a cycle of social withdrawal and further deterioration of the condition. The paper describes the need for a holistic approach in dermatology that goes beyond the biomedical perspective and incorporates social factors to develop effective prevention and treatment strategies. The increasing prevalence of skin diseases in Europe and the expected rise in allergies due to climate change make the consideration of social determinants even more urgent. The findings of this review aim to raise awareness of the complex interconnections between social factors and skin health and contribute to reducing social disparities in skin health.

Socioeconomic Status and Dementia Risk Among Intensive Care Unit Survivors: Using National Health Insurance Cohort in Korea.

BACKGROUND: In aging populations, more elderly patients are going to the intensive care unit (ICU) and surviving. However, the specific factors influencing the occurrence of post-intensive care syndrome in the elderly remain uncertain. OBJECTIVE: To investigate the association between socioeconomic status (SES) and risk of developing dementia within two years following critical care. METHODS: This study included participants from the Korean National Health Insurance Service Cohort Database who had not been diagnosed with dementia and had been hospitalized in the ICU from 2003 to 2019. Dementia was determined using specific diagnostic codes (G30, G31) and prescription of certain medications (rivastigmine, galantamine, memantine, or donepezil). SES was categorized into low (medical aid beneficiaries) and non-low (National Health Insurance) groups. Through a 1:3 propensity score matching based on sex, age, Charlson comorbidity index, and primary diagnosis, the study included 16,780 patients. We used Cox proportional hazard models to estimate adjusted hazard ratios (HR) of dementia. RESULTS: Patients with low SES were higher risk of developing dementia within 2 years after receiving critical care than those who were in non-low SES (HR: 1.23, 95% CI: 1.04-1.46). Specifically, patients with low SES and those in the high-income group exhibited the highest incidence rates of developing dementia within two years after receiving critical care, with rates of 3.61 (95% CI: 3.13-4.17) for low SES and 2.58 (95% CI: 2.20-3.03) for high income, respectively. CONCLUSIONS: After discharge from critical care, compared to the non-low SES group, the low SES group was associated with an increased risk of developing dementia.

Treatment of obesity by acupuncture combined with medicine based on pathophysiological mechanism: A review.

Obesity is a complex, multifactorial disease. The incidence of overweight and obesity has doubled worldwide since 1980, and nearly one-third of the world population is now classified as overweight or obese. Obesity rates are increasing in all age groups and for both sexes, regardless of geographic region, race, or socioeconomic status, although they are generally higher in older adults and women. Although the absolute prevalence of overweight and obesity varies widely, this trend is similar across different regions and countries. In some developed countries, the prevalence of obesity has levelled off over the past few years. However, obesity has become a health problem that cannot be ignored in low- and middle-income countries. Although the drug treatment model of modern medicine has a significant therapeutic effect in the treatment of obesity, its adverse effects are also obvious. Acupuncture combined with Chinese medicine treatment of obesity has prominent advantages in terms of clinical efficacy, and its clinical safety is higher, with fewer adverse reactions. The combination of acupuncture and medicine in the treatment of obesity is worth exploring.

Socioeconomic differences in the utilization of diagnostic imaging and non-pharmaceutical conservative therapies for spinal diseases.

BACKGROUND: A different utilization of health care services due to socioeconomic status on the same health plan contradicts the principle of equal treatment. We investigated the presence and magnitude of socioeconomic differences in utilization of diagnostic imaging and non-pharmaceutical conservative therapies for patients with spinal diseases. METHODS: The cohort study based on routine healthcare data from Germany with 11.7 million patient-years between 2012 and 2016 for patients with physician-confirmed spinal diseases (ICD-10: M40-M54), occupation and age 20 to 64 years. A Poisson model estimated the effects of the socioeconomic status (school education, professional education and occupational position) for the risk ratio of receiving diagnostic imaging (radiography, computed tomography, magnetic resonance imaging) and non-pharmaceutical conservative therapies (physical therapy including exercise therapy, manual therapy and massage, spinal manipulative therapy, acupuncture). RESULTS: Patients received diagnostic imaging in 26%, physical therapy in 32%, spinal manipulative therapy in 25%, and acupuncture in 4% of all patient-years. Similar to previous survey-based studies higher rates of utilization were associated with higher socioeconomic status. These differences were most pronounced for manual therapy, exercise therapy, and magnetic resonance imaging. CONCLUSIONS: The observed differences in health care utilization were highly related to socioeconomic status. Socioeconomic differences were higher for more expensive health services. Further research is necessary to identify barriers to equitable access to health services and to take appropriate action to decrease existing social disparities.

Dairy intake and risk of hip fracture in prospective cohort studies: non-linear algorithmic dose-response analysis in 486 950 adults.

Previous studies on the relationship between dairy consumption and hip fracture risk have reported inconsistent findings. Therefore, we aimed to conduct an algorithmically driven non-linear dose-response meta-analysis of studies assessing dairy intake and risk of developing incident hip fracture. Meta-analysis from PubMed and Google Scholar searches for articles of prospective studies of dairy intake and risk of hip fracture, supplemented by additional detailed data provided by authors. Meta-regression derived dose-response relative risks, with comprehensive algorithm-driven dose assessment across the entire dairy consumption spectrum for non-linear associations. Review of studies published in English from 1946 through December 2021. A search yielded 13 studies, with 486 950 adults and 15 320 fractures. Non-linear dose models were found to be empirically superior to a linear explanation for the effects of milk. Milk consumption was associated with incrementally higher risk of hip fractures up to an intake of 400 g/d, with a 7 % higher risk of hip fracture per 200 g/d of milk (RR 1⋅07, 95 % CI 1⋅05, 1⋅10; P < 0⋅0001), peaking with 15 % higher risk (RR 1⋅15, 95 % CI 1⋅09, 1⋅21, P < 0⋅0001) at 400 g/d versus 0 g/d. Although there is a dose-risk attenuation above 400 g/d, milk consumption nevertheless continued to exhibit elevated risk of hip fracture, compared to zero intake, up to 750 g/d. Meanwhile, the analysis of five cohort studies of yoghurt intake per 250 g/d found a linear inverse association with fracture risk (RR 0⋅85, 95 % CI 0⋅82, 0⋅89), as did the five studies of cheese intake per 43 g/d (~1 serving/day) (RR 0⋅81, 95 % CI 0⋅72, 0⋅92); these studies did not control for socioeconomic status. However, no apparent association between total dairy intake and hip fracture (RR per 250 g/d of total dairy = 0⋅97, 95 % CI 0⋅93, 1⋅004; P = 0⋅079). There were both non-linear effects and overall elevated risk of hip fracture associated with greater milk intake, while lower risks of hip fracture were reported for higher yoghurt and cheese intakes.

Investigating Mortality Disparities Among Insured Patients With Colon Cancer Treated in an Integrated Health care System and Other Private Settings.

BACKGROUND: Lower socioeconomic status (SES) affects health care delivery and is associated with worse outcomes. Integrated healthcare systems (IHS) may help reduce barriers to health care and affect outcomes. Our aim was to compare outcomes of colon cancer cases diagnosed at the largest IHS in California, Kaiser Permanente Southern California (KPSC), to other insured patients (OI) to determine how SES influences mortality. METHODS: This retrospective cohort study included insured adults in southern California diagnosed with colon cancer between 2009 and 2014, using data from the California Cancer Registry, and followed through 2017. Main outcome was all-cause mortality. Person-year mortality rates were calculated for two groups, KPSC and OI. Multivariable hazard ratios were calculated for association between SES quintiles and mortality. RESULTS: Total of 15 923 patients were diagnosed with colon cancer, 4195 patients (26.3%) within KPSC and 11 728 patients (73.7%) in OI. The overall mortality rate per 1000 person-years (PY) was lower in KPSC [103.8/1000 PY (95% CI:98.5-109.3)] compared to OI [139.3/1000 PY (95% CI:135.2-143.4)]. Compared to the highest SES group, the lowest SES group did not experience higher mortality risk in the KPSC population, after adjusting for race/ethnicity and other factors (HR, 95% CI = 1.13, .93-1.38). However, in OI patients, lowest and lower-middle SES groups had higher mortality risk compared to the highest SES group (HR, 95% CI = 1.26, 1.13-1.40 and 1.28, 1.16-1.41, respectively). DISCUSSION: Lower SES was associated with higher mortality risk within the OI group; however, within KPSC no such association was observed. Care coordination in IHS settings mitigate SES-related mortality differences.

Health Disparities in Ovarian Cancer: Report From the Ovarian Cancer Evidence Review Conference.

Health disparity, defined by the Centers for Disease Control and Prevention (CDC) as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations," is seen across multiple diseases. We conducted an evidence review of health disparities and inequities and their mitigation strategies related to ovarian cancer as part of a CDC-sponsored project to develop educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. Our review found profound disparities in outcomes such as survival, treatment, and stage at diagnosis by factors such as race and ethnicity, insurance, socioeconomic status, and geographic location. We found little direct evidence on mitigation strategies. Studies support equivalent response to equivalent treatment between groups, suggesting that adherence to National Comprehensive Cancer Network guidelines can at least partially mitigate some of the differences.

Childbearing Trajectories in a West African Setting: A Sequence Analysis Approach.

The lagging fertility transition in West Africa has important repercussions for global population growth but remains poorly understood. Inspired by Caldwell and colleagues' fertility transition framework, as well as by subsequent research, we examine diversity in women's holistic childbearing trajectories in Niakhar, Senegal, between the early 1960s and 2018 using a sequence analysis approach. We evaluate the prevalence of different trajectories, their contribution to overall fertility levels, and their association with women's socioeconomic and cultural characteristics. Four trajectories were observed: "high fertility," "delayed entry," "truncated," and "short." While the high fertility trajectory was most prevalent across cohorts, delayed entry grew in importance. The high fertility trajectory was more common among women born between 1960 and 1969 and was followed less often by divorced women and those from polygynous households. Women with primary education and those from higher status groups were more likely to experience delayed entry. The truncated trajectory was associated with lack of economic wealth, polygynous households, and caste membership. A short trajectory was related to lack of agropastoral wealth, divorce, and possibly secondary sterility. Our study advances knowledge on fertility transitions in Niakhar-and Sahelian West African contexts more generally-by showing the diversity of childbearing trajectories within high fertility regional contexts.

Neighborhood Disadvantage and Breast Cancer-Specific Survival.

Importance: Neighborhood-level disadvantage is an important factor in the creation and persistence of underresourced neighborhoods with an undue burden of disparate breast cancer-specific survival outcomes. Although studies have evaluated neighborhood-level disadvantage and breast cancer-specific survival after accounting for individual-level socioeconomic status (SES) in large national cancer databases, these studies are limited by age, socioeconomic, and racial and ethnic diversity. Objective: To investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer-specific survival in a majority-minority population. Design, Setting, and Participants: This retrospective multi-institutional cohort study included patients with stage I to IV breast cancer treated at a National Cancer Institute-designated cancer center and sister safety-net hospital from January 10, 2007, to September 9, 2016. Mean (SD) follow-up time was 60.3 (41.4) months. Data analysis was performed from March 2022 to March 2023. Exposures: Neighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES. Main Outcomes and Measures: The primary outcome was breast cancer-specific survival. Random effects frailty models for breast cancer-specific survival were performed controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The Area Deprivation Index was calculated for each patient at the census block group level and categorized into tertiles (T1-T3). Results: A total of 5027 women with breast cancer were included: 55.8% were Hispanic, 17.5% were non-Hispanic Black, and 27.0% were non-Hispanic White. Mean (SD) age was 55.5 (11.7) years. Women living in the most disadvantaged neighborhoods (T3) had shorter breast cancer-specific survival compared with those living in the most advantaged neighborhoods (T1) after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics (T3 vs T1: hazard ratio, 1.29; 95% CI, 1.01-1.65; P < .04). Conclusions and Relevance: In this cohort study, a shorter breast cancer-specific survival in women from disadvantaged neighborhoods compared with advantaged neighborhoods was identified, even after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The findings suggest potential unaccounted mechanisms, including unmeasured social determinants of health and access to care measures. This study also lays the foundation for future research to evaluate whether social adversity from living in a disadvantaged neighborhood is associated with more aggressive tumor biologic factors, and ultimately shorter breast cancer-specific survival, through social genomic and/or epigenomic alterations.

The Role of Religion and Spirituality to Cope with COVID-19 Infections Among People of Lower Socioeconomic Status in Pakistan: An Exploratory Qualitative Study.

Religion and spirituality have been key coping mechanisms of Pakistani Muslims amidst natural calamities such as the COVID-19 pandemic. This study aimed to identify and explore the role of religion and spirituality in the recovery of COVID-19 patients in lower socioeconomics. The data for this qualitative research study were collected from 13 people in Pakistan who survived COVID-19 infection during the wave of the Omicron variant. The participants of this study referenced four key themes about their story of getting infected by COVID-19 and recovering from it and referenced religion and spirituality as an overarching aspect of that story. The patients who recovered believed that COVID-19 was a punishment from God for sinful humanity, which was unavoidable. Amidst such a belief, the studied patients tried to avoid hospitalization but prayed to God for mercy, forgiveness, and help in their recovery. A few who took medical treatment also established and/or strengthened their spiritual connections seeking quick recovery from the infection. The participants of this study believed that their religion or spirituality played a medicinal role in their recovery from COVID-19 infection.

Theory and health disparities: Explaining the relevance of theory in public health research in India.

This paper aims to address the concern that quantitative public health studies do not integrate theoretical considerations. This qualitative study uses content analysis to explore the application of theory in Indian public health articles listed on PubMed. Social determinants such as poverty, income, social class, education, gender, caste, socioeconomic position, socioeconomic status, immigrant status, and wealth were the keywords used to identify the articles analysed in this study. From a selection of 91 public health articles, we identified potential theoretical frameworks based on the pathways/recommendations/explanations mentioned. Additionally, using the case of tuberculosis in India, we highlight how theoretical perspectives play a critical role in providing a holistic view of major health challenges. Finally, by emphasising the need to adopt a theoretical perspective in empirical quantitative research on public health in India, we hope to motivate scholars to include a theory or theoretical paradigm in their future research.

Associations of age, sex, and socioeconomic status with adherence to guideline recommendations on protein intake and micronutrient supplementation in patients with sleeve gastrectomy or Roux-en-Y gastric bypass.

INTRODUCTION: Patients with bariatric surgery often show poor long-term compliance to recommendations for prevention of nutrient deficiency but it is unclear which factors contribute. We investigated the associations of age, sex, and socioeconomic status (SES) with adherence to guideline recommendations on protein intake and micronutrient supplementation. METHODS: In a monocentric cross-sectional study we prospectively recruited patients with sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) and a minimum postoperative period of 6 months. Clinical and demographic data were obtained from the patients' medical files and by questionnaire. Patients reported on supplement usage, recorded their dietary intake for seven days and underwent physical examinations including blood testing. RESULTS: We included 35 patients (SG: n = 25, RYGB: n = 10) with a mean (+SD) postoperative period of 20.2 (±10.4) months. Distributions of age, sex and SES were comparable between the SG and RYGB groups. Non-adherence to recommended protein intake was associated with age ≥ 50 years (p = 0.041) but not sex or SES. Protein intake inversely correlated with markers of obesity. There were no significant associations of age or sex with micronutrient supplementation. Only for vitamins A (p = 0.049) and B1 (p = 0.047) higher SES was associated with greater compliance. The only manifest deficiency associated with non-adherence to micronutrient supplementation was that for folic acid (p = 0.044). CONCLUSION: In patients after bariatric surgery, those of older age and of lower SES might have a greater risk of unfavorable outcome and may require greater attention to micronutrient and protein supplementation.

Trends in Health Behavior of Polish Women in 1986-2021: The Importance of Socioeconomic Status.

In the last 35 years Poland has undergone a series of fundamental economic, social, and biological transformations. With the transition from a centrally planned to a free-market economy, a period of economic and social transformation, Poland's accession to the European Union, and the COVID-19 coronavirus pandemic, living conditions in the country have seen dramatic changes. The aim of this study was to assess whether there were changes in the basic health behaviors of Polish women, and if so, in what directions and with what strength, and whether there were differences in these changes depending on the socioeconomic status. Information on basic lifestyle factors (drinking alcohol, smoking, coffee drinking, and physical activity) and socioeconomic status (level of education, Gini coefficient, Gender Inequality Index, women total employment, employed women being in managerial positions, women among scientists) of 5806 women aged 40-50 years were analyzed. During the 1986-2021 period, based on the same methodology, team of technicians and research tools, six birth cohorts of women were examined in 1986, 1991, 1996, 2006, 2019 and 2021. Highly statistically significant changes were found in the frequencies of declared health behaviors from 1986-2021, according to the order of significance in coffee and alcohol consumption, physical activity levels, and smoking and smoking intensity. In subsequent cohorts, there were fewer and fewer women who did not drink coffee and alcohol, while more drank more than two cups of coffee a day and drank alcohol more often than 2× a week. Furthermore, they were more likely to be physically active, and slightly fewer were smokers. The lifestyles of the women were less likely to depend on their socio-economic status than the cohorts. In 1991 and 1996, there was a marked intensification of unhealthy behavior. Changes in the analyzed health behaviors may have been caused by adaptation to the high level of psychosocial stress observed during the transition of the 1986-2021 period and may result in changes in the biological condition and quality and length of life of Polish women. Research on social differences in health behavior provides an opportunity to analyze the biological effects of changes in the living environment.

More GP Consultations by Violence Victims: Results from the Representative German DEGS1 Study.

Violence is a growing public health problem influencing physical and mental health. Victims tend to contact medical care in the first place, yet a discrepancy between patients' violence experiences (VE) and general practitioners' (GP) awareness is reported. The number of GP visits by victims is of interest. Using data of the nationally representative German Health Interview and Examination Survey for Adults (DEGS1), associations between the prevalence of ≥1 recent VE (last 12 months) and the number of GP contacts were analyzed with respect to age, gender, socio-economic status, and health conditions. The DEGS1 dataset comprised persons aged 18 to 64 years (n = 5938). The prevalence of a recent VE was 20.7%. Compared to non-victims, VE victims visited their GP significantly more often in the preceding 12 months (3.47 vs. 2.87, p < 0.001), which increased markedly in those who were strongly impaired by a recent physical VE (3.55 GP visits) or psychological VE (4.24). The high frequency of GP contacts in VE victims constitutes opportunities to professionally support this vulnerable patient group and underlines the necessity for GPs to integrate VE as a bio-psycho-social problem in a holistic treatment approach.

Population-based evaluation of the impact of socioeconomic status on clinical outcomes in patients with heart failure in integrated care settings.

INTRODUCTION AND OBJECTIVES: Low socioeconomic status (SES) is associated with poor outcomes in patients with heart failure (HF). We aimed to examine the influence of SES on health outcomes after a quality of care improvement intervention for the management of HF integrating hospital and primary care resources in a health care area of 209 255 inhabitants. METHODS: We conducted a population-based pragmatic evaluation of the implementation of an integrated HF program by conducting a natural experiment using health care data. We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January 1, 2015 and December 31, 2019. We compared outcomes between patients exposed to the new HF program and those in the remaining health care areas, globally and stratified by SES. RESULTS: A total of 77 554 patients were included in the study. Death occurred in 37 469 (48.3%), clinically-related hospitalization in 41 709 (53.8%) and HF readmission in 29 755 (38.4%). On multivariate analysis, low or very low SES was associated with an increased risk of all-cause death and clinically-related hospitalization (all Ps <.05). The multivariate models showed a significant reduction in the risk of all-cause death (HR, 0.812; 95%CI, 0.723-0.912), clinically-related hospitalization (HR, 0.886; 95%CI, 0.805-0.976) and HF hospitalization (HR, 0.838; 95%CI, 0.745-0.944) in patients exposed to the new HF program compared with patients exposed to the remaining health care areas and this effect was independent of SES. CONCLUSIONS: An intensive transitional HF management program improved clinical outcomes, both overall and across SES strata.

Disparities in chiropractic utilization by race, ethnicity and socioeconomic status: A scoping review of the literature.

BACKGROUND: Chiropractic is the largest complementary and alternative medicine profession in the United States, with increasing global growth. A preliminary literature review suggests a lack of widespread diversity of chiropractic patient profiles. OBJECTIVE: There have been no prior studies to comprehensively integrate the literature on chiropractic utilization rates by race, ethnicity, and socioeconomic status. The purpose of this scoping review is to identify and describe the current state of knowledge of chiropractic utilization by race, ethnicity, education level, employment status, and income and poverty level. SEARCH STRATEGY: Systematic searches were conducted in PubMed, Ovid MEDLINE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews, and Index to Chiropractic Literature from inception to May 2021. INCLUSION CRITERIA: Articles that reported race or ethnicity, education level, employment status, income or poverty level variables and chiropractic utilization rates for adults (≥18 years of age) were eligible for this review. DATA EXTRACTION AND ANALYSIS: Data extracted from articles were citation information, patient characteristics, race and ethnicity, education level, employment status, income and poverty level, and chiropractic utilization rate. A descriptive numerical summary of included studies is provided. This study provides a qualitative thematic narrative of chiropractic utilization with attention to race and ethnicity, education level, income and poverty level, and employment status. RESULTS: A total of 69 articles were eligible for review. Most articles were published since 2003 and reported data from study populations in the United States. Of the race, ethnicity and socioeconomic categories that were most commonly reported, chiropractic utilization was the highest for individuals identifying as European American/White/non-Hispanic White/Caucasian (median 20.00%; interquartile range 2.70%-64.60%), those with employment as a main income source (median utilization 78.50%; interquartile range 77.90%-79.10%), individuals with an individual or household/family annual income between $40,001 and $60,000 (median utilization 29.40%; interquartile range 25.15%-33.65%), and individuals with less than or equal to (12 years) high school diploma/general educational development certificate completion (median utilization 30.70%; interquartile range 15.10%-37.00%). CONCLUSION: This comprehensive review of the literature on chiropractic utilization by race, ethnicity and socioeconomic status indicates differences in chiropractic utilization across diverse racial and ethnic and socioeconomic populations. Heterogeneity existed among definitions of key variables, including race, ethnicity, education level, employment status, and income and poverty level in the included studies, reducing clarity in rates of chiropractic utilization for these populations. Please cite this article as: Gliedt JA, Spector AL, Schneider MJ, Williams J, Young S. Disparities in chiropractic utilization by race, ethnicity and socioeconomic status: A scoping review of the literature. J Integr Med. 2023; 21(2): 159-167.

The effect of health insurance and socioeconomic status on women's choice in birth attendant and place of delivery across regions in Indonesia: a multinomial logit analysis.

BACKGROUND: Evidence suggests that women gave birth in diverse types of health facilities and were assisted by various types of health providers. This study examines how these choices are influenced by the Indonesia national health insurance programme (Jaminan Kesehatan Nasional (JKN)), which aimed to provide equitable access to health services, including maternal health. METHODS: Using multinomial logit regression models, we examined patterns and determinants of women's choice for childbirth, focusing on health insurance coverage, geographical location and socioeconomic disparities. We used the 2018 nationally representative household survey dataset consisting of 41 460 women (15-49 years) with a recent live birth. RESULTS: JKN coverage was associated with increased use of higher-level health providers and facilities and reduced the likelihood of deliveries at primary health facilities and attendance by midwives/nurses. Women with JKN coverage were 13.1% and 17.0% (p<0.05) more likely to be attended by OBGYN/general practitioner (GP) and to deliver at hospitals, respectively, compared with uninsured women. We found notable synergistic effects of insurance status, place of residence and economic status on women's choice of type of birth attendant and place of delivery. Insured women living in Java-Bali and in the richest wealth quintile were 6.4 times more likely to be attended by OBGYN/GP and 4.2 times more likely to deliver at a hospital compared with those without health insurance, living in Eastern Indonesia, and in the poorest income quantile. CONCLUSION: There are large variations in the choice of birth attendant and place of delivery by population groups in Indonesia. Evaluation of health systems reform initiatives, including the JKN programme and the primary healthcare strengthening, is essential to determine their impact on disparities in maternal health services.

Obesity among African American people in the United States: A review.

Obesity is a growing public health crisis in the United States and is associated with a substantial disease burden due to an increased risk for multiple complications, including cardiovascular and metabolic diseases. As highlighted in this review, obesity disproportionately affects the African American population, women in particular, regardless of socioeconomic status. Structural racism remains a major contributor to health disparities between African American people and the general population, and it limits access to healthy foods, safe spaces to exercise, adequate health insurance, and medication, all of which impact obesity prevalence and outcomes. Conscious and unconscious interpersonal racism also impacts obesity care and outcomes in African American people and may adversely affect interactions between health care practitioners and patients. To reduce health disparities, structural racism and racial bias must be addressed. Culturally relevant interventions for obesity management have been successfully implemented that have shown benefits in weight management and risk-factor reduction. Strategies to improve health care practitioner-patient engagement should also be implemented to improve health outcomes in African American people with obesity. When managing obesity in African American people, it is critical to take a holistic approach and to consider an individual's social and cultural context in order to implement a successful treatment strategy.

Duration of the patient interval in breast cancer and factors associated with longer delays in low-and middle-income countries: A systematic review with meta-analysis.

OBJECTIVE: Breast cancer survival is lower in low- and middle-income countries (LMICs) partially due to many women being diagnosed with late-stage disease. The patient interval refers to the time elapsed between the detection of symptoms and the first consultation with a healthcare provider and is considered one of the core indicators for early diagnosis and treatment. The goal of the current research was to conduct a meta-analysis of the duration of the patient interval in LMICs and investigate the socio-demographic and socio-cultural factors related to longer delays in presentation. METHODS: We conducted a systematic review with meta-analysis (pre-registered protocol CRD42020200752). We searched seven information sources (2009-2022) and included 50 articles reporting the duration of patient intervals for 18,014 breast cancer patients residing in LMICs. RESULTS: The longest patient intervals were reported in studies from the Middle East (3-4 months), followed by South-East Asia (2 months), Africa (1-2 months), Latin America (1 month), and Eastern Europe (1 month). Older age, not being married, lower socio-economic status, illiteracy, low knowledge about cancer, disregarding symptoms or not attributing them to cancer, fear, negative beliefs about cancer, and low social support were related to longer delays across most regions. Longer delays were also related to use of alternative medicine in the Middle East, South-East Asia, and Africa and distrust in the healthcare system in Eastern Europe. CONCLUSIONS: There is large variation in the duration of patient intervals across LMICs in different geographical regions. Patient intervals should be reduced and, for this purpose, it is important to explore their determinants taking into account the social, cultural, and economic context.